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Subcostal and Chevron Incision: Surgical Technique

Urologic Indications for a Subcostal Incision

The subcostal or Chevron incision is used for a transperitoneal approach to the kidney or adrenal gland for larger tumors; see radical nephrectomy or adrenalectomy. A subcostal incision is an option if a flank position for a simple nephrectomy is not possible.

Subcostal of Chevron incision

Patient positioning:

The patient is in a supine position with slight hyperextension of the lumbar spine.

Surgical Technique (Step by Step) of a Subcostal Laparotomy

• The skin incision is shown in fig. subcostal incision. It can be extended to the opposite side along the dotted line (Chevron incision).
• Expose and incise the ventral lamina of the rectus sheath. Incise the abdominal external oblique muscle in direction of the muscle fibers. The rectus muscle is cut with electrocautery. Grasp the posterior lamina of the rectus sheath near the midline between forceps and open the peritoneum. If there are no adhesions, laparotomy is quickly extended as needed with electrocautery; the hand in the abdominal cavity protects the bowel. Transect the ligamentum teres hepatis between ligatures to mobilize the liver.

Wound closure:

The first layer (peritoneum, posterior lamina of the rectus sheath, transverse abdominal muscle) is closed with a continuous running suture (monofilament, elastic, slowly absorbable, suture size USP 0 or 1). The second layer (anterior lamina of the rectus sheath, external and internal oblique abdominal muscle) is closed with a running suture or in an interrupted fashion.

References

J. A. Smith, S. S. Howards, G. M. Preminger, and R. R. Dmochowski, Hinman’s Atlas of Urologic Surgery Revised Reprint. Elsevier, 2019.

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