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Open anterior approaches for lumbar spine procedures

Andrew A. Gumbs, M.D.a, Norman D. Bloom, M.D.a, Fabian D. Bitan, M.D.b,Scott H. Hanan, M.D.a,*

aDepartment of Surgery, Lenox Hill Hospital, 100 East 77th Street, New York, NY 10021, USAbDepartment of Orthopedic Surgery, Lenox Hill Hospital, 100 East 77th Street, New York, NY 10021, USA

Manuscript received March 29, 2006; revised manuscript August 24, 2006

Abstract

With the advent of anterior lumbar interbody fusion (ALIF) and articifial discs as common proceduresfor the treatment many spinal problems such as pseudoarthrosis, degenerative disc disease and internal discdisruption from trauma, anterior exposure has become an increasingly popular procedure for the general,thoracic, urologic and vascular surgeon. Despite this, the body of literature describing this procedure islacking. Dividing the approach for anterior spinal surgery into the thoracolumbar, mid-lumbar, andlumbosacral regions, we describe the basic techniques and anatomy needed to perform these openapproaches, specifically, repairs of disc spaces T12–L2, L2–5, and L5–S1, respectively. The technique forthe retroperitoneal approach will be discussed in detail; however, issues involved with indications fortransperitoneal approach and technical “pearls” will also be discussed. © 2007 Excerpta Medica Inc. Allrights reserved.

The American Journal of Surgery 194 (2007) 98–102

Keywords: Anterior; Retroperitoneal; Exposure; Lumbar; Spine

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ith the advent of anterior lumbar interbody fusion (ALIF)s a common procedure for the treatment of many spinalroblems such as pseudoarthrosis, degenerative disc dis-ase, and internal disc disruption from trauma, anteriorxposure has become an increasingly popular procedure foreneral, thoracic, urologic, and vascular surgeons [1]. De-pite this, the body of literature describing this procedure isacking, especially in the general and vascular surgery lit-rature. Dividing the approach for anterior spinal surgerynto the thoracolumbar, mid-lumbar, and lumbosacral re-ions, we describe the basic techniques and anatomy neededo perform these open approaches, specifically, repairs ofisc spaces T12–L2, L2–5, and L5–S1, respectively. Theechnique for the retroperitoneal approach will be discussedn detail, and issues involved with indications for the trans-eritoneal approach will also be described. The techniquesor thoracic and cervical approaches and laparoscopic pro-edures will not be addressed here.

* Corresponding author. Department of General Surgery, Lenox Hillospital, 130 E. 77th St., Seventh Floor, New York, NY 10021. Tel.:1-212-614-6770; fax: �1-212-598-9181.

tE-mail address: drhanan@optonline.net

002-9610/07/$ – see front matter © 2007 Excerpta Medica Inc. All rights reservoi:10.1016/j.amjsurg.2006.08.085

echniquehoracolumbar region (T12–L2)

The patient is placed in the lateral decubitus position andecured using either a bean-bag or sand bags. Typically, thepproach is via the left side; however, the right chest andetroperitoneum may be approached if need be. A thoraco-bdominal incision is made, generally directly over the 10thr 11th rib depending on the patient’s anatomy and theevels to be exposed. The incision is oriented in an obliqueashion and is carried down onto the abdominal wall for aew centimeters. The subcutaneous tissues, the serratus an-erior, and latissimus dorsi muscles, are divided to exposehe intercostals muscles directly over the desired rib. Theseuscles are divided to expose the superior border of the

ntended rib. The rib is dissected free from its bed in atandard fashion, being careful to avoid the neurovascularorder below. Anteriorly, the costal margin or the rib isdentified and divided. At this point the abdominal wallusculature can be divided. The external and internal ob-

iques are split for a variable distance. It is best to limit thiso the bare minimum to prevent postoperativc muscularysfunction. Immediately below the split costal margin ishe transversalis layer, which can now be divided.

Once this is complete, the peritoneum is dissected off ofhe overlying diaphragm and the psoas muscle, which opens

he retroperitoneal space. The diaphragm can now be taken

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99A.A. Gumbs et al. / The American Journal of Surgery 194 (2007) 98–102

own under direct visualization leaving a distal cuff forepair and staying clear of the more central region to avoidhrenic nerve injury. A self-retaining retractor is placed tobtain exposure within the thoracic and retroperitonealpace. The lung can be gently compressed cranially with aoist lap pad and a minimal decrease in tidal volume;

ingle-lung ventilation is not necessary. The parietal pleuraver the lower thoracic spine is now opened and the tho-aco-lumbar juction exposed. The segmental vessels to theertebral bodies are dissected and divided to gain anteriorccess to the disk spaces. Specific care must be paid to theegmental arteries because of the potential for serious hem-rrhage. These arteries are paired at each vertebral level andupply extra-spinal and intra-spinal structures. These ves-els need to be controlled and ligated on the side, which thexposure is undertaken. This should be done close to theorta to ensure that the collateral blood supply to the spinalord is preserved to protect against cord ischemia [2].

