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https://upload.orthobullets.com/topic/12004/images/retroperitoneal.jpg
https://upload.orthobullets.com/topic/12004/images/with ivc.jpg
https://upload.orthobullets.com/topic/12004/images/great vessels.jpg
Indications
  •  Can access L1 to sacrum
    • slightly more difficult to reach L5-S1 disk space than transperitoneal approach
    • bifurcation of great vessels anterior to L4 vertebral body q
  • Indications
    • psoas abscess drainage (without risk of postoperative ileitits)
    • spinal fusion
    • biopsy or resection of vertebral body
    • disc replacement
    • exposure of sympathetic chain (general surgery)
Postion
  • Place in semilateral position (45 degrees to horizontal)
    • use sandbags or bean bag to hold patient at angle
    • or place patient supine and tilt table
  • Place left side up
    • aorta is more resistent to injury than vena cava
Incision
  • Make incision from
    • posterior half of 12th rib to
    • lateral border of rectus abdominis (midway between umbilicus and pubic symphysis)
Approach
  • Approach to spine
    • incise subcutaneous fat
    • expose aponeurosis of external oblique muscle
    • divide external oblique in line with fibers
    • divide internal oblique in line with incision and perpendicular to muscle fibers
    • divide transverus abdominis in line with skin incision
    • bluntly disect plane between retroperitoneal fat and psoas fascia
    • retract peritoneal cavity medially
      • bring ureter with peritoneal cavity
    • follow surface of psoas muscle to vertebral bodies
    • tie off segmental lumbar arteries of aorta in the field of dissection
  • L4/5 disc space
    • mobilize aorta to the contralateral side
    • place needle in disc and take lateral xray to identify level
  • L5/S1 disc space
    • work between the bifurcation of aorta
    • place needle in disc and take lateral xray to identify level
Dangers
  • Sympathetic chain
    • lateral aspect of vertebral body
  • Genitofemoral nerve
    • anterior surface of psoas muscle attached to fascia 
  • Segmental arteries
    • segmental lumbar arteries and veins q
    • aorta
  • Ureter
    • lies between psoas fascia and peritoneum
      • attached more firmly to peritoneum
      • stroke to produce peristalsis to confirm
  • Superior hypogastric plexus 
    • injury leads to retrograde ejaculation
 

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