Lateral Lumbar Interbody (XLIF / LLIF, transpsoas)

Attire

Size 8 gloves — Biogel underneath + size 8 white gloves on top

Size XL gown ×3

Prep, drape & cautery

Item — exact product	Size	Vendor	Catalog #	Open	PRN
Positioning · warming · DVT prophylaxis (non-sterile, in room)
Sequential compression device (SCD) pump		Cardinal / Kendall	SCD 700	1
SCD compression sleeves (Vasopress), size to patient	M / L	Cardinal	VP501MG / VP501LG	1 pr
Forced-air warming blanket, upper body (Bair Hugger) + unit		3M	52200	1
Foam positioning kit / arm pads / gel rolls		Xodus	SPK10113	1
Surgical skin marker (black) + field marker (purple)		Viscot	1450XL	1
Foley catheter + insertion tray, 16 Fr	16 Fr	BD	903016A	1
Skin prep · antisepsis
Chlorhexidine (Hibiclens) scrub brush				1
ChloraPrep applicator — 2% CHG / 70% IPA, tinted	26 mL	BD (CareFusion)	930815	2
BD Surgiphor wound irrigation — 0.5% PVP-I	450 mL	BD	910110	1
Major basin pack (RSP)		Novo Health	124514C	1
Mastisol liquid adhesive vial	0.66 mL	Ferndale	52348	1
Draping
Blue OR towels (per pack)	17×30 in	Medical Action	7048	2
Steri-Drape impervious towel drape ('1010')	23×35 in	3M	1010	4
Medline InvisiShield towel drape ON ROLL (prep stand)	18×12 in	Medline	DYNJSD1000RL		1
Medline Sterile Surgical Utility Drapes with Tape, 200 EA/CS	38×66 cm	Medline	DYNJP2405	4	2
Ioban 2 antimicrobial incise drape (iodophor)	33×35 in	3M	6651EZ	1
Spine custom pack (PPMC)		Medline	DYNJ69083	1
Split-sheet drape	77×120 in	Medline	DYNJP8304	1
3/4 sheet drape		Medline	DYNJP2414	1
Pocketed CV top drape — bilateral pouches		Medline	DYNJP4220	1
Instrument pouch — adheres to drape	10×11 in	Microtek / Medline	8918	1
C-arm drape (PPMC Ecolab / CCH Tidi C-Armor)	27×60 in	Ecolab / Tidi	4951 / 5523	1
Skin stapler	35 W	Covidien Appose	8886803712	1
Sponges
Raytec gauze sponge, 12-ply, X-ray detectable	4×4 in	Cardinal Health	6939	2
Laparotomy sponge (lap pad), 18×18, per pack	18×18 in	Medline	MDS72038	2
Lap-tape sponge (long/thin), X-ray detectable — narrow channels / gutters	4×18 in	Medline	MDS251504LF		2
Cottonoid patty (neuro)	0.5×0.5 in	Integra	801400		1
Sharps · needles · syringes
Surgeon's blade #10 / #15	#10 / #15	Aspen	371110 / 371115	1 ea
Surgeon's blade #11	#11	Aspen	371211	1
Hypodermic needle 22G / 25G		BD	305127	1
IV catheter / angiocath 18G (local / irrigation)	18G	BD	381454	1
Luer-lock syringe 20 cc		BD	302830	1 ea
Spinal needle — level localization 18G		BD	405181	1
Needle counter box, magnetic	40-ct	Medline	NC40FBR	1
Hemostasis
Bone wax, sterile	2.5 g	Medtronic / Covidien	BW25G	1
Floseal hemostatic matrix	10 mL	Baxter	1503350	1
Recothrom thrombin topical	5000 u	Baxter	ADS202110	1
Surgifoam / Gelfoam absorbable gelatin		Ethicon	1974	1
Aquamantys bipolar sealer wand + cover		Medtronic	01-0020		1
Cautery & suction
ESU pencil + integrated holster		Valleylab / Bovie	E2515H / ESPH	1
Bovie tip scratch pad		Bovie	ESSP	1
Bipolar forceps cord + adaptor (Storz) + pedal		Storz	—	1
Grounding pad / return electrode (REM)		Medtronic	7507	1
Yankauer suction tip		Sage	006629	1
Disposable plastic Frazier suction tips — 16Fr ×2, 12Fr ×2, 10Fr ×2				1
Neptune 2 Ultra suction unit + tubing + canister		Stryker	—	1
Closure · drains · dressing
Lateral: fascia layers 0/2-0 Vicryl				✓
Skin 3-0 clear stratafix (or V-loc) for each incision				✓
Demabond.				✓
Posterior: fascia #1 Vicryl				✓
Dermis: 2-0 Vicryl				✓
skin 3-0 clear stratafix (or V-loc) for each incision				✓
Demabond.				✓
none				✓
Smith & Nephew [3.75" × 3⅜"] OpSite dressing for each lateral incision				✓
Smith & Nephew [4.75" × 4"] OpSite dressing for each posterior incision (typically 2 incisions)				✓
Cautery settings: Bovie 35 / 35 cut-coag, Bipolar 35 · 1 bovie (open) + 1 additional bovie PRN (if co-surgeon) · 2 suctions off bottom of field · grounding pad on thigh. Meds (pharmacy): Local: Exparel (bupivacaine liposome injection 1.3%) 20cc mixed with 0.25% bupivacaine 40cc for a total of 60cc total; TXA (tranexamic acid): 30 mg/kg load + 1 mg/kg/hr infusion throughout the case; Antibiotic: 2g Ancef unless patient has an allergy

