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Eleventh Rib, Extrapleural Approach to Kidney
THE JOURNAL OF UROLOGY
Vol. 73, No. 2, February 1955 Printed in U.S.A.
ELEVENTH RIB, EXTRAPLEURAL APPROACH TO KIDNEY LORANDE M. WOODRUFF From the Department of Urology, Massachusetts General Hospital, Boston, Jlll.ass.
Since the level of the kidney varies considerably among individuals the incision which will afford the best exposure will vary also. A kidney whose pedicle is below the rib cage may be easily accessible with a subcostal, lumbar incision, and one that lies higher may have sufficient mobility so that when freed up it can be drawn into the incision to allow a proper vie,v. A certain number, however, are so placed that their pedicle and upper pole are difficult to expose because they are so high up under the thoracic cage. The extent to which any kidney is so protected is not readily apparent if judged only from an anteroposterior x-ray. This is because only the dorsal portion of the ribs behind the kidneys are well shown. As these ribs turn to form the lateral and anterior portions of the rib cage, they become foreshortened and indistinct. Since the surgical approach is from nearly an oblique angle, it is the oblique x-ray which shows the projection of the ribs as they will be encountered at operation (fig. 1, 1). One notes in examining such x-rays that the oblique downward and forward sweep of the lower ribs carries them diagonally across the kidney region. Also, the anterior portions of the ribs are visible and serve to emphasize the extent to which they cover the kidney. In some instances the twelfth rib is found to lie posterior to the surgical approach, whereas the eleventh rib crosses the kidney obliquely near its midportion. These facts help to explain why through a subcostal incision one often finds a kidney previously thought readily accessible, lying under the rib cage and difficult to expose. By resecting the eleventh rib one gains direct access to the renal hilum. The incision for any renal operation should be selected after due consideration of the extent to which the bony cage overlies the kidney. The degree of fixation of the kidney from inflammation or previous operations, as well as the requirements of exposure for a given procedure, will also influence this choice. vVith routine use of a subcostal incision for all renal operations some are made unnecessarily difficult or hazardous, and some cannot be properly completed. Removal of some portion of this bony rib cage will improve access to the renal area. Resection of the twelfth rib has become widely accepted since it permits several centimeters higher exposure than the subcostal incision. Resection of the tenth rib as advocated by Chute, and by Leadbetter, gives excellent complete exposure. The fact that the pleura is transversed has been shown to make little real difference in complications or difficulties of management. Also the procedure described by N agamatsu and which enjoys considerable popularity, where the twelfth rib is resected along with small segments of the tenth and eleventh, gives comparable exposure yet is extrapleural. The twelfth rib incision has been most widely used because of its simplicity Read at annual meeting, American Urological Association, New York, N. Y. June 1954.
183
i).
184
LORANDE M. WOODRUFF
KIDNEY and RIBS in OBLIQUE PLANE ·•••
1
••• CO~TOPHRENIC
No1e- Normot position- of Sinus,
31
SINUS
Note- Sinus obtiteroled ·. ·
.
