Anterior Retroperitoneal Approach Research Articles

An Unusual Case of Footdrop

Extreme lateral disc herniations are described. Usually, the herniated disc is described as being at the lateral edge of the neural foramen. Herniated discs that lodge beyond this location need to be included in the differential of retroperitoneal lesions impinging on nerve roots. A 76-year-old woman presented with left leg radicular symptoms, including footdrop and a retroperitoneal lesion. Given the location of the lesion and its distance from the edge of the neural foramen, the differential diagnosis favored a nerve sheath tumor. An anterior retroperitoneal approach was taken. At the time of surgery, the lesion proved to be a herniated disc arising from the anterior surface of the L5-S1 disc space, medial to the psoas muscle. The disc herniation resulted in severe compression of the L5 nerve root as the root joined the lumbosacral plexus. This type of even more extreme lateral disc herniation is not widely reported. At this location, there are reports of clinicians confusing discs for tumors and occasionally tumors for discs. Given that some disc herniations are no longer visually adjacent to the foramen, perhaps extreme lateral disc herniation is not an ideal term. This individual case report is supplemented with a review of the literature on this rare condition with specific searches for disc, retroperitoneal, anterior herniation. Using the term anterior disc herniation will aid clinicians in including herniated disc fragments in the differential diagnosis for lesions affecting nerve roots anterior to the spine in this retroperitoneal location.

Internal Fracture Fixation using the Anterior Retroperitoneal Lower Laparotomy Approach in Pelvic Ring and Acetabular Fractures: the First Experience and Outcomes

Internal Fracture Fixation using the Anterior Retroperitoneal Lower Laparotomy Approach in Pelvic Ring and Acetabular Fractures: the First Experience and Outcomes Introduction. The ilioinguinal approach is well established for the treatment of pelvic fractures. As an alternative, the anterior retroperitoneal lower laparatomy (modified Stoppa) approach can be used to expose pelvic and acetabular fractures. We describe our experience with this approach in polytrauma patients with pelvic ring and acetabular fractures. Aim of the Study. The aim of study was to evaluate possibilities and impossibilities of internal fixation of pelvic ring and acetabular fractures using the anterior retroperitoneal lower laparatomy approach. Materials and methods. This retrospective study describes a series of 20 consecutive patients where a modified Stoppa approach was used for pelvic or acetabular fracture fixation. Results. 10 patients with acetabular fractures, six patients with a pelvic ring injury not involving the acetabular joint and 4 patients with a combined fracture were operated through a modified Stoppa approach. Anatomic or satisfactory reduction was achieved in 92% of the acetabular fractures. Pelvic ring fractures had an anatomic (displacement <1 cm) postoperative result in 100%. Conclusions. using this approach may have good the postoperative radiological un surgical results. This is a method of choice for patients with combined trauma with internal organ damage and patients with both side pelvic bone fracture.

Sex life and sexual function in men and women before and after total disc replacement compared with posterior lumbar fusion

Background context Sex life and sexual function may be affected by low back pain (LBP). Sexual dysfunction after anterior lumbar fusion is reported in both men and women, but focus is mainly on impaired male biological function (retrograde ejaculation) as this may cause infertility. This has led to concern as to whether anterior surgery should be employed in men, at least in younger age groups. Purpose To investigate how chronic low back pain (CLBP) of assumed discogenic origin affects sex life and sexual function in patients considered for surgical treatment, whether this is affected by surgical treatment (total disc replacement [TDR] or posterolateral fusion [PLF]/posterior lumbar interbody fusion [PLIF]), and if so, are there differences between the surgical procedures undertaken. Study design A randomized controlled trial comparing TDR and instrumented lumbar spine fusion, performed either as a PLF or PLIF. Patient sample One hundred fifty-two patients were included in this randomized controlled trial to compare the effect on CLBP of either TDR via an anterior retroperitoneal approach or instrumented posterior lumbar fusion, PLF or PLIF. Outcome measures Global assessment of back pain, back pain (visual analog scale [VAS] 0-100), function (Oswestry Disability Index [ODI] 0–100), quality of life (EQ5D [EuroQol] 0–1), and answers on specific sexual function. Methods Outcome was assessed using data from the Swedish Spine Register (SweSpine). In ODI, one question, ODI 8, reflects the impact of back pain on sex life. This question was analyzed separately. Patients also answered a gender-specific questionnaire preoperatively and at the 2-year follow-up to determine any sexual dysfunction regarding erection, orgasm, and ejaculation. Follow-up was at 1 and 2 years. Results Before surgery, 34% reported that their sex life caused some extra LBP, and an additional 30% that their sex life was severely restricted by LBP. After surgery, sex life improved in both groups, with a strong correlation to a reduction of LBP. The gender-specific questionnaire used to measure sexual function after 2 years revealed no negative effect of TDR or Fusion in men regarding erection or retrograde ejaculation. However, 26% of all men in the Fusion group, compared with 3% in the TDR group, reported postoperative deterioration in the ability to achieve orgasm, despite a reduction of LBP. Conclusions Impairment of sex life appears to be related to CLBP. An improvement in sex life after TDR or lumbar fusion was positively correlated to a reduction in LBP. Total disc replacement in this study, performed through an anterior retroperitoneal approach, was not associated with greater sexual dysfunction compared with instrumented lumbar fusion performed either as a PLF or as a PLIF. Sexual function, expressed as orgasm, deteriorated in men in the Fusion group postoperatively, in spite of this group reporting less LBP after 2 years.

