We have read the article in CIRUGÍA ESPAÑOLA by Dr Fletcher-Sanfeliu et al.1 with great interest, as it warns of the need to be well versed in transabdominal surgical maneuvers to approach the retroperitoneum. Unfortunately, this is currently unknown territory for many general surgeons. Although the article is an important contribution, it has some shortcomings and includes erroneous statements because the original bibliographical sources were not used. This requires us to clarify certain points.
Access and excellent surgical exposure, together with an unobstructed surgical field throughout the procedure, are essential to guarantee safe and successful surgery in the treatment of pathologies in this difficult territory.
The transabdominal approach to the right retroperitoneum includes, as the authors indicate, the Cattell-Braasch2 and Kocher3 surgical maneuvers for exposing the perirenal, infrarenal and/or pelvic retroperitoneal compartments, but it is also necessary to add the Prinz4 maneuver with release and medialization of the right liver for the exposure of the right retrohepatic adrenal compartment.
In turn, the transabdominal approach to the left retroperitoneum includes the Buscaglia5 surgical maneuver, which is erroneously called the modified Mattox maneuver in the article. This technique facilitates prerenal exposure of the retroperitoneum thanks to the identification and precise anatomical dissection (due to the surgical “white line”) of the lax areolar tissue of the embryological plane of the Toldt and Gerota fasciae. The Mattox6 maneuver ensures complete retrorenal exposure of the left retroperitoneum by dissecting the natural embryological plane of the Zuckerkandl and transversalis fasciae, and it is the Gómez and Gómez7 maneuver that we need to use when only access to the upper left retrosplenial-pancreatic or adrenal compartment is required.
In our experience, when access to the upper compartments of the retroperitoneum is required (both right and left), it is always necessary to accompany the Prinz4 maneuver in the right upper retroperitoneum and the Gómez and Gómez7 maneuver to access the left upper retroperitoneum with the Cattell-Braasch2 and Buscaglia5, respectively, if not in their entirety at least in part.
However, when the pathology is found in the pelvic, infrarenal and even right or left perirenal compartments, in most cases we have not needed to perform the Prinz4 or Gómez and Gómez7 maneuvers, respectively.
The recent publication of our VideoAtlas8 can function as a reference for all surgical specialists who are faced with these difficult diseases of the retroperitoneum, whose surgical management is extremely difficult and demanding. This project deals with the surgical maneuvers of the main variants for transabdominal access to the retroperitoneum (right, left, simultaneous bilateral and pelvic), and it is richly illustrated with more than 300 figures and diagrams, along with 40 videos of excellent quality.
Conflict of interestsThe authors have no conflict of interests to declare regarding this Letter to the Editor.