STAGE 1 — Lateral interbody (transpsoas)

• Alternative IF hospital has an OSI Pro-Axis table: Lateral decubitus on OSI Mizuho / Pro-Axis flat-top table (5808PV) with hip break. The midpoint between the iliac crest and the greater trochanter is centered over the table break.
• Otherwise, a regular sliding OR table is used, but oriented in reverse. The base of the table is positioned at the patient's feet, away from anesthesia, allowing unobstructed C-arm access from the head of the bed to the patient's flank.
• Patient Placement: The midpoint between the iliac crest and the greater trochanter is centered over the break in the table. Often, the ASIS is exactly at the level of the break in the table. This ensures that when the table is flexed, the iliac crest is pulled caudally, away from the rib cage, maximizing the working window to the lumbar spine.
• An axillary roll is placed under the dependent axilla.
• The hips and knees are maximally flexed to relax the psoas muscle.
• Foam padding is used to protect all bony prominences, especially the dependent fibular head and lateral malleolus.
• The dependent arm is placed on a standard arm board, while the up side arm is supported on an elevated armrest.
• Sticky Rolls: A bedsheet is rolled into a firm, 4-inch diameter cylinder. This is then wrapped with 2- or 3-inch silk tape with the adhesive side facing out. Two of these "sticky rolls" are created and pressed firmly onto the bed padding, one anterior and one posterior to the patient's torso, to act as bolsters.
• Torso Taping: Wide (3-inch) silk tape is applied directly to the skin and wrapped completely around the patient and the table at two levels: (1) just inferior to the axilla and (2) at the level of the greater trochanter. The trochanteric tape must pass distal to the breakable portion of the table to effectively pull the pelvis caudally when the table is flexed.
• Leg Taping: Additional tape beginning at the greater trochanter, passing obliquely along the lateral thigh. Tape carried across the knee, distal to the knee, around the anterior side of the patient/table, underneath the table, and back up posteriorly. Tape then crosses the heel and lateral malleolus, travels along the axis of the tibia, crosses the knee again, wraps under the anterior side of the table, and returns posteriorly. The tape ends near the greater trochanter and is reinforced with additional tape to prevent slippage.
• Final Table Adjustments: The table is placed in reverse Trendelenburg (head up). The head of the bed is then lowered, "breaking" the table at the patient's flank. This flexes the patient's torso laterally, opening the disc space on the operative (up) side.
• Place the table clamp on the patient’s anterior side up near the axilla (out of the way of C-arm). This is where the table-top retractor pole will attach.

C-arm in from the belly side of the patient. Set up early — call for C-arm when surgeon starts positioning. Will obtain True AP/lateral for corridor and disc centering prior to scrubbing in.

NuVasive arm clamp on bed before wires placed; directional / free-run EMG through psoas (lumbar/femoral plexus). Also MEPs, SSEPs, and EMG.

• Lateral access retractor system (ie Nuvasive MaXcess) — rep-brought, with dilators + EMG-stimulating probes.
• Set Spine Basic for incision/closure
• Implant vendor provides: long bipolar; long instruments; Cobb, endplate rasps/curettes (in lateral system), long ring curettes, box osteotomes, long bayonetted scalpel blade, long suction tip.

Lateral interbody cage (static or expandable per level). Lateral plate/screw option available.

ie Nuvasive Modulus and integrated side plate if needed.

BMP 2.05 mg per level (lateral interbody) + packed in cage.

Stryker Sumex Pi Drive 2+ (alternative) / MidasRex MR8 (can use with navigation); high-speed burr for endplate prep.

Floseal (10 cc)

Recothrom + Thrombin soaked Gelfoam/Surgifoam

Surgifoam ± 4 mg Decadron, Gelfoam size 100 for each level (for the psoas irritation)

STAGE 2 — Flip PRONE for posterior pedicle screws

• Reposition prone on open Jackson spine frame w/ prone bolsters, arms above head (re-prep/re-drape). Re-establish monitoring baselines after flip.
• Navigated default — O-arm + Stealth: Set Spine Medtronic Reference (default-open) + NavLock Instruments + spheres 8801075. Reference Revision PRN.
• Pedicle screw–rod system (navigated-compatible) — rep-brought.
• See Card 05 (Posterior Lumbar Fusion) for full prone instrumentation set.

Medications

• Local: Exparel (bupivacaine liposome injection 1.3%) 20cc mixed with 0.25% bupivacaine 40cc for a total of 60cc total
• TXA (tranexamic acid): 30 mg/kg load + 1 mg/kg/hr infusion throughout the case.
• Antibiotic: 2g Ancef unless patient has an allergy

Drain

none

Closure

Lateral: fascia layers 0/2-0 Vicryl

Skin 3-0 clear stratafix (or V-loc) for each incision

Demabond.

Posterior: fascia #1 Vicryl

Dermis: 2-0 Vicryl

skin 3-0 clear stratafix (or V-loc) for each incision

Demabond.

Dressing

Smith & Nephew [3.75" × 3⅜"] OpSite dressing for each lateral incision

Smith & Nephew [4.75" × 4"] OpSite dressing for each posterior incision (typically 2 incisions)