Clinical and radiological outcome of anterior–posterior fusion versus transforaminal lumbar interbody fusion for symptomatic disc degeneration: a retrospective comparative study of 133 patients

Abundant data are available for direct anterior/posterior spine fusion (APF) and some for transforaminal lumbar interbody fusion (TLIF), but only few studies from one institution compares the two techniques. One-hundred and thirty-three patients were retrospectively analyzed, 68 having APF and 65 having TLIF. All patients had symptomatic disc degeneration of the lumbar spine. Only those with one or two-level surgeries were included. Clinical chart and radiologic reviews were done, fusion solidity assessed, and functional outcomes determined by pre- and postoperative SF-36 and postoperative Oswestry Disability Index (ODI), and a satisfaction questionnaire. The minimum follow-up was 24 months. The mean operating room time and hospital length of stay were less in the TLIF group. The blood loss was slightly less in the TLIF group (409 vs. 480 cc.). Intra-operative complications were higher in the APF group, mostly due to vein lacerations in the anterior retroperitoneal approach. Postoperative complications were higher in the TLIF group due to graft material extruding against the nerve root or wound drainage. The pseudarthrosis rate was statistically equal (APF 17.6% and TLIF 23.1%) and was higher than most published reports. Significant improvements were noted in both groups for the SF-36 questionnaires. The mean ODI scores at follow-up were 33.5 for the APF and 39.5 for the TLIF group. The patient satisfaction rate was equal for the two groups.

Anatomical variations of the iliolumbar vein with application to the anterior retroperitoneal approach to the lumbar spine: A cadaver study

Objectives of this study include identification of lumbosacral venous variations, designation of a critical area of dissection for surgical exposure, and comparison between both male/female and right/left-sided anatomy. Attempts were made to provide anatomic nomenclature that accurately describes these structures. Thirty-eight iliolumbar venous systems in 20 cadavers (11 females/9 males) were dissected. Each system was identified as one of three patterns of variation: common venous trunk (combining ascending lumbar and iliolumbar venous systems) with distal veins, common venous trunk without distal veins, and venous systems without a common venous trunk. Dimensions including distances to the inferior vena cava (IVC) confluence, the obturator nerve, and the lumbosacral trunk, and venous stem length were obtained to aid surgical dissection. Differences between males and females and those between right and left sides were compared. Anterior lumbosacral venous variations could be organized into three groups. A Type 1 venous system (common venous trunk with distal veins) was most common (53% of systems). The anatomical name "lateral lumbosacral veins" adequately describes the anatomical location of these veins and does not assume a direction of venous flow or the lack of individual distal veins. A critical area bordered by the obturator nerve anteriorly, the psoas muscle laterally, the spinal column medially, and sacrum posteriorly within 8.2 cm of the IVC confluence should be defined to adequately dissect the lateral lumbosacral veins. Differences in male and female lateral lumbosacral venous anatomy do not alter surgeon's approach to the anterior lumbar spine.

