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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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Questions (5)
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(SBQ09SP.58) Figure A demonstrates a cadaveric dissection of a retroperitoneal approach to the lumbar spine. The aorta, L2 vertebral body, and L3 vertebral body are labeled. Which of the following structures labeled 1-5 identifies the genitofemoral nerve? Review Topic

QID: 3421
FIGURES:
1

Number 1

1%

(11/841)

2

Number 2

12%

(105/841)

3

Number 3

77%

(651/841)

4

Number 4

5%

(46/841)

5

Number 5

2%

(21/841)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ08.22) A surgeon is planning to place an anterior interbody device in the lumbar spine using a retroperitoneal approach. A vertebral body is identified directly posterior to the bifurcation of the aorta. What is the most likely level of this vertebral body? Review Topic

QID: 408
1

L2

11%

(162/1473)

2

L3

9%

(131/1473)

3

L4

67%

(991/1473)

4

L5

12%

(176/1473)

5

S1

0%

(2/1473)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ07.214) An MR aortogram is shown in Figure A. What structure is identified by the red arrow in the coronal and axial views? Review Topic

QID: 875
FIGURES:
1

hypogastric plexus

2%

(13/560)

2

superior mesenteric artery

6%

(35/560)

3

inferior mesenteric artery

8%

(42/560)

4

segmental lumbar artery

83%

(463/560)

5

sympathetic chain

0%

(2/560)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
EVIDENCE & REFERENCES (9)
Topic COMMENTS (3)
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