RETROPERITONEAL APPROACH

TO THE LUMBAR SPINE

M. Dedy Alkarni, MD
Rizky Febrian, MD
 INDICATIONS FOR RETROPERITONEAL APPROCH

• Spinal Decompression
• Lumbar spine fusion
• Psoas abscess drainage
• Open biopsy of vertebral body
• Sympathectomy
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 ANATOMY OVERVIEW

The anterior abdominal

musculature and viscera have
been transected and removed at
the level of the iliac crest.
The arrow indicates the route of
surgery between the peritoneum
anteriorly and the retroperitoneal
structures posteriorly.

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 POSITION

• Left semilateral position with

45 degree tilt to horizontal
with patient facing away from
surgeon.
• Supine position with table
tilted to 45 degree.
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 INCISION

• Make an oblique
flank incision
extending down from
the posterior half of
the 12th rib toward
the rectus abdominis
muscle.

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 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

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 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 .
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 SUPERFICIAL SURGICAL DISSECTION

• 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 .
• Do not cut transversalis
fascia over the peritoneum
as It forms protective layer
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 DEEP DISECTION

• In the anterior part of

the wound, identify
the peritoneum and
its contents.
Posteriorly, identify
the retroperitoneal
fat.

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 DEEP DISECTION

• 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.

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Genitofemoral
nerve
 DEEP DISECTION

• 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.
• 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
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 SUBPERIOSTEAL DISSECTION

• Incise the deeper

layer of prevertebral
fascia
• Incise periosteum
• Subperiosteal
elevation until
anterior surface of
body

L1 L2 L3
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 PEARLS AND DRAWBACKS

• 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.

• Restricted exposure to L 5-S1 disc space.

• Extensive dissection of soft tissue
• Technically difficult
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THANK YOU

678-555-0100