39. Characterization of Intraoperative Neurophysiologic Changes Due to Vascular Compression during Anterior Lumbar Surgery

BACKGROUND CONTEXT: The anterior retroperitoneal approach is often used to gain access to the anterior lumbar spine. During this approach, dissection and retraction of the aorta and iliac vessels may be required. Occult intraoperative vascular insufficiency may lead to catastrophic complications and thus early detection is critical to satisfactory patient outcomes. Intraopertive neurophysiologic monitoring (IONM) using posterior tibial nerve somatosensory evoked potentials (PTN SSEP) is an accepted technique for monitoring neural pathways during spinal procedures.

Arthrodèse antérieure L5-S1 par voie rétropéritonéale et fixation par cage et plaque. Étude prospective de 40 cas avec un recul d’un à 2,2 ans (moyen 1,5 ans)

The aim of this prospective clinical study was to assess outcome after anterior retroperitoneal interbody arthrodesis for L5-S1 discopathy. We used a cage filled with an autologous corticocancellous graft and plate fixation.Forty patients with low back pain unresponsive to medical treatment for more than six months were included in this series. We noted the clinical signs and radiculalgia. Patients were assessed preoperatively, postoperatively, at one year and at last follow-up using the Oswestry score and a visual analog scale (VAS). The plain X-rays disclosed 30 cases of discopathy (16 primary and 14 postdiscectomy) and 10 cases of spondylolisthesis by L5 isthmic lysis (three Meyerding grade 0 and seven grade 1). MRI revealed signs of disc degeneration in all cases with a black disc or modification of the endplate signals (Modic type 1 in 23 and type 2 in 13). The anterior retroperitoneal approach was used in all cases for complete discectomy, arthrodesis with cage insertion and an autologous corticocancellous graft harvested from the iliac bone and fixation using a triangular plate (Pyramid, Medtronic, Memphis TN). Clinical and radiographic follow-up data were available at six weeks and three, six and 12 months in addition to last follow-up. A follow-up using MRI was performed in the event of complications.The population was composed of 25 women and 15 men, mean age 44 years and eight months (range 29-693 years). Thirteen patients presented radiculalgia. There were no vascular or gastrointestinal complications with the anterior approach. Bone healing was achieved at one year in 38 patients (95%). The mean Oswestry score improved from 52 to 16% and the mean VAS from 7.8 to 1.83 at 18 months follow-up. All occupationally-active patients but one resumed their former activity at mean 4.7 months. There were no sexual complications in this series. Low back pain persisted in three patients and five developed transient facet joint symptoms. Two patients developed secondary radiculalgia. We noted two cases of nonunion, in one grade 1 spondylolisthesis and in one grade 1 spondlylolisthesis (with revision for complementary posterior arthrodesis and a good outcome at latest follow-up).Anterior L5-S1 interbody fusion with a cage filled with a corticocancellous autograft fixed with a plate provides good clinical and radiographic results for the stabilization of painful discopathy. The results have been good for isolated L5-S1 discopathy and for grade 0 spondylolisthesis. The limit for this technique would appear to be grade 1 spondylolisthesis with a degraded disc. Performed via an anterior retroperitoneal approach, this method is a good alternative to the classical posterior approach, enabling very low morbidity.

Implications of Lumbar Plexus Anatomy for Removal of Total Disc Replacements Through a Posterior Approach

An anatomic study in which the lumbar plexuses of 14 embalmed cadavers were dissected bilaterally and measured using a posterior approach. To determine the cephalocaudal (root-to-root) distances and the mediolateral (root-to-tether) distances within the lumbar plexus and determine the feasibility for removal of a lumbar total disc replacement (TDR) through these anatomic spaces using a posterior approach. Currently, lumbar TDRs are implanted primarily through an anterior retroperitoneal or transperitoneal approach. However, revision surgeries through these approaches can be complicated by significant adhesions, with potential injuries to intra- and retroperitoneal contents. Advancements in accessing anterior column structures through a posterior lumbar extracavitary approach suggest that posterior removal of TDRs may be an alternative. Unlike the thoracic extracavitary approach in which ligation of the thoracic nerve rarely leaves significant morbidity, the lumbar extracavitary approach cannot rely on the analogous ligation of the lumbar root to achieve access. Therefore, feasibility of the lumbar extracavitary approach depends on the presence of sufficient anatomic space between the tethered nerves of the lumbar plexus. Fourteen adult cadavers (5 M/9F) were dissected through a posterior approach to expose the lumbar plexus bilaterally. The root-to-root distances at levels L2-S1 and corresponding root-to-tether distances at levels L3-L5 were measured bilaterally. Root-to-root distance was smallest at the male L5-S1 interval (11.7 +/- standard deviations 4.1 mm). Root-to-tether distance was smallest at the female L5 (43.1 +/- standard deviations 8.4 mm). These plexus measurements compare favorably with the CHARITE TDR components, in which the thickest sliding core is 11.0 mm in height and the largest endplate is 42.0 mm in width. This anatomic study suggests that posterior TDR removal is possible in the lumbar spine without undue risk to the surrounding nervous structures.

