Anterior Lumbal Surgery Approach- Arief.pptx

Anterior Lumbal Surgery

1. Anterior Lumbar Surgery d r. Muhammad Arief Munandhar Ilmiah Spine

2. I NTRODUCTION Anterior Lumbar Interbody Fusion (ALIF) Indication : Any lumbar abnormalities including protrusion, degenerative condition, inflammation, etc. Jian-gang Shi, Wen Yuan JS. Surgical Anatomy of the Thoracic Spine. In: Anatomy Atlas and Interpretation of Spine Surgery. Springer International Publishing; 2018. p. 133-148 .

3. Lumbar Intervertebral Disc Protrusion (Including Recurrent Lumbar Disc Herniation) Lumbar Instability Lumbar Degeneration And Lumbar Isthmic Spondylolisthesis Tumors (Primary Or Metastatic) On The Distal Lumbar Or Sacral Spine, Lumbar Or Sacral Inflammation (Tuberculous Or Purulent) Lumbar Spinal Trauma. Main Indication of ALIF Jian-gang Shi, Wen Yuan JS. Surgical Anatomy of the Thoracic Spine. In: Anatomy Atlas and Interpretation of Spine Surgery. Springer International Publishing; 2018. p. 133-148 .

4. ALIF Very important and necessary Preoperative CT or MRI examination Function : Determine the anatomy among the abdominal aorta, vena cava, and iliac vessels in the segments requiring surgery Jian-gang Shi, Wen Yuan JS. Surgical Anatomy of the Thoracic Spine. In: Anatomy Atlas and Interpretation of Spine Surgery. Springer International Publishing; 2018. p. 133-148 .

5. General anesthesia thus patients placed supine D etermination level of surgery  done using C-arm fluoroscopy POSITION POSITIONING THE PATIENT Position and incision for exposure of the lumbar spine via the paramedian retroperitoneal approach Jian-gang Shi, Wen Yuan JS. Surgical Anatomy of the Thoracic Spine. In: Anatomy Atlas and Interpretation of Spine Surgery. Springer International Publishing; 2018. p. 133-148 .

6. POSITION For exposure one / two levels Use the Transverse skin incision  made from the midline to the lateral border of the rectus abdominis For exposure one / two/ more levels Use the slightly curved longitudinal incision  centered over the lateral border of the rectus abdominis Exposure of the anterior rectus fascia Jian-gang Shi, Wen Yuan JS. Surgical Anatomy of the Thoracic Spine. In: Anatomy Atlas and Interpretation of Spine Surgery. Springer International Publishing; 2018. p. 133-148 .

7. Palpated t he lateral border of the rectus abdominis EXPOSURE : anterior rectus fascia is incised Retract the rectus muscles medially, thus expose posterior rectus fascia and transversalis fascia. Inferior epigastric vessel  ligated / protected with moisture drape and retract laterally Jian-gang Shi, Wen Yuan JS. Surgical Anatomy of the Thoracic Spine. In: Anatomy Atlas and Interpretation of Spine Surgery. Springer International Publishing; 2018. p. 133-148 .

8. Incised the transversalis fascia  exposed peritoneal fat and peritoneum EXPOSURE The incision should not be lower than the inferior epigastric vessel Exposure of the preperitoneal fat Jian-gang Shi, Wen Yuan JS. Surgical Anatomy of the Thoracic Spine. In: Anatomy Atlas and Interpretation of Spine Surgery. Springer International Publishing; 2018. p. 133-148 .

9. Bluntly separate the retroperitoneal space until it reaches the anterior vertebrae EXPOSURE Retract the peritoneum and the abdominal viscera to the medial side. Should be ligated and cut close to the vena cava and aorta Segmental Vessels Retroperitoneal space of the lumbosacral level Jian-gang Shi, Wen Yuan JS. Surgical Anatomy of the Thoracic Spine. In: Anatomy Atlas and Interpretation of Spine Surgery. Springer International Publishing; 2018. p. 133-148 .

