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Flank Incision: Indications, Anatomy and Surgical Technique

Flank incision: the patient is placed in a lateral position on a flexed operation table.

Urologic Indications for a Flank Incision

Kidney Surgery

• Simple nephrectomy or radical nephrectomy
• Partial nephrectomy
• Open nephrolithotomy

Surgery of the Ureter

• Nephroureterectomy
• Open pyeloplasty
• Ureteroureterostomy

Preoperative Patient Preparation for a Flank Incision

• Insertion of a transurethral catheter
• Epidural anesthesia
• General anesthesia
• Patient positioning: the patient is placed in a lateral position on a flexed operation table, see fig. flank incision.
• Perioperative antibiotic prophylaxis, if the urinary or gastrointestinal tract is entered or if risk factors for surgical site infections are present.

Flank Incision: Surgical Technique

• Skin incision above and in the direction of the 11th intercostal space (between 11th and 12th rib).
• Split the external oblique abdominal muscle in the direction of the muscle fibers just above the 12th rib. Portions of the serratus anterior muscle and latissimus dorsi muscle are transected as necessary to expose the ribs.
• Transect the internal oblique abdominal muscle perpendicular to the muscle fibers with electrosurgical cautery. The transverse abdominal muscle is split between the muscle fibers.
• Injury to the subcostal nerve must be avoided. Access below the 12th rib is not advisable.
• Transection of the intercostal muscles is done with care not to injure the pleura. Insert a retractor between the ribs (without breaking them).
• Open the renal fascia and bluntly dissect the layer between the perirenal fat and the psoas muscle. Dissect the peritoneum of the perirenal fat to expose the kidney from all sides.

Wound closure:

The muscles are closed in two layers, either with a continuous running suture (monofilament, elastic, slowly absorbable, suture size USP 0 or 1) or an interrupted suture. The first layer includes the transverse abdominal muscle and the internal oblique abdominal muscle. The second layer includes the external oblique abdominal, serratus anterior, and latissimus dorsi muscle.

References

J. L. Duque, K. R. Loughlin, and S. Kumar, “Morbidity of flank incision for renal donors.,” Urology, vol. 54, no. 5, pp. 796–801, 1999.

J. A. Smith, S. S. Howards, G. M. Preminger, and R. R. Dmochowski, Hinman’s Atlas of Urologic Surgery Revised Reprint. Elsevier, 2019.

M. C. Kriegmair et al., “Single- vs multiple-layer wound closure for flank incisions: results of a prospective, randomised, double-blinded multicentre study.,” BJU international, vol. 127, no. 1, pp. 64–70, 2021.

  Deutsche Version: Flankenschnitt