Retroperitoneal mesenchymal chondrosarcoma mimicking a large retroperitoneal sacral schwannoma

We report a case of retroperitoneal chondrosarcoma in which preoperative radiological study induced to a possible diagnosis of sacral schwannoma. A 25-year-old woman was admitted to our neurosurgical institute for a progressive sciatic pain with gait difficulties with a sudden radicular deficit with right positive Lasegue's sign at 30 degrees, loss of Achilles reflex, sensory deficit on right S1 dermatome, and complete motor deficit of right plantar flexion. We performed an en bloc removal of the lesion via an anterior retroperitoneal approach. We believe that the treatment of choice is radical surgical excision of the tumor with complete en-bloc removal of the lesion; postoperative radiotherapy and chemotherapy should be valuated case by case.

Efficacy of Linezolid Versus Vancomycin in the Treatment of Methicillin-Resistant Staphylococcus aureus Discitis

A rabbit model was used to assess the efficacy of linezolid and vancomycin for the treatment of discitis due to methicillin-resistant Staphylococcus aureus (MRSA). Nontreated controls were used for comparison. The purpose of this study was to determine if there was a therapeutic difference between using linezolid and vancomycin in the treatment of MRSA discitis. Vancomycin is currently the gold standard treatment for medical management of MRSA discitis. Linezolid is a relatively new drug that has been approved for treatment of MRSA infections, but currently there is no research demonstrating its efficacy at treating infections of the disc space. Twenty-four rabbits were inoculated with MRSA at two adjacent lumbar disc spaces via an anterior retroperitoneal approach. Six rabbits were to receive only pain medication and to serve as controls. Ten rabbits were assigned to a 5-day course of intravenous vancomycin, and 8 were assigned to a 5-day course of intravenous linezolid. Disc spaces were sent for quantitative culture after the 5-day treatment course. The mean culture growth for the disc spaces was not statistically different between the linezolid treated group and the nontreated controls. While vancomycin treatment did lead to lower bacterial loads when compared with controls, the reduction was not statistically significant. When bacterial counts for the vancomycin group and linezolid group were compared, vancomycin treatment resulted in less bacterial growth. This difference was statistically significant. Linezolid is a clinically attractive alternative to vancomycin due to its mild side effect profile and oral bioavailability. However, in this MRSA discitis model with a short treatment course, vancomycin was superior to linezolid.

Lumbar interbody fusion using autologous bone marrow mesenchymal stem cell-calcium phosphate ceramic composite in rhesus monkey

To determine the osteogenic capacity of autologous bone marrow mesenchymal stem cells (BMSCs)-calcium phosphate ceramic composites in vitro and implanted as a bone graft substitute for lumbar anterior interbody fusion in rhesus monkeys. From March 2003 to April 2005, 9 adult rhesus monkeys underwent lumbar L(3 - 4) and L(5 - 6) discectomy and interbody fusion via an anterior retroperitoneal approach. Two fusion sites in each animal were randomly assigned to two of three treatments: autogenous tricortical iliac crest bone graft (autograft group, n = 6) or cell-free ceramic graft (ceramic group, n = 6) or BMSCs-ceramic composite graft (BMSCs group, n = 6). Autologous BMSCs were culture-expanded and stimulated with osteogenic supplement. The cell-ceramic composites were constructed in a rotary dynamic cell culture system. The spinal fusion segments were evaluated by radiography, biomechanical testing, histologic analysis and histomorphometric analysis at 3 months post-surgery. Biomechanical testing showed that spinal segments from the autograft group and the BMSCs-ceramic group were statistically and significantly stiffer than the cell-free ceramic group. The BMSCs-ceramic group and the autograft group showed equivalent biomechanical stiffness by statistical analysis. Histologically, both the autograft group and the BMSCs-ceramic group achieved osseous union, but the cell-free ceramic group had a fibrous union. Quantitative histologic analysis showed that the amount of bone formation was significantly greater in the autograft group and the BMSCs-ceramic group compared with the cell-free ceramic group. However, the amount of ceramic residue was significantly greater in the cell-free ceramic group versus the BMSCs-ceramic group. The results indicate that BMSC-ceramic composites can enhance bone regeneration and achieve osseous spinal fusion 3 months after the implantation in rhesus monkey interbody fusion model. Cell-free ceramics has an unsatisfactory efficacy in spinal fusion due to its tense fibrous fusion.

