So you stand on the right side of the patient, you have made the roof-top incision and you are inside the peritoneal cavity. The lower skin flap of the incision has been tacked down on the right iliac fossa skin and you have to carry on. How do you proceed?

Step No 1: Find your way

Using your left hand, grab the sigmoid colon, pull it gently towards the patient’s midline and recognise the left parabolic grove of Toldt. Using a pair of Metzenbaum scissors, sharply divide the peritoneum just at the border of the sigmoid colon and the parietal peritoneum. Carry on downwards, until the total sigmoid colon has been mobilised. Similarly, carry on upwards, parallel to the descending colon until you recognise the spleen.

Step No 2: Identify the aorta

Pull slightly the sigmoid and the descending colon until you recognise the left psoas muscle. A bit more medially, you will feel the abdominal aorta. Looking a bit lower down, you will easily recognise the left common iliac artery which you can dissect, and pass an elastic sling around it.

Step No 3: Make your retrorenal space to the diaphragm

Now, you need to mobilize everything to the right. However, the spleen is attached on the diaphragm and there is always the danger of capsule tear. How do you proceed? Easy-peasy. Put you right palm just over the left psoas muscle and move it slightly upwards. There is nothing to fear about. Your hand is moving on an avascular area behind the left kidney, until you come to the end: the diaphragm. That’s it you have created the retrorenal space up to the diaphragm.

Step No 4: Mobilise everything to the right

Now, everything needs to get moved to the right. With your left hand, pull gently the spleen and with a pair of scissors sharply divide all the splenophrenic ligament (actually all the attachments of the spleen with the diaphragm). As long as you have dissected the posterior part of the left kidney (see Step No 3), now everything can roll easily to the patient’s right: spleen, stomach, pancreas, left kidney. Some attachments of the stomach and oesophagus to the diaphragm still exist which you just need similarly divide. Put a wet swab on the top of spleen and you are almost there.

Next: Aortic dissection

Previous: Skin incision

The roof top approach to the suprarenal aorta

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