Lumbar spine – anterolateral approach

* position – semilateral at 45 deg supported with sandbag with L side up (aortic side vs. caval side)

* incision
– oblique flank incision from post. 1/2 of 12th rib toward lateral border of rectus abdominis about midway btw umbilicus & pubic symphysis

* no internervous plane

* dissection
– expose aponeurosis of ext. oblique
– divide in line of fibers
– divide int. oblique & transversus in line with skin incision
– expose retroperitoneal space/fat
– using blunt dissection, develop plane btw retroperitoneal fat & fascia overlying psoas
– retract peritoneal cavity med.
– ureter taken with peritoneal contents (attached loosely to peritoneum)
– identify aorta, cava & lumbar vertebral bodies
– place needle in involved discs –> xray

* dangers
– sympathetic chain – lies on lateral aspect of vert. body on med. aspect of psoas
– genitofemoral n. – lies on ant. med. surface of psoas
– segmental lumbar art. & veins – must be tied to prevent bleeding
– vena cava – avoid vigorous retraction
– aorta
– ureter
> runs in med. aspect of field btw peritoneum & psoas
> usu falls forward with peritoneum

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