The American Journal of Surgery 194 (2007) 98 102

How I do it

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,*
b

Department of Surgery, Lenox Hill Hospital, 100 East 77th Street, New York, NY 10021, USA Department 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 articial discs as common procedures for the treatment many spinal problems such as pseudoarthrosis, degenerative disc disease and internal disc disruption 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 is lacking. Dividing the approach for anterior spinal surgery into the thoracolumbar, mid-lumbar, and lumbosacral regions, we describe the basic techniques and anatomy needed to perform these open approaches, specically, repairs of disc spaces T12L2, L25, and L5S1, respectively. The technique for the retroperitoneal approach will be discussed in detail; however, issues involved with indications for transperitoneal approach and technical pearls will also be discussed. 2007 Excerpta Medica Inc. All rights reserved.
Keywords: Anterior; Retroperitoneal; Exposure; Lumbar; Spine

With the advent of anterior lumbar interbody fusion (ALIF) as a common procedure for the treatment of many spinal problems such as pseudoarthrosis, degenerative disc disease, and internal disc disruption from trauma, anterior exposure has become an increasingly popular procedure for general, thoracic, urologic, and vascular surgeons [1]. Despite this, the body of literature describing this procedure is lacking, especially in the general and vascular surgery literature. Dividing the approach for anterior spinal surgery into the thoracolumbar, mid-lumbar, and lumbosacral regions, we describe the basic techniques and anatomy needed to perform these open approaches, specically, repairs of disc spaces T12L2, L25, and L5S1, respectively. The technique for the retroperitoneal approach will be discussed in detail, and issues involved with indications for the transperitoneal approach will also be described. The techniques for thoracic and cervical approaches and laparoscopic procedures will not be addressed here.

* Corresponding author. Department of General Surgery, Lenox Hill Hospital, 130 E. 77th St., Seventh Floor, New York, NY 10021. Tel.: 1-212-614-6770; fax: 1-212-598-9181. E-mail address: drhanan@optonline.net

Technique Thoracolumbar region (T12L2) The patient is placed in the lateral decubitus position and secured using either a bean-bag or sand bags. Typically, the approach is via the left side; however, the right chest and retroperitoneum may be approached if need be. A thoracoabdominal incision is made, generally directly over the 10th or 11th rib depending on the patients anatomy and the levels to be exposed. The incision is oriented in an oblique fashion and is carried down onto the abdominal wall for a few centimeters. The subcutaneous tissues, the serratus anterior, and latissimus dorsi muscles, are divided to expose the intercostals muscles directly over the desired rib. These muscles are divided to expose the superior border of the intended rib. The rib is dissected free from its bed in a standard fashion, being careful to avoid the neurovascular border below. Anteriorly, the costal margin or the rib is identied and divided. At this point the abdominal wall musculature can be divided. The external and internal obliques are split for a variable distance. It is best to limit this to the bare minimum to prevent postoperativc muscular dysfunction. Immediately below the split costal margin is the transversalis layer, which can now be divided. Once this is complete, the peritoneum is dissected off of the overlying diaphragm and the psoas muscle, which opens the retroperitoneal space. The diaphragm can now be taken

0002-9610/07/$ see front matter 2007 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2006.08.085

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down under direct visualization leaving a distal cuff for repair and staying clear of the more central region to avoid phrenic nerve injury. A self-retaining retractor is placed to obtain exposure within the thoracic and retroperitoneal space. The lung can be gently compressed cranially with a moist lap pad and a minimal decrease in tidal volume; single-lung ventilation is not necessary. The parietal pleura over the lower thoracic spine is now opened and the thoraco-lumbar juction exposed. The segmental vessels to the vertebral bodies are dissected and divided to gain anterior access to the disk spaces. Specic care must be paid to the segmental arteries because of the potential for serious hemorrhage. These arteries are paired at each vertebral level and supply extra-spinal and intra-spinal structures. These vessels need to be controlled and ligated on the side, which the exposure is undertaken. This should be done close to the aorta to ensure that the collateral blood supply to the spinal cord is preserved to protect against cord ischemia [2]. Because the artery of Adamkiewicz is fundamental in supplying blood ow to the anterior and posterior spinal arteries in the thoraco-lumbar area, selective angiography of the artery of Adamkiewicz has been advocated in the preoperative work-up of patients to aid in choosing surgical approach in the hopes of minimizing risks for paraplegia. Large segmentals can also be individually occluded temporarily with vascular clamps while spinal monitoring takes place. If no changes are identied, these vessels can be divided. This artery usually arises on the left between T8 10, but its origin can vary between T7 and L4; as a result, special care must be taken when dissecting out vertebral bodies at these levels [2]. At this region care should be taken to avoid injury to the retroperitoneal lymphatics (cisterna chyli/thoracic duct) as large lymphoceles can develop. Should an injury occur, oversewing the lymphatic chain with a non-absorbable suture (2-0 silk) should remedy the situation. If the diaphragm was incised, a large bore chest tube is placed and the diaphragm is repaired with a non-absorbable stitch after the orthopedic procedure is completed. The thoracic cavity is closed by rst placing rib approximating sutures and then repairing the intercostals musculature. The serratus anterior and latissimus dorsi muscles are reapproximated with running non-absorbable stitches and the anterior abdominal wall is reconstructed layer by layer with this technique as well. Mid-lumbar region (L2L5) A left paramedian incision is made to avoid the more prominent common iliac vein on the right and carried down through the subcutaneous tissue until the external oblique fascia is identied. This layer is incised at its medial extent, where it is still aponeurotic. At this point, the rectus sheath is opened and the rectus muscle is mobilized to identify the posterior rectus sheath and semilunar line. Mobilization of the rectus can be toward the midline or toward lateral; we prefer mobilization from medial to lateral to avoid disruption of the segmental inervation to the abdominal wall. At the level of the semilunar line, the retroperitoneal space can be developed by bluntly dissecting the peritoneum in a lateral to medial direction and off of the overlying posterior