Revisability of the CHARITÉ Artificial Disc Replacement

A prospective, randomized, multicenter, FDA-regulated Investigational Device Exemption clinical trial. To analyze the incidence of, and reasons for, reoperation in all patients (treatment and control) enrolled in the IDE study. This is the first report of the incidence and nature of reoperations following lumbar TDR as part of a controlled, prospective, multicenter trial. A total of 688 patients meeting the inclusion and exclusion criteria were enrolled in one of three arms of the study at 14 centers across the United States. This cohort includes 71 nonrandomized cases, 205 randomized cases, and 313 continued access cases, all receiving the CHARITE Artificial Disc, as well as 99 randomized cases in the control group (ALIF with threaded fusion cages and autograft). A detailed analysis was performed of clinical chart notes, operative notes, and adverse event reports for all patients requiring reoperation following their index surgery. Of the 589 patients with TDR, 52 (8.8%) required reoperation. Of the 99 patients with lumbar fusion, 10 (10.1%) required reoperation, and an additional 2 required surgery for adjacent level disease (P = 0.7401). There were 24 TDR patients who underwent a repeated anterior retroperitoneal approach, with 22 (91.7%) having had a successful removal of the prosthesis. Seven of the 24 TDR prostheses requiring removal were revised to another CHARITE Artificial Disc. The mean time to reoperation in all patients was 9.7 months. A total of 29 patients (4.9%) in the TDR group required posterior instrumentation and fusion as did 10 (10.1%) in the control group (P = 0.0562). At 2 years or more follow-up, 93.9%(553/589 = 93.9%) of patients receiving TDR with the CHARITE Artificial Disc had a successfully functioning prosthesis with a mean of over 7 degrees of flexion-extension mobility. Lumbar TDR with the CHARITE Artificial Disc did not preclude any further procedures at the index level during primary insertion, with nearly one third being revisable to a new motion-preserving prosthesis and just over two thirds being successfully converted to ALIF and/ or posterior pedicle screw arthrodesis, the original alternative procedure.

Clinical and Radiological Outcomes With the Charité™ Artificial Disc

This is the first report of clinical and radiologic outcomes for the CHARITE artificial disc with a minimum follow-up of 10 years. A total of 107 patients indicated for total lumbar disc replacement were implanted with the CHARITE prosthesis. Of these 107, 100 were followed for a minimum of 10 years (range 10-13.4 years). A total of 147 prostheses were implanted with 54 one-level and 45 two-level procedures and 1 three-level procedure. The prostheses were placed through a standard anterior retroperitoneal approach. Clinically, 62% had an excellent outcome, 28% had a good outcome, and 10% had a poor outcome. Of the 95 eligible to return to work, 88 (91.5%) either returned to the same job as prior to surgery or a different job. These included 63.2% (12) of those working in heavy labor employment returning to the same job. Mean flexion/extension motion was 10.3 degrees for all levels (12.0 degrees at L3-L4, 9.6 degrees at L4-L5, 9.2 degrees at L5-S1). Mean lateral motion was 5.4 degrees . In the sagittal plane, 9 (6.1%) were anterior of geometric center, 50 (34.0%) were centered, and 88 (59.9%) were posterior of center. In the frontal plane, 110 (75%) were centered, and 37 (25%) were noted to be lateral to center. Slight subsidence was observed in two patients, but they did not require further surgery. No subluxation of the prostheses and no cases of spontaneous arthrodesis were identified. There was one case of disc height loss of 1 mm. Five patients required a secondary posterior arthrodesis. A good or excellent clinical outcome rate of 90% and a return to work rate of 91.5% compare favorably with results described in the literature for fusion for the treatment of lumbar degenerative disc disease. With a minimum follow-up of 10 years, the CHARITE artificial disc demonstrated excellent flexion/extension and lateral range of motion with no significant complications.

