These operations may be performed through a lumbar incision, commencing below the angle between the last rib and the outer border of the erector spinar, and extending down and out to about 1 inch above the anterior superior spine. Where necessary, the incision may be extended down and inwards into the inguinal region- still extraperitoneal. The incision involves pretty free section of the muscles and subsequent weakening, and especially in women the space between the last rib and iliac crest is frequently short, making removal of large tumours difficult. Further, it is not possible to inspect the condition of the supposed sound kidney prior to removal of a diseased one, and hence nephrectomy is generally performed through an abdominal incision, the peritoneum, of course, being opened. In either operation the vessels and ureters are ligatured and the organ removed. The possibility of irregular branches of artery or vein entering the kidney away from the hilum should be kept in mind. Occasionally from disease the kidney contracts adhesions to surrounding organs-duodenum, colon, vena cava, aorta, etc.-and in order to avoid injury to these important structures it is sometimes necessary to remove the kidney by a subcapsular operation, which is rendered easier by the diminished size of the renal vessels in such affections. (Suturing Kidney To Parietes In Normal Position)
In the abdominal operation the incision is frequently made in the linea semilunaris, and the peritoneum incised along the outer border of the colon, which is then drawn inwards so as to expose the kidney. Nephrorrhaphy (nephropexy) is generally performed through the lumbar incision, the proper capsule of the kidney being split along the posterior border, reflected for fully ½ inch along either side, and the reflected capsule then stitched to the transversalis fascia and muscles. The wound is allowed to granulate so as further to fix the kidney by fibrous adhesions.