•u DtAPHRA.GM, PLEURA ond KIDNEY in OBLIQUE. PLANE • 0
FIG. 1
and similarity to the subcostal approach. Removal of the eleventh rib, if done extrapleurally, is practically a corollary of this. It is very similar except in detail. When the exposure obtained from the twelfth rib incision would not be sufficiently high and yet there seems insufficient need for a transthoracic or N agamatsu incision, removal of the eleventh rib extrapleurally may be the logical intermediate step. Removal of the eleventh rib has been avoided by many because it
EXTRAPLEURAL APPROACH TO KIDNEY
185
involved a transthoracic approach, It is, however, possible to remove the eleventh rib and remain extrapleural. This is done by releasing the pleural envelope beneath the rib bed and allowing it to retract upward, If either the eleventh or twelfth rib is removed, it should be realized that the diaphragm attaches not only to the tip of the eleventh rib but to the tip of the twelfth and posteriorly to the fascia below it. The pleura, lying upon this diaphragm, extends down to form the costophrenic sinus, in the narrow juncture of diaphragm with the rib cage. The anterior and posterior surfaces of pleura in this sinus are in apposition as the lung does not descend this far in normal respiration (fig. 1, 2). This envelope lies immediately beneath the periosteum of the ribs upon the curving surface of the diaphragm and is loosely adherent to each. It also extends dmvn to, and often below the twelfth rib. Consequently if this rib is resected, care must be taken in dissecting through the posterior portion of the rib bed not to enter it. It is possible, however, once the rib has been removed to
Frn. 2. Kidney incisions
identify the pleura and diaphragm in this area. With some care the posterior diaphragm attachments can be cut allowing it to retract upward. The tip of the pleura lying upon it can be bluntly freed allowing it to retract upward also. Once this is done the posterior angle of the wound will open, giving a considerable increase in exposure. The gain from releasing these attachments in the posterior angle of the wound is very real. If the eleventh rib is removed an entirely similar situation prevails except that the pleural margin extends farther anterior to cross the rib at about the junction of the anterior and middle thirds. It also extends downward behind the twelfth rib so that it must be freed bluntly from the posterior surface of this rib (fig. 1, 3). By cutting the diaphragm attachments, as ·well as by releasing the pleural sac, both will retract up,vard to give the same wide posterior angle to the wound, and the same wide exposure, though now at a higher level. \Ve claim no particular originality for this procedure. Certainly resection of the eleventh rib is a standard thoracic approach and the extrapleural principle has been widely used, particularly for sympathectomies. Hudson recently reported a series of adrenalectomies by a somewhat similar procedure involving the same principles. Our interest in this incision has not been held primarily by details of procedure, but rather by the principle of a family of incisions which will give adequate exposure depending on the anatomical location of the kidney, and the
186
LORANDE M. WOODRUFF
A
BED Of ELEVENTH RtB WITH PLEURAL RE.fLECT10N AND DIAPHRAGM EXPOSED
~····re ..
.,:...:
, .....;
I• I.
'.
.-~euR,... Mo~i~1zio _t.JPWl'l_f'i'P.S Of'F ?IAPH.~AGM
. ····----···. ·-....
..·-·~:-:.,
-·
C
PERIRENAL FASCIA OPENED
FIG. 3
187
EXTRAPLEURAL APPROACH TO KIDNEY
pathological condition under treatment. The eleventh rib incision is the logical intermediate. That it can be done extrapleurally increases its usefulness (fig. 2). The method we have used is as follows: The patient is intubated and placed in the usual lateral position. An incision is made along the eleventh rib from behind its angle and extending anteriorly onto the abdominal wall. The forward extent varies with the size and obesity of the patient and the width of exposure desired. If during the operation a wider view is found necessary, one or both recti muscles can be transected and the incision extended even into the opposite lower quadrant. The eleventh rib is then cleaned of overlying muscles to behind its angle. The periosteum is stripped from its surface and an elevator insinuated around the rib near its anterior end. This stripping is started anterior to the pleural margin, and only when well established is it carried posteriorly. In this way the pleura is not damaged. The rib is removed to behind its angle. The anterior abdominal muscles are next transected to expose the peritoneum and Gerota's fascia. At the tip of the eleventh rib bed the diaphragmatic fibers crossing to the twelfth rib now become apparent and the anterior pleural margin can be identified (fig. 3, A). In some instances this is more readily apparent than others. The fibers of the diaphragm are transected from before backwards nearly to the pleural margin, and as this is done the pleura becomes tensed and more clearly defined (fig. 3, B). By blunt finger dissection the pleura is freed from the posterior surface of the twelfth rib. Any fibrous attachments holding the lower edge of the pleural margin no,v become fairly plain and can either be cut carefully under vision or bluntly freed with a finger. The pleura retreats progressively upward as this is done, and as the freeing is completed, it disappears behind the tenth rib. Moist packs are then placed along the margins of the wound and a self-retaining rib spreader employed (fig. 1, C). One now obtains an unobstructed oblique view across the right or left upper quadrant, the center of which is at the renal hilum. Wound closure is like that of a twelfth rib incision except that the severed cliaphragm attachments are re-approximated by a series of interrupted mattress sutures. Care is taken not to pass these through the pleural margin which lies upon it. We have used this incision in 36 cases of the types shown in table 1. There has been no mortality. The complications have been 1 case of wound infection and 2 cases of pncumothorax requiring aspiration. TABLE
Renal cyst. Renal tumor. Renal calculi. Renal tuberculosis. Renal artery aneurysm. Adrenalectomy . Total ..
