The eleventh rib transcostal incision: technique for an extrapleural approach.

The transcostal extrapleural flank approach to the kidney requires an understanding of thoracic and abdominal wall anatomy to prevent injury to the pleura and subsequent pneumothorax. Isolation of the intercostal neurovascular bundle, division of the lumbodorsal fascia inferior to the rib bed and simultaneous dissection of the diaphragmatic insertion along the superior and posterior aspects of the 12th rib toward the lumbocostal arch are necessary surgical maneuvers before release of the diaphragm, exposure of Gerota's fascia and positioning of a flank retractor. Pneumothorax usually results from attempts to separate the pleura from the diaphragm, dissection within the intercostal space rather than along the diaphragmatic insertions and failure to release the diaphragm fully as far as the lumbocostal arch before placement of the retractor. Precise appreciation of the pericostal anatomy allows the urological surgeon to remain extrapleural during this commonly used flank incision.