Position of patient

The patient is placed on the operating table with the right side elevated at an angle of 30° to the table by two sandbags placed underneath the right posterior trunk. The costal margin is at the level of the flexion break of the table, the right arm is suspended from an ether screen with towels, and the left arm is extended on an arm board cephalad to the ether screen. The table is "broken" at the level of the costal margin and at the knees so as to widen the space between the right costal margin and right iliac crest, and to make it possible to perform the operation easily through a right subcostal incision (A1, A-2). The incision extends from the xiphoid to well into the flank and is made two finger breadths below the costal margin. The skin is incised superficially with the scalpel and the other layers with the electrocautery, which greatly reduces the blood loss and shortens the operating time. When the electrocautery is used, it is usually unnecessary to clamp any blood vessels with hemostats. The right rectus abdominis, external oblique, and transverse abdominis muscles are completely divided and the medial 3-4cm of the latissimus dorsi muscle is incised. The peritoneum often contains many collateral veins and is incised with the electrocautery to obtain immediate hemostasis.


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