1. Types of cases
14 5 12
1 1 3 36
188
LORANDE M. WOODRUFF
On several occasions the pleura has been opened inadvertently; in each it has been closed either immediately or at the completion of the operation and the pleura aspirated. If for any reason a satisfactory airtight closure was not possible a small thoracotomy tube on water-seal or suction for 48 hours has been used to prevent pneumothorax. The increased width and height of exposure gained by this incision allow safe, easy dissection of the renal vessels. Thus in many nephrectomies in which a mass ligation of the pedicle might otherwise have been necessary, because of improved exposure, individual ligation of the vessels could be safely performed. The view obtained of the upper pole also allows careful dissection of the adrenal from the kidney and performance of adrenalectomy with some facility. When previous operations upon the kidney have caused fixation or extensive scars, it may be more practicable to use a high incision such as this through normal tissue, particularly as this will afford direct access to the region of the hilum. Pain during healing is difficult to assess, but it is our impression that it is less than with a lumbar incision which necessitates cutting considerably more muscle. Since the intercostal nerve is exposed and lies on the lower margin of the field it is easily preserved. In removing renal tumors, access to the region of the great vessels is sufficient that Gerota's fascia can be stripped from the diaphragm, and the renal and perirenal tissue together with lymph nodes can be cleanly removed. SUMMARY
Removal of the eleventh rib and reflecting the underlying pleura upward intact is a practical procedure. Very wide exposure of the renal pedicle and upper pole is obtained. With a very high kidney or one bound by scar and difficult to access, or where a wide exposure is required, this incision should be considered. REFERENCES CHUTE, R. AND SouTTER, L.: J. Urol., 61: 688, 1949. LEADBETTER, F., COOPER, J. F. AND CHUTE, R.: 90: 486, 1950. NAGANIATSU, G. R., LERMAN, P.H. AND BERNAN, M. H.: J. Urol., 67:787, HUDSON, P.: Ann. Surg., 139: 44, 1954.
w.
1952.
Vol. 73, No. 2, February 1955 Printed in U.S.A.
ELEVENTH RIB, EXTRAPLEURAL APPROACH TO KIDNEY LORANDE M. WOODRUFF From the Department of Urology, Massachusetts General Hospital, Boston, Jlll.ass.
Since the level of the kidney varies considerably among individuals the incision which will afford the best exposure will vary also. A kidney whose pedicle is below the rib cage may be easily accessible with a subcostal, lumbar incision, and one that lies higher may have sufficient mobility so that when freed up it can be drawn into the incision to allow a proper vie,v. A certain number, however, are so placed that their pedicle and upper pole are difficult to expose because they are so high up under the thoracic cage. The extent to which any kidney is so protected is not readily apparent if judged only from an anteroposterior x-ray. This is because only the dorsal portion of the ribs behind the kidneys are well shown. As these ribs turn to form the lateral and anterior portions of the rib cage, they become foreshortened and indistinct. Since the surgical approach is from nearly an oblique angle, it is the oblique x-ray which shows the projection of the ribs as they will be encountered at operation (fig. 1, 1). One notes in examining such x-rays that the oblique downward and forward sweep of the lower ribs carries them diagonally across the kidney region. Also, the anterior portions of the ribs are visible and serve to emphasize the extent to which they cover the kidney. In some instances the twelfth rib is found to lie posterior to the surgical approach, whereas the eleventh rib crosses the kidney obliquely near its midportion. These facts help to explain why through a subcostal incision one often finds a kidney previously thought readily accessible, lying under the rib cage and difficult to expose. By resecting the eleventh rib one gains direct access to the renal hilum. The incision for any renal operation should be selected after due consideration of the extent to which the bony cage overlies the kidney. The degree of fixation of the kidney from inflammation or previous operations, as well as the requirements of exposure for a given procedure, will also influence this choice. vVith routine use of a subcostal incision for all renal operations some are made unnecessarily difficult or hazardous, and some cannot be properly completed. Removal of some portion of this bony rib cage will improve access to the renal area. Resection of the twelfth rib has become widely accepted since it permits several centimeters higher exposure than the subcostal incision. Resection of the tenth rib as advocated by Chute, and by Leadbetter, gives excellent complete exposure. The fact that the pleura is transversed has been shown to make little real difference in complications or difficulties of management. Also the procedure described by N agamatsu and which enjoys considerable popularity, where the twelfth rib is resected along with small segments of the tenth and eleventh, gives comparable exposure yet is extrapleural. The twelfth rib incision has been most widely used because of its simplicity Read at annual meeting, American Urological Association, New York, N. Y. June 1954.
