Surgical repair of the abdominal bulge: Correction of a complication of the flank incision for retroperitoneal surgery

m l m r n r n e n t u he flank incision, a commonly used surgical approach o the retroperitoneum, affords access to the retroperitoeal structures without violating the peritoneal cavity. he incision generally extends from the periumbilical egion to the 11 intercostal space, although variations xist. Common applications include access to the aorta r iliac vessels and to the kidney or proximal ureter. lthough this approach was first described in the 1830s y Sir Astley Cooper, it did not become widely used in ascular surgery until it was reintroduced by Rob in 963 for access to the abdominal aorta. In the current ascular surgery literature, debate continues concerning he superiority of the retroperitoneal or transperitoneal pproach to the abdominal aorta. This debate notithstanding, there is agreement that the retroperitoneal pproach to the aorta is indicated in certain clinical sitations including obesity, multiple earlier laparotomies, orseshoe kidney, and suprarenal aortic aneurysms. In ddition, this incision is one of the preferred approaches o the kidney. Because the flank incision has become more widely sed, its complications have become better recognized. hese complications include local pain, intercostal neuopathy, incisional hernia, and the entity termed abominal or flank bulge or eventration. A flank bulge is ot a hernia because there is no underlying fascial defect. nstead, the protuberance of the abdomen is caused by a axity of the abdominal musculature. This laxity is beieved to be secondary to intercostal nerve injury as the ncision extends laterally toward the intercostal space. n two published series of patients undergoing a retro-