Authors of section

Authors

Alex Vaccaro, Frank Kandziora, Michael Fehlings, Rajasekaran Shanmughanathan

Executive Editor

Luiz Vialle

General Editor

German Ochoa (in memoriam)

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Mini open retroperitoneal approach (L4-S1)

1. Preliminary Remarks

The exact incision site will depend on the level of the fracture. The disc space L1/2 and above cannot be reached with this approach.

The straight anterior approach (retroperitoneal approach) is excellent for corpectomy, spinal canal decompression, and vertebral body replacement. The lumbotomy is ideal for plating.

Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1)

2. Skin incision

Under fluoroscopic control, the fractured vertebra or injured disc and the adjacent segments are marked on the skin.

Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1)

In the following, alternative options for skin incisions are depicted, depending on surgeon's and patient's preference

Shown are the midline skin incision, the pararectal skin incision, and the transverse skin incision.

Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1)

The skin is incised on the mark.

Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1)

3. Exposure

After dissection of the subcutaneous tissue, the anterior rectus sheet is incised and the rectus muscle is mobilized to the medial or lateral side, depending on the incision and surgeon's preference.

Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1)

The posterior rectus sheet is opened and the peritoneum is exposed.

Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1)

Next the peritoneum is carefully retracted using a hand.

Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1)

Depending on the level of the fracture, the great vessels are approached differently.

L4/5
For the L4/5 level, vessels have to be retracted to the opposite side.

L5/S1
For L5/S1, the vertebrae are accessed in between the vessels bifurcation.

Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1)

Pitfall: Iliolumbar vein
If L4/L5 is approached, the ascending iliolumbar vein should be ligated. Otherwise significant bleeding might occur.

Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1)

4. Retraction system

A retraction system is mandatory at this point.

Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1)

5. Closure

A retroperitoneal drain is inserted.

Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1)

The wound is then closed in layers.

Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1)