183
i).
184
LORANDE M. WOODRUFF
KIDNEY and RIBS in OBLIQUE PLANE ·•••
1
••• CO~TOPHRENIC
No1e- Normot position- of Sinus,
31
SINUS
Note- Sinus obtiteroled ·. ·
.
•u DtAPHRA.GM, PLEURA ond KIDNEY in OBLIQUE. PLANE • 0
FIG. 1
and similarity to the subcostal approach. Removal of the eleventh rib, if done extrapleurally, is practically a corollary of this. It is very similar except in detail. When the exposure obtained from the twelfth rib incision would not be sufficiently high and yet there seems insufficient need for a transthoracic or N agamatsu incision, removal of the eleventh rib extrapleurally may be the logical intermediate step. Removal of the eleventh rib has been avoided by many because it
EXTRAPLEURAL APPROACH TO KIDNEY
185
involved a transthoracic approach, It is, however, possible to remove the eleventh rib and remain extrapleural. This is done by releasing the pleural envelope beneath the rib bed and allowing it to retract upward, If either the eleventh or twelfth rib is removed, it should be realized that the diaphragm attaches not only to the tip of the eleventh rib but to the tip of the twelfth and posteriorly to the fascia below it. The pleura, lying upon this diaphragm, extends down to form the costophrenic sinus, in the narrow juncture of diaphragm with the rib cage. The anterior and posterior surfaces of pleura in this sinus are in apposition as the lung does not descend this far in normal respiration (fig. 1, 2). This envelope lies immediately beneath the periosteum of the ribs upon the curving surface of the diaphragm and is loosely adherent to each. It also extends dmvn to, and often below the twelfth rib. Consequently if this rib is resected, care must be taken in dissecting through the posterior portion of the rib bed not to enter it. It is possible, however, once the rib has been removed to
Frn. 2. Kidney incisions
identify the pleura and diaphragm in this area. With some care the posterior diaphragm attachments can be cut allowing it to retract upward. The tip of the pleura lying upon it can be bluntly freed allowing it to retract upward also. Once this is done the posterior angle of the wound will open, giving a considerable increase in exposure. The gain from releasing these attachments in the posterior angle of the wound is very real. If the eleventh rib is removed an entirely similar situation prevails except that the pleural margin extends farther anterior to cross the rib at about the junction of the anterior and middle thirds. It also extends downward behind the twelfth rib so that it must be freed bluntly from the posterior surface of this rib (fig. 1, 3). By cutting the diaphragm attachments, as ·well as by releasing the pleural sac, both will retract up,vard to give the same wide posterior angle to the wound, and the same wide exposure, though now at a higher level. \Ve claim no particular originality for this procedure. Certainly resection of the eleventh rib is a standard thoracic approach and the extrapleural principle has been widely used, particularly for sympathectomies. Hudson recently reported a series of adrenalectomies by a somewhat similar procedure involving the same principles. Our interest in this incision has not been held primarily by details of procedure, but rather by the principle of a family of incisions which will give adequate exposure depending on the anatomical location of the kidney, and the
186
LORANDE M. WOODRUFF
A
BED Of ELEVENTH RtB WITH PLEURAL RE.fLECT10N AND DIAPHRAGM EXPOSED
~····re ..
.,:...:
, .....;
I• I.
'.
.-~euR,... Mo~i~1zio _t.JPWl'l_f'i'P.S Of'F ?IAPH.~AGM
. ····----···. ·-....