Because the artery of Adamkiewicz is fundamental inupplying blood flow to the anterior and posterior spinalrteries in the thoraco-lumbar area, selective angiography ofhe artery of Adamkiewicz has been advocated in the pre-perative work-up of patients to aid in choosing surgicalpproach in the hopes of minimizing risks for paraplegia.arge segmentals can also be individually occluded tempo-

arily with vascular clamps while spinal monitoring takeslace. If no changes are identified, these vessels can beivided. This artery usually arises on the left between T8–0, but its origin can vary between T7 and L4; as a result,pecial care must be taken when dissecting out vertebralodies at these levels [2]. At this region care should be takeno avoid injury to the retroperitoneal lymphatics (cisternahyli/thoracic duct) as large lymphoceles can develop.hould an injury occur, oversewing the lymphatic chainith a non-absorbable suture (2-0 silk) should remedy the

ituation.If the diaphragm was incised, a large bore chest tube is

laced and the diaphragm is repaired with a non-absorbabletitch after the orthopedic procedure is completed. The tho-acic cavity is closed by first placing rib approximatingutures and then repairing the intercostals musculature. Theerratus anterior and latissimus dorsi muscles are reapproxi-ated with running non-absorbable stitches and the anterior

bdominal wall is reconstructed layer by layer with thisechnique as well.

id-lumbar region (L2–L5)A left paramedian incision is made to avoid the more

rominent common iliac vein on the right and carried downhrough the subcutaneous tissue until the external obliqueascia is identified. This layer is incised at its medial extent,here it is still aponeurotic. At this point, the rectus sheath

s opened and the rectus muscle is mobilized to identify theosterior rectus sheath and semilunar line. Mobilization ofhe rectus can be toward the midline or toward lateral; werefer mobilization from medial to lateral to avoid disrup-ion of the segmental inervation to the abdominal wall. Athe level of the semilunar line, the retroperitoneal space cane developed by bluntly dissecting the peritoneum in a

ateral to medial direction and off of the overlying posterior l

ectus sheath. This layer can then be divided in a verticalirection to allow for muscle sparing and to facilitate clo-ure. The peritoneal sac is now bluntly dissected off of thesoas muscle, taking care to identify the ipsilateral ureter,ntil the left iliac artery and vein are identified. This incisionan usually be used to expose L2–S1.

At this point the exposure is aided by the use of aelf-retaining retractor. We use both the Balfour RetractorSpectrum, Stow, OH) and the Omni-Retractor (Omni, St.aul, MN). The multiple varied blades available in both of

hese systems assist in the actual dissection. Multiple re-eated adjustments of these blades can complete the expo-ure. The left iliac artery and vein are retracted medially,nd any segmental vessels are divided laterally. Care mustgain be taken at this stage to control any segmentalranches that may affect the orthopedic surgeon’s exposure.t this region care must again be used to avoid injury to the

etroperitoneal lymphatics and lumbar sympathetics. Moremportant is the need to avoid injury to the vascular struc-ures. The ileolumbar or ascending vein is generally a largeranch overlying the L5 body. This vessel can tether theliac vein and prevent adequate exposure of the L4/5 diskpace. We generally dissect this vessel and divide it (Fig. 1).he L5 root, which often runs in close proximity to thisranch, should be located. When the ascending branch iseft intact, undue traction on the left iliac vein should bevoided, because minor tears can lead to major hemorrhag-ng.

At this point the orthopedic portion of the procedure isndertaken (Fig. 2). After vigorous hemostasis is confirmed,he blades are removed one by one to assure a dry field. Theound is irrigated and the abdominal wall is reconstructed

n a layered fashion.

ig. 1. Division of ileo-lumbar vein for exposure of mid-lumbar and

umbo-sacral region.

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100 A.A. Gumbs et al. / The American Journal of Surgery 194 (2007) 98–102

umbo-sacral region (L5–S1)Access to the lumbo-sacral spine can be obtained via

everal incisions. Some prefer a right paramedian incisionlose to the midline to avoid injury to the nerves innervatinghe rectus, an oblique incision running from the iliac crest to

point between the umbilicus and pubis or a transversencision with either a muscle-cutting or muscle-splittingpproach [2]. A low transverse incision can be used as well,ncising the anterior fascia transversely to expose the rectususcles. These muscles can be cut, but we recommendobilizing the midline to again enter the preperitoneal

pace and mobilize the peritoneal envelope from left lateral

Fig. 2. Postoperative view of L4/5 artificial disc replacement.

cFig. 3. Exposure of L5/S1, note ligation of middle sacral vessels.

