1438 



SUKFACE AND SUKGICAL ANATOMY. 



Exposure of Kidney from behind. In exposing the kidney from the loin, 

 by a vertical incision between the lateral border of the sacrospinalis and the free 

 posterior border of the external oblique muscle, the following structures are 

 divided from without inwards: (1) the integuments; (2) the lower fibres of the 

 latissimus dorsi and serratus posterior inferior muscles ; (3) the middle layer of the 

 lumbar aponeurosis, just lateral to the sacrospinalis compartment, and parallel to the 

 lateral fibres of the quadratus lumborum muscles ; (4) the anterior layer of the lumbar 

 aponeurosis (which forms the aponeurotic origin of the transversus muscles), and the 

 transversalis fascia ; (5) the paranephric fat ; (6) the perinephric fascia ; (7) the 

 perinephric fat surrounding the true capsule of the kidney. The kidney may be 

 readily mobilised and brought to the surface by shelling it out of its fatty capsule 



Rib IX 



RibX 



Rib XI 

 Descending colon 



Rib IX 



RibX 



Rib XI 



Ascending colon 



FIG. 1109. DISSECTION OF THE SPLEEN, LIVER, AND KIDNEYS FROM BEHIND, IN A SUBJECT HARDENED BY 

 FORMALIN INJECTION. (From Cunningham.) 



with the finger. Better access to the renal vessels can be obtained if the incision is 

 made a little nearer the median plane, so as to open into the sacrospinalis compart- 

 ment. This allows of the muscle itself being retracted medially more efficiently. 



In exposing the kidney by an oblique incision in the loin, the latissimus dorsi 

 and serratus posterior inferior muscles are divided at the medial part of the 

 wound, while at its lateral part the posterior fibres of the external and internal 

 oblique muscles are divided; next, the aponeurotic origin of the transversus 

 muscle and the transversalis fascia are split so as to expose the extra-peritoneal 

 fat and the peritoneum, as it is reflected from the ascending colon on to the* 

 lateral aspect of the abdominal wall. The latter structures are then stripped 

 forwards and medially off the anterior surface of the kidney, until the hilum and 

 renal vessels are reached. The sacrospinalis and quadratus lumborum muscles 

 are retracted well medially, and it is often necessary to divide the lateral fibres 

 of the quadratus muscle. 



