Twelfth Rib Approach

Abstract

The 12th rib resection with flank incision was developed to allow better exposure of the kidney (Fig. 22.1).1^–3 The 12th rib and its periosteal bed are joined at the rib’s tip by the insertion of the diaphragm and of the transversus abdominis fascia and muscle. They form an anchoring point to resist cephalad retraction. By removing the 12th rib, opening the 12th rib bed, and freeing the muscle insertions of the tip of the 12th rib, one has greater exposure for cephalad retraction when exposing the kidney, retroperitoneal space, or spine. Resection of the rib and the periosteum of the rib bed allows release of the posterior lumbocostal ligament, which is a strong tether against cephalad retraction, and frees the fibers of the internal/external oblique muscles. With the added exposure, the L1 vertebral body and distal segments can be adequately visualized.