Periumbilical anterior retroperitoneal approach for lumbar disc replacement: Technical description with an illustrative case

Materials and methods

This article is presented as a technical note featuring a single illustrative case of the periumbilical anterior retroperitoneal approach for LDR. The patient underwent surgery for symptomatic multilevel DDD after unsuccessful conservative management. As this report was intended to describe the surgical technique rather than serve as a comparative clinical study or case series, formal inclusion and exclusion criteria were not established. The illustrative case underwent surgery at a single institution in March 2025 by a spine surgeon experienced in anterior lumbar spine surgery and LDR.

Case presentation

A 65-year-old man presented with a history of LBP radiating to the left lower extremity along the L3–L4 and L4–L5 dermatomal distributions. He had experienced similar symptoms intermittently for approximately one year; however, the pain had significantly worsened over the previous 2 months before presentation. The pain persisted in all positions and became severe enough to require wheelchair assistance for mobility. There was no history of trauma or any precipitating event. The patient had no prior surgical history and no history of coagulopathy or bleeding tendencies. He also denied any tobacco use. Before evaluation, the patient had been treated with analgesic medications, including nonsteroidal anti-inflammatory drugs and tramadol, which provided only temporary relief, as the symptoms recurred immediately after discontinuation of the medications. On physical examination, the patient was 165 cm tall and weighed 80.5 kg. Lumbar range of motion was limited due to pain, particularly during flexion and extension. Tenderness over the lower lumbar region was noted on palpation. Neurological examination demonstrated radiating pain along the left L3–L4 and L4–L5 dermatomes without evidence of motor deficit. No bowel or bladder dysfunction was reported. The pre-operative Visual Analog Scale (VAS) pain score was 8/10. Conventional imaging demonstrated DDD at the L3–L4 and L4–L5 levels [Figure 1]. The patient subsequently underwent LDR using the periumbilical anterior retroperitoneal approach.

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Figure 1: Pre-operative lateral radiograph of the lumbar spine demonstrating degenerative disc changes at the L3–L4 and L4–L5 levels.

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Patient positioning

The patient is positioned supine with the hips and knees fully extended, placed in a slight Trendelenburg position, and the arms abducted to 90°. A Foley catheter is inserted preoperatively to decompress the bladder. Standard sterile draping is then performed. Patient positioning should allow unobstructed circumferential use of the C-arm at the operative levels throughout the procedure.

Surgical incision and periumbilical approach

A periumbilical skin incision is created in a 270° arc with the opening directed cranially. Dissection is carried out through the subcutaneous tissue in a semicircular fashion, building a pad of adipose tissue beneath the umbilicus. The basal fat layer surrounding the umbilicus is further dissected to visualize its vascular structures.^[6]

The anterior rectus sheath is incised along the midline or slightly paramedian plane [Figure 2]. The rectus abdominis muscle is gently retracted superiorly and laterally, providing access to the posterior rectus sheath and transversalis fascia. The arcuate line is then divided at its most lateral portion, and the peritoneum together with the ureter is carefully mobilized medially, thereby exposing the psoas muscle and anterior lumbar spine [Figure 3]. The anterior retroperitoneal approach is generally performed from the left side, particularly for L4–L5 and more cranial lumbar levels, as a right-sided approach places the surgeon in closer proximity to the inferior vena cava and may increase the risk of venous injury. For the L5–S1 level, however, either the left- or right-sided approach may be utilized because the operative corridor lies below the vascular bifurcation. The ureter is identified and protected throughout the exposure, and routine ureteral stenting is typically not performed unless specifically indicated by patient anatomy or prior surgical history. A deep retractor is subsequently inserted to optimize visualization of the major vascular structures [Figure 4].

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Figure 2: The anterior sheath of the rectus is then cut in a paramedian position, about 1 cm laterally from the linea alba.

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Figure 3: Incision of the arcuate line in its most lateral portion, and the peritoneum and the left ureter are then gently pushed medially until the psoas muscle is exposed.

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Figure 4: A deep retractor is inserted, and the big vessels (white arrow) are visualized and mobilized.

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At the L4–L5 disc level, vascular exposure may require careful medial mobilization of the aorta, inferior vena cava, and common iliac vessels. Multiple venous structures, including the iliolumbar vein, middle sacral vein, and other segmental venous branches, may require ligation to facilitate adequate exposure. In particular, ligation of the middle sacral vein may be necessary to improve visualization and reduce the risk of intraoperative bleeding while minimizing the risk of vascular injury, particularly to the common iliac vein and inferior vena cava. The exposure may vary depending on the targeted disc level. For L5-S1, the exposure is typically straightforward [Figure 5]; once the bifurcation is mobilized superiorly, the sacral promontory becomes easily accessible.

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Figure 5: Surgical field at the L5–S1 level with the retractor in place.

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At the L3-L4 level, all segmental arteries originating from the aorta must be identified and ligated. The aorta is then displaced medially to expose the intervertebral disc. Occasionally, additional small segmental vessels branching from the aorta may require ligation to optimize the surgical field.

Implantation

After exposing the intervertebral disc space, the operative level is confirmed using fluoroscopic guidance with the C-arm before disc excision. A retractor is placed for optimal access. The disc is excised, and cartilaginous endplates are carefully removed to preserve subchondral bone and prevent implant subsidence. Trial prostheses are inserted under fluoroscopic guidance, centered on the disc space and aligned with the sagittal plane. Following discectomy and endplate preparation, sequential trialing was performed under fluoroscopic guidance to determine the appropriate implant size and position. Preparation of the vertebral endplates was subsequently completed according to standard disc arthroplasty principles while maintaining alignment within the disc space. The prosthesis was assembled and prepared before implantation. Following implantation of the metallic endplates, the polyethylene core was inserted and secured according to the manufacturer’s recommended technique [Figure 6]. Final fluoroscopic assessment was subsequently performed to confirm appropriate implant positioning, alignment, and articulation before removal of the instrumentation. Final position imaging is obtained in both lateral and anteroposterior views. The surgical wound is then closed routinely, appropriate to the exposure used [Figure 7].

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Figure 6: Intraoperative images showing (a) insertion of the polyethylene inlay (green arrow) into the grooves and (b) final placement of the inlay (green arrow).

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Figure 7: Postoperative images showing (a) the healed skin incision and (b) lateral radiograph demonstrating satisfactory implant positioning.

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Post-operative care

The patient may begin ambulating under supervision within 1–3 days postoperatively, using a simple corset and walker when out of bed. Isometric leg exercises are encouraged during the first 2 weeks. Excessive bending and lifting should be avoided during this period.

Results and short-term follow up

The procedure was completed without intraoperative vascular, urologic, or neurologic complications. Postoperatively, the patient remained hemodynamically stable and reported symptom improvement, with no immediate post-operative wound-related or systemic complications observed. During the first 6 post-operative weeks, light bending and lifting activities were gradually introduced, with progressive return to normal daily activities. At the 6-week follow-up, the patient demonstrated symptomatic improvement, with the VAS pain score decreasing from 8/10 preoperatively to 2/10, without evidence of wound-related, neurologic, vascular, or systemic complications. At the 3-month follow-up, the patient continued to demonstrate sustained clinical improvement. The VAS pain score further decreased to 1/10, and the patient had returned to normal daily activities without functional limitations. No complications were observed throughout the follow-up period.