Retroperitoneal approach to the lumbar spine1
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Retroperitoneal approach to the lumbar spine1

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Retroperitoneal approach to the lumbar spine1 Retroperitoneal approach to the lumbar spine1 Presentation Transcript

  • RETROPERITONEAL APPROACH TO THE LUMBAR SPINE DR. ASHISH AGARWAL. DR.NITIN PAIKRAO. DEPT. OF ORTHOPAEDICS B.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
    • Left semilateral position with 45 degree tilt to horizontal with patient facing away from surgeon.
    • Supine position with table tilted to 45 degree.
  • .
    • POSITION OF PATIENT FOR RETROPERITONEAL APPROCH
    midline. Figure 6-31 Place the patient in the semilateral position for the anterolateral (retroperitoneal) approach to the lumbar
  • INCISION
    • AN OBLIQUE FLANK INCISION FROM THE POSTERIOR HALF OF THE 12TH RIB TO MIDWAY BETWEEN THE UMBILICUS AND THE PUBIC SYMPHYSIS .
    • INCISION FOR RETROPERITONEL APPROCH
    posteriorly. 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.
    • EXTERNAL OBLIQUE MUSCLE FIBRES ARE SPLITTED ALONG DIRECTION OF ITS MUSCLE FIBRES
    it. Figure 6-34 Incise the external oblique muscle and aponeurosis in line with its fibers and in line with the skin incision
  • .
    • 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 .
  • .
    • .
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    Figure 6-36 Divide the underlying transversus abdominis muscle in line with the skin incision.
  • DO NOT CUT TRANSVERSALIS FASCIA AS IT 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
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    • 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 PSOAS
    • IDENTIFY POSTERIOR MARGIN OF VERTEBRAL BODY
    • IDENTIFY PEDICLE
    • IDENTIFY NEURAL FORAMINA
    • DECOMPRESS CORD
    • IDENTIFY EXISTING NERVE ROOT
    • USE 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.
  • .
    • .
    FRACTURE L2 VERTEBRA
  •  
    • .
    EXPANDIBLE CAGES
  • .
    • .
  • L3 FRACTURE
  • L3 FRACTURE
  •  
  •  
  • L1 FRACTURE
  • L1 FRACTURE
  •  
  •  
    • Drawbacks of Retroperitoneal Approch :
    • Restricted exposure to L 5-S1 disc space.
    • Extensive dissection of soft tissue
    • Technically difficult
  • .
    • THANK YOU !!!