Surgical anatomy of the abdomen and retroperitoneum

Making the incision

The abdomen and retroperitoneum are generally explored via a generous midline incision, usually made from the xiphoid to pubis in order to facilitate effective exposure. A less extensive incision may be useful only if a specific diagnosis has been established prior to operation. An adequate midline laparotomy incision will provide the greatest access to all of the structures in the abdomen and retroperitoneum. Additional incisional options exist that may augment exposure to specific areas.

A thoracoabdominal approach gives access to certain structures high in the abdomen. This generally involves a seventh or eighth interspace anterolateral thoracotomy that is brought down to the sternum. The ribs are divided flush with the sternum. The diaphragm is then taken down off the chest wall radially. Approximately 1 to 2 inches should be left on the chest wall for later diaphragmatic reconstruction. The diaphragm should be taken down all the way to the aorta on the left and the vena cava on the right. A left-sided thoracoabdominal approach is probably the best exposure for the supraceliac aorta. A right-sided thoracoabdominal incision increases the exposure of the posterior portion of the right lobe of the liver, as well as the retrohepatic vena cava.

A midline incision can be extended into a median sternotomy. This extension provides ready access to the anterior mediastinal structures. If an atriocaval shunt is to be used to treat a retrohepatic caval injury, a sternotomy will most expeditiously facilitate this maneuver, providing access to the right atrial appendage. In addition, if one wishes to control the inferior vena cava (IVC) within the pericardium to achieve complete vascular isolation of the liver, a sternotomy or a right-sided thoracoabdominal incision will give the surgeon good access to perform this maneuver.

Exposure of the deep pelvic vasculature can also be difficult through a standard laparotomy and may require additional exposure maneuvers. Several options exist to improve access. A groin incision allows for vascular control of the common femoral artery and vein at the level of the inguinal ligament. A combination of a full laparotomy and groin incision can aid in repair of a vascular injury immediately adjacent to the inguinal ligaments.

The inguinal ligament can be retracted or divided to give access to the distal external iliac vessels. Another option is to perform a retroperitoneal incision similar to those used for renal transplant. This “hockey stick” incision, which comes down through the retroperitoneum, exposes the distal iliac artery and vein well but is only useful in a stable patient. Distal pelvic vascular repair can then be accomplished. Although rarely required, if a transplant incision is combined with a midline incision, the bridge of skin, subcutaneous tissue, and fascia between the two incisions can become ischemic or an infarct.