o medial. The ipsilateral ureter should be identified andwept with the peritoneum toward the midline. Dissection isarried down between the iliac vessels to expose the sacralromontory and L5/S1 disk. The middle sacral vessels arexposed and divided to complete this exposure (Fig. 3).are should be taken at this level to avoid unnecessary usef electrocautery to prevent pelvic sympathetic disruption,hich can result in retrograde ejaculation in a male patient.

ransperitonealWhen previous surgery makes the retroperitoneal ap-

roach impossible due to excessive scar tissue, the trans-eritoneal approach can be used. Once access to the peri-oneal cavity is obtained via either a paramedian orransverse incision, the white line of Toldt can be mobilizedor exposure of the lumbar discs (Fig. 4). The dissection ishen carried out as above. For transperitoneal exposure ofhe lumbo-sacral region the colon does not need to beobilized (Fig. 5), but the peritoneum needs to be excised

o enter into the disc interspace (Fig. 6).

ommentsALIF has become an increasingly popular procedure

ecause of several advantages over the posterior approach:educed incidence of nerve damage, the ability to perform aore complete disc excision, and the ability to place a larger

nterbody fusion device with what should be higher rates ofusion [1].

Because of the diaphragm at the thoraco-lumbar junc-ion, this part of the spine is one of the most difficult regionsor surgeons to access. Traditionally this junction is ac-

ig. 4. Taking down of the white line of Toldt for exposure of lumbar discpaces, note anterior displacement of left ureter (arrow).

essed below the 9th or 10th rib, requiring a chest tube at the

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101A.A. Gumbs et al. / The American Journal of Surgery 194 (2007) 98–102

nd of the case [2]. By entering the retroperitoneal space athe 11th rib, an extrapleural approach can obviate the needor chest tube placement. Although this procedure has aeputation for providing reduced exposure, a retrospectivenmatched review of 26 consecutive patients by Kim et alrom Toronto did not substantiate this. Nonetheless, theyid report increased operative time due to the difficulty inreserving the integrity of the pleural cavity [3]. An addi-ional advantage of this approach is the potential for de-reased morbidity from pulmonary complications and hos-ital stay. Closure of this type of incision is usually moreifficult and can be facilitated with mesh.

Potential complications of the anterior approach are nu-erous and range from lymphoceles, ureteral injuries, ret-

operitoneal fibrosis, rectus muscle hematoma, pancreatitis,emoral nerve palsy, pseudomeningocele, and latissimusorsi rupture, to retrograde ejaculation and impotence4–16]. As a result, we offer patients the option to bankperm preoperatively [17].

Minimally invasive techniques for spine procedures haveeen described and include: lumbar corpectomy with ante-ior reconstruction and laparoscopic retroperitoneal expo-ures, and discectomies with anterior lumbar fusions. Thesere not performed by our group because of the increasedomplication rates [11–14]. A group out of the University of

isconsin reported their experience with 50 consecutiveatients that underwent either an open retroperitoneal ap-roach or a laparoscopic transperitoneal one, finding a sig-ificantly higher incidence of complications in the laparo-copic group (4% vs 20%). They also noted a trend towardsompromised fusions due to limited exposures, althoughperative time and hospital time were not significantly dif-erent [1]. When compared to the retroperitoneal approach,ransperitoneal exposures have been found to have an in-reased risk of retrograde ejaculation for exposures of L4hrough S1 [15].

Endoscopic techniques for retroperitoneal access to the

ig. 5. Transperitoneal exposure of L5/S1 in previously approached pa-

ients.

umbar spinefor ALIF have been described since the late990s [16,18]. Known as lumboscopy, the retroperitonealpace is accessed similarly to total extraperitoneal (TEP)aparoscopic hernia repairs, using CO2 insufflation and aalloon spacer. Also referred to as a balloon-assisted endo-copic retroperitoneal gasless (BERG) approach, this tech-ique not only has the advantage of being performed withinimally invasive techniques, but it does not require vio-

ation of the peritoneum [18]. A recent experience reportedomplications in 3 of 46 (7%) patients, requiring hardwareemoval in 1 (2%) patient [19].

In conclusion, because of advantages over posterior re-airs, demand for anterior spinal approaches will only in-rease. Even though larger prospective randomized trials aretill needed, minimally invasive techniques have not shownny advantage over the open approach. Open retroperitonealxposures to the thoraco-lumbar, mid-lumbar, and lumbo-acral vertebral bodies are safe procedures and should be inhe repertoire of general and vascular surgeons. Evenhough experienced orthopedic spine surgeons can haveomparable complication rates, a combined approach re-uces complication rates in anterior spinal surgery by max-mizing the various surgical skills of the orthopedic oreurosurgical spine surgeon and the general or vascularxposure surgeon [20,21].

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[4] Mathews HH, Evans MT, Molligan HJ, et al. Laparoscopic discec-

ig. 6. Transperitoneal approach of L5/S1 after placement of artificialisc.

tomy with anterior lumbar interbody fusion. A preliminary review.Spine 1995;20:1797–802.

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