Retroperitoneal approach to the lumbar spine1
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Transcript of Retroperitoneal approach to the lumbar spine1
RETROPERITONEAL APPROACH TO THE LUMBAR SPINE
DR. ASHISH AGARWAL.DR.NITIN PAIKRAO.
DEPT. OF ORTHOPAEDICSB.Y.L.NAIR CH. HOSPITAL
INDICATIONS FOR RETROPERITONEAL
APPROCH
l 1.SPINAL DECOMPRESSION.
2.LUMBAR SPINE FUSION.
3. PSOAS ABSCESS DRAINAGE.
4.OPEN BIOPSY OF VERTEBRAL BODY
5. SYMPATHECTOMY
POSITION OF PATIENT
1. Left semilateral position with 45 degree tilt
to horizontal with patient facing away from
surgeon.
2. Supine position with table tilted to 45
degree.
.
Figure 6-31 Place the patient in the semilateral position for the
anterolateral (retroperitoneal) approach to the lumbar
POSITION OF PATIENT FOR RETROPERITONEAL APPROCH
midline.
INCISION
• AN OBLIQUE FLANK INCISION FROM THE
POSTERIOR HALF OF THE 12TH RIB TO
MIDWAY BETWEEN THE UMBILICUS AND THE
PUBIC SYMPHYSIS .
posteriorly.
INCISION FOR RETROPERITONEL APPROCH
Figure 6-33 Make an oblique flank incision extending down from the
posterior half of the 12th rib toward the rectus abdominis muscle
SUPERFICIAL SURGICAL DISSECTION
• DIVIDE THE APONEUROSIS OF THIS MUSCLE IN THE LINE OF ITS FIBERS, WHICH IS IN LINE WITH THE SKIN INCISION.
• THE EXTERNAL OBLIQUE MUSCLE SHOULD BE SPLITTED IN THE LINE OF ITS FIBERS I.E. LIKE HANDS IN POCKETS.
Figure 6-34 Incise the external oblique muscle and aponeurosis in line
with its fibers and in line with the skin incision
EXTERNAL OBLIQUE MUSCLE FIBRES ARE SPLITTED ALONG DIRECTION OF ITS MUSCLE FIBRES
it.
.
SUPERFICIAL SURGICAL DISSECTION
.
• DIVIDE THE INTERNAL OBLIQUE MUSCLE IN LINE WITH THE SKIN INCISION AND PERPENDICULAR TO THE LINE OF ITS MUSCULAR FIBERS. THIS DIVISION CAUSES PARTIAL DENERVATION, BUT IF THE MUSCLE IS CLOSED PROPERLY, POSTOPERATIVE HERNIAS CAN BE AVOIDED .
.FIGURE 6-35 DIVIDE THE INTERNAL OBLIQUE IN LINE WITH THE SKIN
INCISION AND PERPENDICULAR TO THE LINE OF ITS MUSCULAR FIBERS.
.
DISSECTION OF INTERNAL OBLIQUE MUSCLE
.
UNDER THE INTERNAL OBLIQUE MUSCLE
LIES THE TRANSVERSUS ABDOMINIS
MUSCLE. IT SHOULD BE DIVIDED IN LINE
WITH THE SKIN INCISION TO EXPOSE THE
RETROPERITONEAL SPACE .
.
.
Figure 6-36 Divide the underlying
transversus abdominis muscle in line
with the skin incision.
DO NOT CUT TRANSVERSALIS FASCIA
ASIT FORMS PROTECTIVE LAYER
OVER THE PERITONEUM
.IN THE ANTERIOR PART OF THE WOUND, IDENTIFY THE PERITONEUM AND ITS CONTENTS. POSTERIORLY, IDENTIFY THE RETROPERITONEAL FAT.
.
• Using SPONGE ON SPONGE HOLDER, develop a plane between the retroperitoneal fat and the fascia that overlies the psoas muscle .
• Place a Dever retractor over the peritoneal contents and retract them to the right upper quadrant. The ureter, which is attached loosely to the peritoneum, is carried forward with it.
video
video
.
PERITONEUM WITH ITS CONTENT IS PUSHED ANTERIORLY TO EXPOSE THE LUMBAR SPINE AND MAJOR VESSELS.
video
.• IDENTIFY THE PSOAS FASCIA, BUT DO
NOT ENTER THE MUSCLE.
• FOLLOW THE SURFACE OF THE PSOAS
MEDIALLY TO REACH THE
ANTERIOLATERAL SURFACE OF THE
VERTEBRAL BODIES.
. LEVEL CONFIRMATION
• PLACE A NEEDLE INTO THE
INVOLVED LUMBAR VERTEBRA AND
TAKE A RADIOGRAPH TO IDENTIFY
THE EXACT LOCATION.
.• THE AORTA AND VENA CAVA EFFECTIVELY ARE
TIED TO THE WAIST OF THE VERTEBRAL BODIES
BY THE LUMBAR SEGMENTAL ARTERIES AND
VEINS.
• THESE SMALLER VESSELS MUST BE LOCATED
INDIVIDUALLY ON THE INVOLVED VERTEBRAE
AND TIED SO THAT THE AORTA AND VENA CAVA
CAN BE MOBILIZED AND THE ANTERIOR PART OF
THE VERTEBRAL BODY REACHED
IDENTIFY SEGMENTAL VESSEL
TWO LAYERS OF PREVERTEBRAL FASCIA
SEGMENTAL VESSELS IN BETWEEN
INFILTRATE
PREVERTEBRAL
FASCIA
video
INCISE
• 11 NO BLADE
• OUTER LAYER OF PREVERTEBRAL FASCIA
DISSECTION OF SEGMENTAL VESSELS
• HOLD OUTER LAYER OF PREVERTEBRALFASCIA WITH KOCHERS
• DISSECTION WITH PEANUT• IDENTIFY THE VESSELS• LIGATE THE VESSELS• COAGULATE• CUT BETWEEN THE LIGATURE.
SUBPERIOSTEAL DISSECTION
• INCISE THE DEEPER LAYER OF PREVERTEBRAL FASCIA
• INCISE PERIOSTEUM• SUBPERIOSTEAL ELEVATION TILL ANT.SURFACE OF BODY• ROLLER PACK AND PENCIL PERIOSTEM• LESS CHANCES OF DAMAGING MAJOR VESSELS• MINIMISE BLOOD LOSS
.ELEVATE PSOASIDENTIFY POSTERIOR MARGIN OF VERTEBRAL BODYIDENTIFY PEDICLEIDENTIFY NEURAL FORAMINADECOMPRESS CORDIDENTIFY EXISTING NERVE ROOTUSE BIPOLAR NEAR NEURAL STRUCTURES
CAVEAT…………• The ureter is attached loosely to the peritoneum. If
doubt , it should be stroked gently to produce peristalsis.
• The sympathetic chain is found between the vertebral bodies and the psoas muscle laterally,
• The genitofemoral nerve lies on the anterior aspect of the psoas muscle.
.
.
FRACTUREL2 VERTEBRA
.
EXPANDIBLECAGES
.
.
L3 FRACTURE
L3 FRACTURE
L1 FRACTURE
L1 FRACTURE
Drawbacks of Retroperitoneal Approch :
1. Restricted exposure to L 5-S1 disc
space.
2. Extensive dissection of soft tissue
3. Technically difficult
.
THANK YOU !!!