A midline transperitoneal incision may be used for patients undergoing exploratory laparotomy for trauma, during which an indication for nephrectomy may be discovered. It is not a common incision in planned surgeries on the kidney, however, because the surgeon is often forced to operate caudal to the kidney. Such an approach can make it difficult to achieve control of the hilar vessels, especially in obese patients.

A thoracoabdominal incision is used when radical nephrectomy is required in a patient with a large, right-sided upper pole tumor. The main advantage to this approach is the excellent exposure of the suprarenal area because inadequate retraction of the liver from another approach could impede vascular control and complicate removal of a large mass. The incision begins in the eighth or ninth right intercostal space near the angle of the rib and is carried medially to the midpoint of the left rectus muscle. The dissection is carried down to the pleura and diaphragm, which are circumferentially incised to expose the liver. The liver is then fully mobilized and retracted cephalad. Next, the duodenum is mobilized medially to expose the kidney and hilum. After the kidney is removed, the diaphragm must be sutured, a chest tube placed, and the pleura repaired. This approach is associated with a considerable risk of injury to the lung, and there is also significant postoperative morbidity associated with the use of a chest tube. Therefore, this approach should be reserved only for large, right-sided upper pole tumors that cannot be safely removed with an anterior subcostal or chevron incision.