Abstract
The indications for laparoscopic retroperitoneal surgery have recently been greatly extended and the technique has become popular, but concomitant pleural injury or pneumothorax has been reported from numerous hospitals in Japan. Which anatomical information is useful to avoid surgical injury of the suggested weak portion of the diaphragm? We identified a diaphragm-free triangular area or Bochdalek’s triangle in 90.1% of elderly Japanese cadavers (100/111 cadavers), comprising about 622.8 mm2 in area (height 47.9 mm, base 25.0 mm). In most cases (80.1%; 129/161), the entire triangle was restricted to the superior side of the 12th rib in addition to the medial side of the distal end of the rib. A “potential foramen” (PF) was defined as the diaphragm-free triangle >100 mm2 in area on the parietal pleura. Most triangles (77.6%, 125/161) met this criterion. The PF was often covered by the kidney (93.3%), and had a mean area of 318.9 mm2. The PF was located 42.3 mm from the distal end of the 12th rib, while the inferior pleural margin was 27.8 mm superior to the rib end. When the triangle was large, the PF was also large, with the PF often occupying >50% of the triangle area (62/125; 49.6%). To avoid the distal end of the 12th rib, in laparoscopic retroperitoneal surgery, we recommend making a transverse skin incision at the midpoint between the end of the 12th rib and the iliac crest.
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References
Aoki M, Suzuki K, Hirano T et al (2003) Surgical result classified by tumor size in laparoscopic adrenalectomy. Naibunpitugeka 20:187–190
Arenson AM, McKee JD, Taylor I (1985) Hypertrophied muscular bands in the region of the foramen of Bochdalek as a cause for an accessory fissure within the liver. Ultrasound Med Biol 11:461–465
Azocar RJ, Rios JR, Hassan M (2002) Spontaneous pneumothorax during laparoscopic adrenalectomy secondary to a congenital diaphragmatic defect. J Clin Anesth 14:365–367
Baba S, Ito K, Yanaihara H et al (1999) Retroperitoneoscopic adrenalectomy by a lumbodorsal approach: clinical experience with solo surgery. World J Urol 17:54–58
Baba S, Iwamura M (2003) Retroperitoneal and lateral approach. In: Matsuda T (ed), Urological Laparoscopic Surgery, Tokyo, Medical View, 56
Blake D, Hamilton M (2000) Laparoscopic adrenalectomy: transperitoneal and retroperitoneal approaches. In: Bishoff JT (ed) Atlas of laparoscopic retroperitoneal surgery. WB Saunders Company, Philadelphia, p 197
Bolli M, Oertli D, Staub JJ et al (2002) Laparoscopic adrenalectomy: the new standard? Swiss Med Wkly 132:12–16
Cohen EL, Kim SW, Schanzer H et al (1985) Living-related donor nephrectomy by eleventh rib intraperitoneal extrapleural incision. Urology 25:579–581
deAbreu SC, Gill IS (2003) Laparoscopic radical nephrectomy: retroperitoneal approach. In: Nakada S (ed) Essential urologic laparoscopy. Humana Press, New Jersey, p 109
del Pizzo JJ, Jacobs SC, Bishoff JT et al (2003) Pleural injury during laparoscopic renal surgery: early recognition and management. J. Urol 169:41–44
Deviri E, Nathan H, Luchansky E (1988) Medial and lateral arcuate ligaments of the diaphragm: attachment to the transverse process. Anat Anz 166:63–67
Ferner H (1964) Pernkopf Atlas of topographical and applied human anatomy, 2nd edn. Saunders Company, Philadelphia, p 44
Gill IS (1997) Retroperitoneal laparoscopic nephrectomy. Urol Clin North Am 25:343–360
Greenfield LJ (1993) Surgery: scientific principles and practice. Lippincott-Raven Publishers, Philadelphia, p 1122
Habuchi T (2003) Retroperitoneal and lateral approach. In: Matsuda T (ed), Urological laparoscopic surgery. Tokyo, Medical View, p 43
Henry JF, Defechereux T, Raffaelli M et al (2000) Complications of laparoscopic adrenalectomy: results of 169 consecutive procedures. World J Surg 24:1342–1346
Kato H, Nishizawa O (2001) Supracostal approach: an excellent exposure for renal and adrenal surgery. Acta Urol Jpn 47:449–452
Kawahara G, Sugiyama G, Kitai T et al (1968) A topographic anatomical study of trigonum lumbocostale of the diaphragm. Acta Anat Jpn 43:215–235
Kopsch F (1955) Rauber–Kopsch Lehrbuch und Atlas der Anatomie des Menschen, 19th edn. Georg Thieme Verlag, Stuttgart, p 387