rectus sheath. This layer can then be divided in a vertical direction to allow for muscle sparing and to facilitate closure. The peritoneal sac is now bluntly dissected off of the psoas muscle, taking care to identify the ipsilateral ureter, until the left iliac artery and vein are identied. This incision can usually be used to expose L2S1. At this point the exposure is aided by the use of a self-retaining retractor. We use both the Balfour Retractor (Spectrum, Stow, OH) and the Omni-Retractor (Omni, St. Paul, MN). The multiple varied blades available in both of these systems assist in the actual dissection. Multiple repeated adjustments of these blades can complete the exposure. The left iliac artery and vein are retracted medially, and any segmental vessels are divided laterally. Care must again be taken at this stage to control any segmental branches that may affect the orthopedic surgeons exposure. At this region care must again be used to avoid injury to the retroperitoneal lymphatics and lumbar sympathetics. More important is the need to avoid injury to the vascular structures. The ileolumbar or ascending vein is generally a large branch overlying the L5 body. This vessel can tether the iliac vein and prevent adequate exposure of the L4/5 disk space. We generally dissect this vessel and divide it (Fig. 1). The L5 root, which often runs in close proximity to this branch, should be located. When the ascending branch is left intact, undue traction on the left iliac vein should be avoided, because minor tears can lead to major hemorrhaging. At this point the orthopedic portion of the procedure is undertaken (Fig. 2). After vigorous hemostasis is conrmed, the blades are removed one by one to assure a dry eld. The wound is irrigated and the abdominal wall is reconstructed in a layered fashion.

Fig. 1. Division of ileo-lumbar vein for exposure of mid-lumbar and lumbo-sacral region.

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

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

Lumbo-sacral region (L5S1) Access to the lumbo-sacral spine can be obtained via several incisions. Some prefer a right paramedian incision close to the midline to avoid injury to the nerves innervating the rectus, an oblique incision running from the iliac crest to a point between the umbilicus and pubis or a transverse incision with either a muscle-cutting or muscle-splitting approach [2]. A low transverse incision can be used as well, incising the anterior fascia transversely to expose the rectus muscles. These muscles can be cut, but we recommend mobilizing the midline to again enter the preperitoneal space and mobilize the peritoneal envelope from left lateral

to medial. The ipsilateral ureter should be identied and swept with the peritoneum toward the midline. Dissection is carried down between the iliac vessels to expose the sacral promontory and L5/S1 disk. The middle sacral vessels are exposed and divided to complete this exposure (Fig. 3). Care should be taken at this level to avoid unnecessary use of electrocautery to prevent pelvic sympathetic disruption, which can result in retrograde ejaculation in a male patient. Transperitoneal When previous surgery makes the retroperitoneal approach impossible due to excessive scar tissue, the transperitoneal approach can be used. Once access to the peritoneal cavity is obtained via either a paramedian or transverse incision, the white line of Toldt can be mobilized for exposure of the lumbar discs (Fig. 4). The dissection is then carried out as above. For transperitoneal exposure of the lumbo-sacral region the colon does not need to be mobilized (Fig. 5), but the peritoneum needs to be excised to enter into the disc interspace (Fig. 6). Comments ALIF has become an increasingly popular procedure because of several advantages over the posterior approach: reduced incidence of nerve damage, the ability to perform a more complete disc excision, and the ability to place a larger interbody fusion device with what should be higher rates of fusion [1]. Because of the diaphragm at the thoraco-lumbar junction, this part of the spine is one of the most difcult regions for surgeons to access. Traditionally this junction is accessed below the 9th or 10th rib, requiring a chest tube at the