..·-·~:-:.,
-·
C
PERIRENAL FASCIA OPENED
FIG. 3
187
EXTRAPLEURAL APPROACH TO KIDNEY
pathological condition under treatment. The eleventh rib incision is the logical intermediate. That it can be done extrapleurally increases its usefulness (fig. 2). The method we have used is as follows: The patient is intubated and placed in the usual lateral position. An incision is made along the eleventh rib from behind its angle and extending anteriorly onto the abdominal wall. The forward extent varies with the size and obesity of the patient and the width of exposure desired. If during the operation a wider view is found necessary, one or both recti muscles can be transected and the incision extended even into the opposite lower quadrant. The eleventh rib is then cleaned of overlying muscles to behind its angle. The periosteum is stripped from its surface and an elevator insinuated around the rib near its anterior end. This stripping is started anterior to the pleural margin, and only when well established is it carried posteriorly. In this way the pleura is not damaged. The rib is removed to behind its angle. The anterior abdominal muscles are next transected to expose the peritoneum and Gerota's fascia. At the tip of the eleventh rib bed the diaphragmatic fibers crossing to the twelfth rib now become apparent and the anterior pleural margin can be identified (fig. 3, A). In some instances this is more readily apparent than others. The fibers of the diaphragm are transected from before backwards nearly to the pleural margin, and as this is done the pleura becomes tensed and more clearly defined (fig. 3, B). By blunt finger dissection the pleura is freed from the posterior surface of the twelfth rib. Any fibrous attachments holding the lower edge of the pleural margin no,v become fairly plain and can either be cut carefully under vision or bluntly freed with a finger. The pleura retreats progressively upward as this is done, and as the freeing is completed, it disappears behind the tenth rib. Moist packs are then placed along the margins of the wound and a self-retaining rib spreader employed (fig. 1, C). One now obtains an unobstructed oblique view across the right or left upper quadrant, the center of which is at the renal hilum. Wound closure is like that of a twelfth rib incision except that the severed cliaphragm attachments are re-approximated by a series of interrupted mattress sutures. Care is taken not to pass these through the pleural margin which lies upon it. We have used this incision in 36 cases of the types shown in table 1. There has been no mortality. The complications have been 1 case of wound infection and 2 cases of pncumothorax requiring aspiration. TABLE
Renal cyst. Renal tumor. Renal calculi. Renal tuberculosis. Renal artery aneurysm. Adrenalectomy . Total ..
1. Types of cases
14 5 12
1 1 3 36
188
LORANDE M. WOODRUFF
On several occasions the pleura has been opened inadvertently; in each it has been closed either immediately or at the completion of the operation and the pleura aspirated. If for any reason a satisfactory airtight closure was not possible a small thoracotomy tube on water-seal or suction for 48 hours has been used to prevent pneumothorax. The increased width and height of exposure gained by this incision allow safe, easy dissection of the renal vessels. Thus in many nephrectomies in which a mass ligation of the pedicle might otherwise have been necessary, because of improved exposure, individual ligation of the vessels could be safely performed. The view obtained of the upper pole also allows careful dissection of the adrenal from the kidney and performance of adrenalectomy with some facility. When previous operations upon the kidney have caused fixation or extensive scars, it may be more practicable to use a high incision such as this through normal tissue, particularly as this will afford direct access to the region of the hilum. Pain during healing is difficult to assess, but it is our impression that it is less than with a lumbar incision which necessitates cutting considerably more muscle. Since the intercostal nerve is exposed and lies on the lower margin of the field it is easily preserved. In removing renal tumors, access to the region of the great vessels is sufficient that Gerota's fascia can be stripped from the diaphragm, and the renal and perirenal tissue together with lymph nodes can be cleanly removed. SUMMARY
Removal of the eleventh rib and reflecting the underlying pleura upward intact is a practical procedure. Very wide exposure of the renal pedicle and upper pole is obtained. With a very high kidney or one bound by scar and difficult to access, or where a wide exposure is required, this incision should be considered. REFERENCES CHUTE, R. AND SouTTER, L.: J. Urol., 61: 688, 1949. LEADBETTER, F., COOPER, J. F. AND CHUTE, R.: 90: 486, 1950. NAGANIATSU, G. R., LERMAN, P.H. AND BERNAN, M. H.: J. Urol., 67:787, HUDSON, P.: Ann. Surg., 139: 44, 1954.
w.
1952.