In the past ten years there has been rapid development of minimally invasive surgical techniques in many disciplines of surgery, allowing major surgical procedures to be performed with marked reduced morbidity to the individual patient. In the area of Anterior Spinal Surgery, the thoroscopic and laparoscopic approaches have been well described and utilized. This paper will describe a retroperitoneal approach to the Lumbar Spine that is less invasive than the laparoscopic approach, requires no insufflation, and mitigates the use
of trocars. In addition, the post-operative morbidity is decreased with
less pain and diminished ilieus.
The Approach is suitable for the lumbar spine L2 through S1 level. The
patient undergoes routine preoperative preparation as for the transabdominal
laparoscopic approach. The patient is placed in the supine position and
undergoes routine prep. There is no need for trendelenberg. An initial transverse incision is made just left of the midline, just above the pubis, about 3 cm. in length. It is carried down through the subcutaneous tissues to the anterior rectus sheath, which is incised transversely and the rectus is
retracted medially. At this level, the posterior sheath is quite attenuated
and is barely present. What is there is incised and with blunt finger dissection, the retroperitoneal space is entered. The space is enlarged with blunt dissection or with a retroperitoneal balloon dissector. The peritoneal sack will retract quite easily, but caution should be taken to assure the ureter remains adherent to the sack and does not stay overlying the iliac vessel. Once the sac is retracted off the L5-S1 space, retractors, such as the Aesculap are used to isolate the working area. The procedure then proceeds utilizing the laparoscopic video camera for visualization when needed
The approach for the higher levels is essentially the same. If L5-S1
has been exposed, then the retroperitoneal balloon insufflator is placed
into the retroperitoneal space through this incision, and the peritoneum
is dissected bluntly off the anterior parites. A second incision is made
overlying the level to be approached, and carried down through the anterior
fascia of the rectus. Again the rectus is retracted medially and the posterior
fascia opened. If the balloon dissector has not already removed the peritoneum,
blunt finger dissection will complete the dissection and the peritoneal
sac is retracted to the right and out of the field. If L5-S1 has not been
approached, the initial incision is made overlying the level to be approached,
the dissection Is carried down through the rectus sheath as described, and
with blunt dissection the retroperitoneal space is entered. The balloon
dissector is inserted, and the peritoneum is retracted off that level of
the spine.
This approach applies to L2-L5 . The higher lumber levels are better approached laterally . This technique offers a simpler, more direct approach to the anterior lumbar spine. It is less invasive than the transabdominal laparoscopic approach, and has less morbidity in the post-operative period: less pain and shortened ileus in particular. To date, we have had no complications in 20 patients relating to the performance of this approach. |