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

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end of the case [2]. By entering the retroperitoneal space at the 11th rib, an extrapleural approach can obviate the need for chest tube placement. Although this procedure has a reputation for providing reduced exposure, a retrospective unmatched review of 26 consecutive patients by Kim et al from Toronto did not substantiate this. Nonetheless, they did report increased operative time due to the difculty in preserving the integrity of the pleural cavity [3]. An additional advantage of this approach is the potential for decreased morbidity from pulmonary complications and hospital stay. Closure of this type of incision is usually more difcult and can be facilitated with mesh. Potential complications of the anterior approach are numerous and range from lymphoceles, ureteral injuries, retroperitoneal brosis, rectus muscle hematoma, pancreatitis, femoral nerve palsy, pseudomeningocele, and latissimus dorsi rupture, to retrograde ejaculation and impotence [4 16]. As a result, we offer patients the option to bank sperm preoperatively [17]. Minimally invasive techniques for spine procedures have been described and include: lumbar corpectomy with anterior reconstruction and laparoscopic retroperitoneal exposures, and discectomies with anterior lumbar fusions. These are not performed by our group because of the increased complication rates [1114]. A group out of the University of Wisconsin reported their experience with 50 consecutive patients that underwent either an open retroperitoneal approach or a laparoscopic transperitoneal one, nding a signicantly higher incidence of complications in the laparoscopic group (4% vs 20%). They also noted a trend towards compromised fusions due to limited exposures, although operative time and hospital time were not signicantly different [1]. When compared to the retroperitoneal approach, transperitoneal exposures have been found to have an increased risk of retrograde ejaculation for exposures of L4 through S1 [15]. Endoscopic techniques for retroperitoneal access to the

Fig. 6. Transperitoneal approach of L5/S1 after placement of articial disc.

lumbar spinefor ALIF have been described since the late 1990s [16,18]. Known as lumboscopy, the retroperitoneal space is accessed similarly to total extraperitoneal (TEP) laparoscopic hernia repairs, using CO2 insufation and a balloon spacer. Also referred to as a balloon-assisted endoscopic retroperitoneal gasless (BERG) approach, this technique not only has the advantage of being performed with minimally invasive techniques, but it does not require violation of the peritoneum [18]. A recent experience reported complications in 3 of 46 (7%) patients, requiring hardware removal in 1 (2%) patient [19]. In conclusion, because of advantages over posterior repairs, demand for anterior spinal approaches will only increase. Even though larger prospective randomized trials are still needed, minimally invasive techniques have not shown any advantage over the open approach. Open retroperitoneal exposures to the thoraco-lumbar, mid-lumbar, and lumbosacral vertebral bodies are safe procedures and should be in the repertoire of general and vascular surgeons. Even though experienced orthopedic spine surgeons can have comparable complication rates, a combined approach reduces complication rates in anterior spinal surgery by maximizing the various surgical skills of the orthopedic or neurosurgical spine surgeon and the general or vascular exposure surgeon [20,21]. References
[1] Zdeblick TA, David SM. A prospective comparison of surgical approach for anterior L4-L5 fusion: laparoscopic versus mini anterior lumbar interbody fusion. Spine 2000;25:26827. [2] Anderson TM, Mansour KA, Miller JI Jr. Thoracic approaches to anterior spinal operations: anterior thoracic approaches. Ann Thorac Surg 1993;55:144751. [3] Kim M, Nolan P, Finkelstein JA. Evaluation of 11th rib extrapleuralretroperitoneal approach to the thoracolumbar junction. Technical note. J Neurosurg 2000;93(suppl):168 74. [4] Mathews HH, Evans MT, Molligan HJ, et al. Laparoscopic discectomy with anterior lumbar interbody fusion. A preliminary review. Spine 1995;20:1797 802.

Fig. 5. Transperitoneal exposure of L5/S1 in previously approached patients.

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A.A. Gumbs et al. / The American Journal of Surgery 194 (2007) 98 102 [14] Hannon JK, Faircloth WB, Lane DR, et al. Comparison of insufation vs. retractional technique for laparoscopic-assisted intervertebral fusion of the lumbar spine. Surg Endosc 2000;14:300 4. [15] Burgos J, Rapariz JM, Gonzalez-Herranz P. Anterior endoscopic approach to the thoracolumbar spine. Spine 1998;23:242731. [16] Sasso RC, Kenneth Burkus J, LeHuec JC. Retrograde ejaculation after anterior lumbar interbody fusion: transperitoneal versus retroperitoneal exposure. Spine 2003;28:1023 6. [17] Cohn EB, Ignatoff JM, Keeler TC, et al. Exposure of the anterior spine: technique and experience with 66 patients. J Urol 2000;164: 416 8. [18] Olinger A, Hildebrandt U, Mutschler W, et al. First clinical experience with an endoscopic retroperitoneal approach for anterior fusion of lumbar spine fractures from levels T12 to L5. Surg Endosc 1999; 13:12159. [19] Vazquez RM, Gireesan GT. Balloon-assisted endoscopic retroperitoneal gasless (BERG) technique for anterior lumbar interbody fusion (ALIF). Surg Endosc 2003;17:268 72. [20] Holt RT, Majd ME, Vadhva M, et al. The efcacy of anterior spine exposure by an orthopedic surgeon. J Spinal Disord Tech 2003;16: 477 86. [21] Bianchi C, Ballard JL, Abou-Zamzam AM, et al. Anterior retroperitoneal lumbosacral spine exposure: operative technique and results. Ann Vasc Surg 2003;17:137 42.

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