Flank Approach

Like the posterior approach, the flank approach is extraperitoneal. It is most useful for obese patients in whom exposure offered by other approaches would be compromised. In these patients, the flank approach uses gravity to assist with retraction by allowing the patient's adipose tissue to fall away from the incision. The flank approach is also useful in the presence of a large adrenal mass in a patient with scarring and adhesions in the abdomen from previous surgeries. Finally, the flank approach is used when a laparoscopic procedure is converted to an open approach, as the patient will already be in the lateral decubitus position. Disadvantages of this approach are that exposure is only unilateral, and may be limited, particularly on the right side. It is therefore best suited to patients with small, unilateral adrenal disease. Compared to the posterior approach, however, the larger flank incision allows the surgeon to place both hands into the incision.

The patient is placed in the lateral decubitus position after being intubated. The abdominal pannus, if present, should fall forward. The operating table is flexed to maximize the distance between the costal margin and the iliac crest. An intercostal (Turner-Warwick), transcostal, or subcostal incision may be used.1516 The incision is made at the tip of the 11th or 12th rib (approximately the midaxillary line) and extends along the border of the rib posteriorly. The latissimus dorsi, external and internal obliques, transversus abdominis, and intercostal muscles are divided along the upper margin of the rib. Intercostal or transcostal incisions provide better exposure than the subcostal incision, particularly for glands in a cephalad position. A plane between the diaphragm and retroperitoneum is then developed, facilitating entry into the retroperitoneal space. Alternatively, the flank approach can be accomplished transthoracically prior to entry into the retroperitoneum. The procedure then follows as in the posterior approach.

How To Reduce Acne Scarring

How To Reduce Acne Scarring

Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.

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