The mini-invasive anterior extra peritoneal approach to the pelvis

Retroperitoneal pelvic tumours are rare and their surgical approach is challenging. Various surgical approaches have been proposed. We present here an original mini-invasive anterior retroperitoneal approach the pelvic retroperitoneum, which was successful in a 26-year-old woman who had a benign schwannoma of the left sacral plexus. This technique presents advantages over other techniques that were considered in this case, as the least invasive and safest procedure.

Evaluation of Autologous Bone Marrow Mesenchymal Stem Cell–Calcium Phosphate Ceramic Composite for Lumbar Fusion in Rhesus Monkey Interbody Fusion Model

Autologous bone marrow mesenchymal stem cell (BMSC)-calcium phosphate ceramic composites were constructed in vitro and implanted as a bone graft substitute for lumbar anterior interbody fusion in rhesus monkeys to determine the osteogenic capacity of the composites. Nine adult rhesus monkeys underwent lumbar L3-L4 and L5-L6 diskectomy and interbody fusion via an anterior retroperitoneal approach. Two fusion sites in each animal were randomly assigned to two of three treatments: autogenous tricortical iliac crest bone graft (autograft group), cell-free ceramic graft (ceramic group), or BMSC-ceramic composite graft (BMSC group). Autologous BMSCs were expanded in culture and stimulated with osteogenic supplement. The spinal fusion segments were evaluated by radiography, biomechanical testing, histologic analysis, and histomorphometric analysis 3 months postsurgery. The BMSC group achieved lumbar interbody fusion superior to that of the ceramic group, both biomechanically and histologically. The BMSC group and the autograft group showed equivalent biomechanical stiffness. Ceramic residues were significantly greater in the ceramic group versus the BMSC group. The results indicate that BMSC-ceramic composites can enhance bone regeneration and achieve osseous spinal fusion 3 months after implantation in the rhesus monkey interbody fusion model.

Bilateral occlusion of common iliac artery following anterior retroperitoneal approach for lumbar fracture instrumentation

There are only four reports on unilateral occlusion of the common iliac artery following ipsilateral anterior retroperitoneal approach to the lumbar spine. To the authors' knowledge, there are no previous reports on delayed bilateral iliac artery occlusion following retroperitoneal approach. We report on a rare case of a 37-year-old paraplegic man who sought this department with bilateral iliac artery occlusion and simultaneous unilateral thromboembolism to the left popliteal artery. The problem occurred following retroperitoneal approach for instrumentation of an L2 fracture performed 2 years ago. The left leg was amputated above the knee because of gangrene, while a left-sided abdominal-to-femoral artery bypass was performed to salvage the right leg. Six months later, the right leg was amputated below the knee because the patient was admitted again with gangrene of his right foot. Following that, the loosened anterior hardware was removed via a right retroperitoneal approach. Revision surgery revealed an apposition of the common iliac vessels from the loosened hardware, while the vertebral bodies at the affected area were severely osteoporotic. Spine surgeons should be aware for the appearance of this disastrous complication following anterior retroperitoneal surgery in patients with loss of sensation in the lower extremities who do not present subjective symptoms of ischemia. The presence of hardware loosening and migration, loss of correction and pseudarthrosis are the warning signs for diagnosis of such a complication.

Staged Thoracic and Abdominal Aortic Aneurysm Repair Using Stent Graft Technology and Surgery in a Patient with Acute Renal Failure

A 52-year-old male presented with severe hypertension and acute renal failure. Carbon dioxide (CO(2)) angiography identified a saccular thoracic aortic aneurysm, right renal artery stenosis, left renal artery occlusion, an infrarenal aortic aneurysm, celiac artery, and inferior mesenteric artery (IMA) orificial stenoses. Via an anterior retroperitoneal approach, bilateral renal artery thromboendarterectomy, infrarenal aortic aneurysmectomy, and IMA reimplantation were performed. The patient's tortuous iliac arteries were straightened to permit future passage of a thoracic stent graft by mobilizing the aortic bifurcation and anastomosing it to a Dacron graft within 4 cm of the renal vessels. Two weeks later, a stent graft was placed via a femoral incision utilizing CO(2) angiography, successfully excluding the saccular thoracic aneurysm. Recovery from both procedures was quick, with rapid return of renal function, and alleviation of the hypertension. At 8 months follow-up, his renal arteries and aorta are patent.