Kumar A, Tripathi DM, Srivastava A (2003) Mini incision live donor nephrectomy: an optimal approach for the developing countries. Clin Transplant 17:498–502
Lee DI, Clayman RV (2004) Use of gelatin matrix to rapidly repair diaphragmatic injury during laparoscopy. Urology 63:419 (author reply)
Lindner HH, Kemprud E (1971) A clinicoanatomical study of the arcuate ligament of the diaphragm. Arch Surg 103:600–605
Martin LM, Donaldson-Hugh ME, Cameron MM (1997) Cerebrospinal fluid hydrothorax caused by transdiaphragmatic migration of a ventriculoperitoneal catheter through the foramen of Bochdalek. Childs Nerv Syst 13:282–284
Mirbaha MM (1973) Anterior approach to the thoraco-lumbar junction of the spine by a retroperitoneal-extrapleural technique. Clin Orthop 91:41–47
Netter FK (2006) Atlas of human anatomy. http://www.netterimages.com./image/list.htm?s=diaphragm, numbers 2067, 2107
Norton JA (1999) Pituitary and adrenal. In: Schwartz SI (ed), Principles of surgery, 7th edn. McGraw-Hill Health, New York, pp 1630–1651
Olsson LE, Swana H, Friedman AL et al (1998) Pleurotomy, pneumothorax, and surveillance during living donor nephroureterectomy. Urology 52:591–593
Raynor RW, DelGuercio LRM (1986) The eleventh rib transcostal incision: an extrapleural, transperitoneal approach to the upper abdomen. Surgery 99:95–101
Romanes G (1972) Cunningham’s textbook of anatomy. Oxford University Press, London, pp 342–343
Saito T, Den S, Tanuma K et al (1999) Anatomical bases for paravertebral anesthetic block: fluid communication between the thoracic and lumbar paravertebral regions. Surg Radiol Anat 21:359–363
Salmons S (1995) Muscles of the thorax. In: Williams P (ed) Gray’s anatomy, 38 edn. Churchill Livingstone, Edinburgh, pp 813–819
Shimada M (1952) Study on the diaphragm in Japanese embryos and new-borns, part 1. Trigonum lumbocostale. J Tokyo Med Univ 3 + 4:1–28
Silverman PM, Cooper C, Zeman RK (1992) Lateral arcuate ligaments of the diaphragm: anatomic variations at abdominal CT. Radiology 185:105–108
Siren J, Haglund C, Haapiainen R (2000) An institutional experience with 40 first lateral transperitoneal laparoscopic adrenalectomies. Surg Laparosc Endosc Percutan Tech 10:382–386
Standring S, Ellis H, Healy J, Johnson D, Williams A (2005) Gray’s anatomy, 39th edn. Elsevier Churchill Livingstone, London, pp 1082–1083, 1093
Sung GT, Hsu TH, Gill IS (2001). Retroperitoneoscopic adrenalectomy: lateral approach. J Endourol 15:505–511
Sung GT, Gill IS (2002) Anatomic landmarks and time management during retroperitoneoscopic radical nephrectomy. J Endourol 16:165–169
Terachi T (1997) Anatomy for laparoscopic surgery. In: Ono Y (ed) Surgery of the adrenal and kidney. Tokyo, Medical View, pp 236–239
Toldt C (1903) Anatomischer Atlas, 3rd edn. Urban & Schwarzenberg, Berlin, p 286
Townsend CM (2001) Textbook of surgery. W.B. Saunders Company, Philadelphia, pp 690–691
Venkatesh R, Kibel AS, Lee D et al (2002) Rapid resolution of carbon dioxide pneumothorax (capno-thorax) resulting from diaphragmatic injury during laparoscopic nephrectomy. J Urol 167:1387–1388
Walz MK, Peitgen K, Hoermann R et al (1996) Posterior retroperitoneoscopy as a new minimally invasive approach for adrenalectomy: results of 30 adrenalectomies in 27 patients. World J Surg 20:769–74
Waterman BJ, Robinson BC, Snow BW et al (2004) Pneumothorax in pediatric patients after urological laparoscopic surgery: experience with 4 patients. J Urol 171:1256–1258
Yoneda K, Shiba E, Watanabe T et al (2000) Laparoscopic adrenalectomy: lateral transabdominal approach vs. posterior retroperitoneal approach. Biomed Pharmacother 54 (Suppl 1):215–219
Acknowledgments
We are grateful to Professor Yukio Dodo (Tohoku University Scholl of Medicine), Professor Yoshinobu Ide (Tokyo Dental University) and Professor Osamu Amano (Myokai University School of Dentistry) for permission to use cadaveric materials and resources during tight schedules of education.
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Kawada, M., Murakami, G., Yajima, T. et al. Potential foramen to allow communication between the pleural cavity and retroperitoneal space during laparoscopic surgery: a cadaver study of Bochdalek’s triangle. Surg Radiol Anat 29, 105–113 (2007). https://doi.org/10.1007/s00276-007-0186-4
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DOI: https://doi.org/10.1007/s00276-007-0186-4