[A modified retroperitoneal approach to the kidney in patients with a highly deformed thorax: obtaining a wide operative field through subperiosteal resection of the 10th, 11th and 12th ribs].

We herein report a technique which facilitates a retroperitoneal approach to the kidney in cases of highly deformed thorax due to kyphoscoliosis. The operation consists of a lumbar oblique incision with removal of the 11th rib, combined with the additional removal of the 12th and 10th ribs. Resection of the upper two ribs was performed subperiosteally, leaving the periosteum of the deep side untouched. However, the deep side periosteum of the 12th rib was incised caudal from the pleural margin in order to facilitate exposure of the diaphragm. The retroperitoneal space was entered through the tip of the 11th rib bed. The diaphragm was incised dorso-medially at a level 1 cm caudal from the lower margin of the pleura, to an extent necessary to enable the pleura together with the cranial diaphragm to be manoeuvred in an upward direction. Two cases with renal tuberculosis associated with high-grade kyphosis and one case with staghorn calculi accompanied with lordosis were operated on utilizing this technique. In the former two cases, the thoracic cage was in direct contact with the iliac bone and there was practically no space between the rib border and the iliac crest. This was also true of the third case, but the grade of deformity was not as extensive as in the former two cases. Removal of the 10th, 11th and 12th ribs could be achieved without injuring the pleura and a satisfactorily large operating field could thus be developed which enabled a simple nephrectomy to be performed without difficulty. The characteristic feature of the described approach is that resection of the 10th and 11th ribs is simply to facilitate manoevrability of the wound margin, without going through the rib bed. The technique could be advantageous in selected cases where there is a highly deformed thorax.