Transperitoneal subcostal approach provides better access to hilum cf. retroperitoneal flank approach (which is preferred for partial nephrectomies).
Assess resectability pre-op – “medial extent determines resectability”
Technique:
- Makuuchi incision – xiphisternum to above level of umbilicus with lateral extension towards costal margin (alternative: complete transverse, two finger breadths above umbi).
- Open anterior rectus sheath and divide rectus, identifying and controlling superior epigastric vein
- Suture corner of incision to ipsilateral shoulder for retraction, set up fixed table retractor
- Open peritoneum, divide falciform ligament on right
- Medialise colon along Toldt using traction and right angles, kocherise duodenum on right, be wary of tail of pancreas on left
- Develop anterior pararenal space, in the plane between kidney and mesocolon (this may be difficult in XGP etc.)
- Divide splenic or hepatic peritoneal attachments as needed and retract cranially carefully with packs
- Ensure adequate exposure with packing of bowel and liver/spleen and fixed retractor
- Identify gonadal / cava and trace superiorly to hilum, developing psoas plane
- Ligate renal artery then vein with stapler
- Upper pole dissection +/- adrenalectomy, taking care of adrenal vein on right if appropriate
- Divide lateral attachments and divide ureter
- Consider drain, close in layers
Thoraco-abdominal
- Supine with roll to elevate ipsilateral side, ipsilateral arm elevated next to head
- Upper midline incision combined with incision through 8th or 9th intercostal space to posterior axillary line, including division of costal cartilage (with Mayo scissors)
- Excise rib if needed
- Pleural opened on end expiration
- Diaphragm divided laterally and radially avoiding the phrenic nerve – closed at end with interrupted figure of 8 prolene