The muscle-sparing incision to approach the “window” behind the rectus abdominis muscle. (A) Skin incision, two finger-breadths above the pubic bone. External oblique aponeurosis was incised to create a small window to inspect the iliohypogastric nerve. The iliohypogastric nerve was identified and spared. (B) The aponeurosis of the internal oblique and the transversus abdominis muscle and rectus sheath were incised. (C) The rectus abdominis muscle and the inferior epigastric vessels were exposed. (D) The rectus abdominis muscle was retracted to expose the window.
The RAMWI for HARN has the benefit of a Pfannenstiel incision because it is scar-concealing and muscle sparing. It also has the advantage of a Gibson incision in the retroperitoneal approach for the kidney, ureter, and bladder cuff. In accessing the window behind the RAM by retracting and not incising it, wound-related morbidities (such as incisional hernia or bulge) were not present in our patients during short-term follow up. This window could be an important alternative portal for hand-assisted laparoscopic surgeries.