Principles of Urologic Surgery: Incisions and Access

Question 1

The traditional pelvic Gibson incision is an ___ or ____ incision from a few centimeters medial to the anterior ____ extending down toward the inguinal fold and terminating just lateral to the____ or continued to above the____

Answer 1

The traditional pelvic Gibson incision is an oblique or curvilinear incision from a few centimeters medial to the anterior superior iliac spine (ASIS) extending down toward the inguinal fold and terminating just lateral to the rectus muscle or continued to above the symphysis pubis

Question 2

For midline incisions, One should identify by palpation the ____, the aponeuroses of the abdominal wall muscles in the midline, and incise along it to avoid cutting through the rectus abdominus muscle.

Answer 2

One should identify by palpation the linea alba, the aponeuroses of the abdominal wall muscles in the midline, and incise along it to avoid cutting through the rectus abdominus muscle.

Question 3

what vessels to avoid during abdominal incisions

Answer 3

1. Lateral cutaneous nerves
2. Anterior cutaneuos perforating nerves

3 Superficial epigastric artery and vein

4, inferior epigastric artery and vein

5. Lumbar artery and nerve
6. subcostal artery
7. Thoracic artery and nerve

4

Question 4

types of flank approach incision

Answer 4

1. 12th rib supracostal
2. 11th rib transcostal
3. thoracoabdominal
4. foley muscle splitting
5. flank subcostal

Question 5

Positioning for dorsal lumbotomy position. The position of the patient on the operating table is important and is characterized by three main features. The laterolateral axis makes a____ with the operating table. It is not necessary for the table to be bent too much because the muscles do not need to be stretched; on the contrary, it is better if they are relaxed to allow easier retraction. The thorax is turned ___ and the pelvis ___ to allow a better opening of the ___ space. The legs and the upper arm are positioned as usual for a flank incision.

Answer 5

Positioning for dorsal lumbotomy position. The position of the patient on the operating table is important and is characterized by three main features. The laterolateral axis makes a 45-degree angle with the operating table. It is not necessary for the table to be bent too much because the muscles do not need to be stretched; on the contrary, it is better if they are relaxed to allow easier retraction. The thorax is turned ventrally and the pelvis dorsally to allow a better opening of the dorsolumbar space. The legs and the upper arm are positioned as usual for a flank incision.

Question 6

The only contraindication to a scrotal incision is ___ or ____, which should be approached through an____

Answer 6

The only contraindication to a scrotal incision is presumed testicular or intrascrotal malignancy, which should be approached through an inguinal incision

Question 7

Perineal incisions are most commonly used as an approach to the __ and ___

Answer 7

Perineal incisions are most commonly used as an approach to the proximal urethra and base of the penis.

Question 8

The radical perineal prostatectomy is done through a large ____. The apex of the incision is about ___cm from the ___, and the ____ are used as landmarks.

Answer 8

The radical perineal prostatectomy is done through a large inverted horseshoe incision. The apex of the incision is about 2 cm from the anal verge, and the ischial tuberosities are used as landmarks.

Question 9

Which of the following is not considered an indication for an open abdominal approach (as opposed to minimally invasive)?

a. Multiple prior abdominal surgeries b. Complex renal mass with caval thrombus c. Previous abdominal hernia repair with mesh d. Patient with multiple comorbidities e. Surgeon’s preference and experience

Answer 9

d. Patient with multiple comorbidities. With an aging and more complex population, having multiple comorbidities on its own is not an indication for open surgery compared to minimally invasive surgery. Answers a, b, c, and e are all considered relative indications for open surgery. Patients with multiple previous abdominal procedures are more likely to have adhesions and difficulties establishing a pneumoperitoneum. Complicated renal tumors with caval thrombi, although possible to do laparoscopically, should be considered for open surgery. A large abdominal wall mesh could significantly complicate a minimally invasive approach, and surgeon skill and preference is another important consideration for an open approach

Question 10

Following a motor vehicle crash (MVC), a 35-year-old male is found to have a significant right-sided renal hilar injury on imaging. He becomes hemodynamically unstable, despite intravenous fluid resuscitation and massive transfusion protocol. The decision is made to take him to the OR. What incision should you use?

a. Flank incision b. Complete midline incision c. Chevron incision d. Subcostal incision e. Thoracoabdominal incision

Answer 10

b. Complete midline incision. Trauma nephrectomies should always be approached with a laparotomy or complete midline incision. The other approaches would not be appropriate in this clinical setting.

Question 11

Which approach of abdominal wall fascial closure has been shown to have a higher rate of abdominal wall hernias?

a. Rapidly absorbable suture, running continuous closure b. Rapidly absorbable suture, interrupted closure c. Slowly absorbable suture, running continuous closure d. Slowly absorbable suture, interrupted closure

Answer 11

. a. Rapidly absorbable suture, running continuous closure. In a 2002 meta-analysis of closure techniques for midline abdominal incisions, Riet et al. found that continuous rapidly absorbable sutures had significantly more incisional hernias than slowly absorbable or non-absorbable sutures. No difference in hernia rates between slowly absorbable and non-absorbable sutures