Anterior-Retroperitoneal Living Donor Nephrectomy: Technique and Outcomes

Of 133 consecutive renal transplants, 61 (46%) were living donor grafts recovered in an anterior-retroperitoneal approach. Donor demographics, operative-anesthetic care, length of stay (LOS), hospital charges, and complications were reviewed with donor and recipient follow-up of 4 to 40 months. Donors included 35 women and 26 men, ages 22 to 61 years (mean, 42.2); thirty-nine were living related and 22 were living unrelated donors. Pretransplant evaluation defined renal anatomy and function (minimal creatinine clearance, 75 cc/minute). Hospital admission occurred the morning of donation. Nephrectomy by the anterior-retroperitoneal approach (no rib resection) was followed by postoperative epidural pain control, early resumption of diet, progressive ambulation, and aggressive pulmonary care. Operating room time door-to-door averaged 2 hours, 43 minutes (range, 1 hour, 45 minutes-3 hours, 55 minutes). Donors were hospitalized for 2 (n = 7), 3 (n = 24), 4 (n = 19), and 5 to 8 (n = 11) days (mean LOS, 3.75; range, 2-8 days). The mean charge for donor hospitalization was $15,329 (range, $10,808-$29,579). One donor required transfusion; another was readmitted for wound drainage and pneumonia treated medically. All donors remain well with normal renal function. One early graft loss (3 days) occurred from arterial intimal dissection; all others gained life-sustaining function. Recipient (98%) and graft (92%) survival was excellent at 4 to 40 months. Anterior-retroperitoneal living donor nephrectomy is safe and effective, permitting hospital LOS of usually <4 days, early recovery, and no lasting complications. Excellent donor and recipient results from this procedure should compel critical assessment of techniques requiring more extensive operative exposure or more costly operating room and hospital approaches to donor surgical management.

Minimally invasive anterior retroperitoneal approach to the lumbar spine. Emphasis on the lateral BAK.

Eighteen patients with lumbar instability from fractures, postlaminectomy syndrome, or infection were treated prospectively with minimally invasive retroperitoneal lumbar fusions. To determine if interbody Bagby and Kuslich fusion cages and femoral allograft bone dowels can be inserted in a transverse direction via a lateral endoscopic retroperitoneal approach to achieve spinal stability. Endoscopic spinal approaches have been used to achieve lower lumbar fusion when instrumentation is placed through a laparoscopic, transperitoneal route. However, complications of using this approach include postoperative intra-abdominal adhesions, retrograde ejaculation, great vessel injury, and implant migration. This study is the first clinical series investigating the use of the lateral retroperitoneal minimally invasive approach for lumbar fusions from L1 to L5. Eighteen patients underwent anterior interbody decompression and/or stabilization via endoscopic retroperitoneal approaches. In most cases, three 12-mm portals were used. Two parallel transverse interbody cages restored the neuroforaminal height and the desired amount of lumbar lordosis was achieved by inserting a larger anterior cage, distraction plug, or bone dowel. The overall morbidity of the procedure was lower than that associated with traditional "open" retroperitoneal or laparotomy techniques, with a mean length of hospital stay of 2.9 days (range, outpatient procedure to 5 days). The mean estimated intraoperative blood loss was 205 cc (range, 25-1000 cc). There were no cases of implant migration, significant subsidence, or pseudoarthrosis at mean follow-up examination of 24.3 months (range, 12-40 months) after surgery. This preliminary study of 18 patients illustrates that endoscopic techniques can be applied effectively through a retroperitoneal approach with the patient in the lateral position. Unlike the patients who had undergone transperitoneal procedures described in previous reports, in these preliminary 18 patients, there were no cases of retrograde ejaculation, injury to the great vessels, or implant migration.

Iliacus Abscess

Iliacus muscle abscess originating from the sacroiliac joint was diagnosed prior to operation in a 13-year-old boy with the assistance of technetium-99m bone imaging and computerized tomography. Pre-operative identification of the iliacus abscess enabled the surgeon to select an anterior (apophyseal splitting) retroperitoneal approach, which permitted drainage of both the ilium and the iliacus muscle.