Extraperitoneal approach to the lumbar spine with video assistance

Study Design. Description of a new operative technique for anterior lumbar and lumbosacral fusion using an anterior extraperitoneal approach optimized by video assistance. Objectives. To propose a less invasive technique for anterior lumbar fusion with low-grade morbidity. Summary of Background Data. Either anterior trans-peritoneal or anterolateral extraperitoneal approaches commonly are performed, but each involves specific drawbacks. The authors attempted to modify and simplify these approaches with the addition of retroperitonoscopy. Methods. A small, vertical 4- to 5-cm incision is made on the midline, centered on the umbilicus for the L4-L5 approach and halfway between umbilicus and pubic symphysis for the L5-S1 approach. The peritoneum is dissected from the left abdominal wall, and the anterior aspect of the spine progressively is exposed. The endoscope is introduced laterally, providing excellent visualization of the prevertebral area. A specially designed retractor allows retraction of the iliac vessels. Results. A midline anterior approach allows disc resection and grafting in a strict midline position. The extraperitoneal approach simplifies the postoperative course. Video assistance permits an approach to the spine by a short incision and facilitates the prevertebral dissection. Surgery with video assistance should be differentiated from true endoscopic surgery, which ids performed under CO2 insufflation with exclusive endoscopic vision. Conclusions. Video assistance allows for an anterior extraperitoneal approach to the lumbar spine and has the potential for lower morbidity, increasing the possibilities of anterior fusion in the management of lumber disc disease.