An extrapleural approach with rib removal for the eleventh rib flank incision.

The transcostal extrapleural flank approach to the kidney requires an understanding of the anatomy of the thoracic and abdominal wall 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 aspect of the twelfth rib toward the lumbocostal arch are necessary surgical maneuvers. This should be done prior to the 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 fully the diaphragm as far as the lumbocostal arch prior to placement of the retractor. Precise appreciation of the pericostal anatomy allows the urologic surgeon to remain in the extrapleural space during this commonly used flank incision.