Question 12

A 25-year-old patient has been cleared to donate her left kidney to her cousin who recently was started on dialysis for end-stage renal disease. She is seeing you for pre-surgical consultation. You inform her you will be performing the nephrectomy laparoscopically and will be extracting the kidney through ___________ because this has been shown to have _________. a. extension of the inferior port site; lower morbidity and incisional hernia rates b. extension of the midline port site; decreased pain scores and complications c. pfannenstiel incision; lower morbidity and incisional hernia rates d. pfannenstiel incision; decreased pain scores and complications e. extension of the superior most port site; decreased pain scores and complications

Answer 12

c. Pfannenstiel incision; lower morbidity and incisional hernia rates. A prospective study comparing Pfannenstiel incision versus port site expansion for nephrectomies showed that morbidity and length of stay were shorter in the pfannensteil group, while a metaanalysis for extractions in laparoscopic bowel surgery showed lower hernia rates with pfannensteil

Question 13

A 45-year-old female had deceased donor renal transplant placed 5 years ago. She has been noncompliant with immunosuppressive medications and the allograft has failed. She has developed periallograft abscess, and the allograft must be removed. Which incision is best for renal allograft nephrectomy? a. Lower midline b. Inguinal incision c. Subcostal incision d. Gibson incision e. Flank incision

Answer 13

d. Gibson incision. Renal transplants and renal allograft nephrectomies are performed through a traditional Gibson incision, which gives extraperitoneal access to the iliac vessels and bladder.

Question 14

Which of the following is NOT an advantage of the thoracoabdominal incision as an approach to large renal tumors? a. Exposure of adjacent thorax b. Exposure of retroperitoneum c. Early vascular control d. Large incision e. Access to inferior vena cava (IVC) for advanced disease/caval thrombus

Answer 14

d. Large incision. The thoracoabdominal incision, although considered to be a large invasive incision, provides the added benefit of significantly improved exposure, ability to achieve early vascular control, and access to major vessels (including the IVC) and organs for advanced renal tumors.

Question 15

Which is the second muscle layer incised in a typical flank incision? a. External oblique b. Internal oblique c. Serratus anterior d. Latissimus dorsi e. Transversalis

Answer 15

b. Internal oblique. The muscle and fascial layers encountered in a traditional flank incision, from skin to abdomen, are the external oblique, internal oblique, and transversalis muscles

Question 16

Which of the following is not considered a true flank incision approach? a. 12th rib supracostal b. 11th rib transcostal c. Subcostal d. 9th rib supracostal

Answer 16

d. 9th rib supracostal. True flank incisions include the 12th rib supracostal, 11th rib transcostal, and subcostal approaches. Going above this level is often in the context of a thoraco-abdominal incision rather than a true flank incision.

Question 17

Which nerve must be carefully handled to avoid injury during surgery in the inguinal canal? a. Femoral nerve b. Sciatic nerve c. Genitofemoral nerve d. Ilioinguinal nerve e. Lateral femoral cutaneous nerve

Answer 17

d. Ilioinguinal nerve. The ilioinguinal nerve runs in the inguinal canal alongside the spermatic cord and should be identified upon opening and closure of an inguinal incision above the inguinal ligament. The genital branch of the genitofemoral nerve is present with the cord structures but is not exposed in the inguinal canal. The other nerves listed do not run through the inguinal canal.

Question 18

Which incision was used for the first-ever planned nephrectomy? a. Thoracoabdominal incision b. Flank incision c. Posterior lumbodorsal incision d. Subcostal incision e. Gibson incision

Answer 18

c. Posterior lumbodorsal incision. The first-ever planned nephrectomy was performed in 1870 through a posterior lumbodorsal incision by Simon. This incision had multiple benefits over other open approaches. These include lack of muscle or rib distortion, faster convalescence, and decreased intra-peritoneal complications.

Question 19

Which are NOT considered benefits of the dorsal lumbotomy approach compared to flank incisions? a. Rib and muscle sparing b. Less postoperative pain c. Decreased hospitalization d. Better surgical exposure for vascular control e. Decreased intra-peritoneal complications

Answer 19

d. Better surgical exposure for vascular control. The dorsal lumbotomy approach, although not as common now, did boast multiple advantages over subcostal or anterior abdominal approaches. These include faster convalescence, less pain, less musculoskeletal complications (flank bulge), decreased hospitalization, and less intra-peritoneal complications. The major disadvantage was limited surgical exposure to the renal hilum and vessels for vascular control.

Question 20

Which of the following is NOT a border of the lumbodorsal region? a. 12th rib–superiorly b. Quadratus lumborum–inferiorly c. Spinal processes–medially d. Iliac crest–inferiorly e. Line between anterior superior iliac spine (ASIS) and costal margin–laterally

Answer 20

b. Quadratus lumborum–inferiorly. The borders of the lumbodorsal region are the 12th rib superiorly, iliac crest inferiorly, spinous processes of vertebral columns medially, and a line between the ASIS (anterior superior iliac spine) and costal margin laterally. The incision is generally made directly over the quadratus lumborum, but it is not a border of this region.

Question 21

4. Which superficial muscles are NOT encountered during a dorsal lumbotomy approach?
   a. Internal oblique b. External oblique c. Latissimus dorsi d. Sacrospinalis e. Quadratus lumborom

Answer 21

a. Internal oblique. The superficial muscles encountered are the sacrospinalis (medially), latissimus dorsi (posteriorly), and external oblique (anteriorly). The incision is deepened through the lumbodorsal fascia where the sacrospinalis muscle is encountered and a “Y” should be made around it