A dorsal lumbotomy incision can be used when retroperitoneal access to the kidney is desired in patients who have fibrosis associated with prior abdominal or flank incisions. The incision is started over the erector spinae muscles at the level of the twelfth rib, then continued downward and laterally toward the iliac crest. The thoracolumbar fascia is incised lateral to the quadratus lumborum and erector spinae muscles, which are retracted medially. The transversalis fascia is then divided to expose the paranephric fat. An advantage of this approach is that it avoids transection of the abdominal muscles; however, it provides limited access to the hilum, making it difficult to control vascular complications.

The major advantages of retroperitoneal open access include the avoidance of the peritoneal space, which reduces the rate of injury to intraabdominal organs and the risk of postoperative ileus. The major disadvantage is that the renal vessels are not as easily visualized as in a transperitoneal approach.