EXTRAPLEURAL RETROPERITONEAL APPROACH

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EXTRAPLEURAL RETROPERITONEALAPPROACH

• Incision along 12th rib to one finger breadth
  above ASIS
• Divide latissimus dorsi muscle followed by
  deeper abdominal muscles
• Mobilize peritoneum from lateral abdominal wall
  and strip from undersurface of diaphragm
• Detach Henles ligament and quadratus lumborum
  from L1

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EXTRAPLEURAL RETROPERITONEAL APPROACH

• Resect medial portion of 12th rib
• Retract lateral half 12th rib caudally sparing
  the subcostal nerve
• Transect diaphragm above medial arcuate ligament
• Expose vertebrae as described previously

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Incision for extrapleural retroperitoneal
approach to the thoracolumbar spine.
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EXTERNAL AND INTERNAL OBLIQUE MUSCLES
TRANSVERSE MUSCLE
LATISSIMUS DORSI DIVIDED
PERITONEUM
12th RIB
GREATER PSOAS MUSCLE
PERIOSTEUM OF 12th RIB
LEFT LUNG
SUBCOSTAL NERVE
THORACIC DIAPHRAGM
The 12th rib is partially resected, allowing the
parietal pleura to be retracted with a sponge
stick.
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PERITONEUM
ASCENDING LUMBAR VEIN
LEFT DIAPHRAGMATIC CRUS DIVIDED
SYMPATHETIC CHAIN
GREATER PSOAS MUSCLE
12th RIB
GENITOFEMORAL NERVE
THORACIC DIAPHRAGM DIVIDED
SUBCOSTAL NERVE
QUADRATUS LUMBORUM
LEFT MEDIAL ARCUATE LIGAMENT
Following division of the diaphragm and left
diaphragmatic cuts, the spine is exposed caudal
and cephalad to the diaphragm.