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Thoracoabdominal Incision for Laparotomy

Thoracoabdominal incision: from the 7th intercostal space to the costal arch, then following a paramedian line (2 cm of the linea alba) down to the umbilicus.

Urologic Indications for a Thoracoabdominal Laparotomy

Indications for a thoracoabdominal incision are radical nephrectomy or adrenalectomy for huge tumors or retroperitoneal lymphadenectomy for bulky disease with retrocrural lymph node metastases.

Preoperative Patient Preparation

• Insertion of a transurethral catheter
• Epidural anesthesia
• General anesthesia
• Supine position with hyperextension of the lumbar spine, lifting the ipsilateral shoulder to 30 degrees (oblique positioning pillows) and hanging the ipsilateral arm to a bracket with 90 degrees anteversion in the shoulder joint and 90 degrees of flexion in the elbow joint.
• Perioperative antibiotic prophylaxis, if the urinary or gastrointestinal tract is entered or if risk factors for surgical site infections are present.

Surgical Technique of a Thoracoabdominal Incision

• Skin incision see fig. thoracoabdominal incision: from the 7th intercostal space to the costal arch, then following a paramedian line (2 cm of the linea alba) down to the umbilicus.
• Incision of the trunk muscles to the 8th rib (latissimus dorsi, serratus anterior, external oblique muscle)
• Paramedian incision of the anterior lamina of the rectus sheath
• The rectus abdominis is dissected below the costal arch and the muscle is pushed laterally. The posterior lamina of the rectus sheath and the peritoneum are opened.
• Cut the intercostal muscles in the 7th intercostal space at the cranial margin of the 8th rib. Open the pleural cavity at the costal arch. The costal arch is cut with a rib shear.
• A thoracic retractor is used to spread the intercostal space, an additional retractor is used for the laparotomy. The diaphragm is cut near the origin, until sufficient exposure of the retroperitoneum is achieved.

References

  Deutsche Version: thorakoabdominelle Laparotomie