10. If the L4/L5 disc space is to be exposed, all the branches of the left common iliac vein must be ligated and cut to enable the movement of the common iliac vein EXPOSURE If the exposure is to L5/S1, there is no need to mobilize the iliac vessels; however, ligation and transection of the middle sacral artery and vein are needed Exposure of the anatomic structure of the anterior vertebral body Jian-gang Shi, Wen Yuan JS. Surgical Anatomy of the Thoracic Spine. In: Anatomy Atlas and Interpretation of Spine Surgery. Springer International Publishing; 2018. p. 133-148 .

11. The superior hypogastric plexus is bluntly dissected to either side of the vertebral body. EXPOSURE : CAUTION During surgery, DO NOT use an electrotome under the aortic bifurcation to prevent the superior hypogastric plexus from being injured. Jian-gang Shi, Wen Yuan JS. Surgical Anatomy of the Thoracic Spine. In: Anatomy Atlas and Interpretation of Spine Surgery. Springer International Publishing; 2018. p. 133-148 .

12. Incise the anterior annulus fibrosus  using long handle blade Remove the disc contents  using rongeurs and curettes DISCECTOMY Jian-gang Shi, Wen Yuan JS. Surgical Anatomy of the Thoracic Spine. In: Anatomy Atlas and Interpretation of Spine Surgery. Springer International Publishing; 2018. p. 133-148 .

13. DISCECTOMY Use a shaver to prepare the end plate to gain a mild bleeding end plate for bone graft and fusion. The intervertebral fusion cage with a proper size and graft bones is placed into the intervertebral disc. FUSION Jian-gang Shi, Wen Yuan JS. Surgical Anatomy of the Thoracic Spine. In: Anatomy Atlas and Interpretation of Spine Surgery. Springer International Publishing; 2018. p. 133-148 .

14. Left : Placement of an intervertebral fusion cage (anteroposterior fluoroscopy) Right : Placement of an intervertebral fusion cage (lateral fluoroscopy) The anteroposterior fluoroscopy and lateral fluoroscopy show the anterior intervertebral fusion cage is located well Jian-gang Shi, Wen Yuan JS. Surgical Anatomy of the Thoracic Spine. In: Anatomy Atlas and Interpretation of Spine Surgery. Springer International Publishing; 2018. p. 133-148 .

15. Abdominal Fascia / Sheath Including anterior sheath of the rectus abdominis muscle, the rectus abdominis muscle, the posterior sheath of the rectus abdominis muscle, and the peritoneum RELATED ANATOMY OF ALIF Common Iliac Arteries Consists of of three or four ganglions and interganglionic branches Lumbar Sympathetic Trunk Origins : abdominal aorta at the level of the L4 vertebral body or L4–L5 intervertebral disc and end in front of the sacroiliac joint 03 01 02 Jian-gang Shi, Wen Yuan JS. Surgical Anatomy of the Thoracic Spine. In: Anatomy Atlas and Interpretation of Spine Surgery. Springer International Publishing; 2018. p. 133-148 .

16. The anterior sheath of the rectus abdominis muscle  the rectus abdominis muscle  the posterior sheath of the rectus abdominis muscle  peritoneum Abdominal Fascia / Sheath Jian-gang Shi, Wen Yuan JS. Surgical Anatomy of the Thoracic Spine. In: Anatomy Atlas and Interpretation of Spine Surgery. Springer International Publishing; 2018. p. 133-148 .

17. COMMON ILIAC ARTERIES COMMON ILIAC ARTERIES INTERNAL ILIAC ARTERIES EXTERNAL ILIAC ARTERIES Run in the deep surface of the parietal peritoneum, and there are ureters and the genital gland vessels run in front of them Jian-gang Shi, Wen Yuan JS. Surgical Anatomy of the Thoracic Spine. In: Anatomy Atlas and Interpretation of Spine Surgery. Springer International Publishing; 2018. p. 133-148 .

18. Lumbar Sympathetic Trunk Located between the vertebral column and the psoas major muscle and covered by the prevertebral fascia. Jian-gang Shi, Wen Yuan JS. Surgical Anatomy of the Thoracic Spine. In: Anatomy Atlas and Interpretation of Spine Surgery. Springer International Publishing; 2018. p. 133-148 .

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