Primary right-sided retroperitoneal approach for anterior lumbar interbody fusion: a technical note and case series

Anterior lumbar interbody fusion (ALIF) is commonly performed via a left-sided retroperitoneal approach, often in collaboration with access surgeons. However, the dominance of this laterality lacks clear evidence-based rationale. This study reports a standardized right-sided retroperitoneal approach for stand-alone ALIF performed solely by a spine surgeon, evaluates its feasibility and safety, and highlights its potential advantages.

We conducted a retrospective, monocentric case series of all patients who underwent stand-alone ALIF via a primary right-sided approach between January 2017 and August 2024 by a single right-handed spine surgeon. A detailed surgical technique is described. Perioperative and demographic data were collected, including operative time, hospital stay, implant configuration, and complications. Descriptive statistics were computed using R and Python.

Fifty-nine patients (mean age 55.88 years, 64.41% female) underwent surgery, with most procedures at the L5-S1 level (89.83%). The mean operative time was 115.59 minutes (excluding complex and proctorship cases), and the adjusted mean hospital stay was 3.81 days. The complication rate was low (3.39%), with no severe adverse events or reoperations. All patients received stand-alone polyetheretherketone (PEEK) cages, predominantly 36 mm wide. No vascular injuries or mortality occurred.

The right-sided retroperitoneal approach for ALIF is feasible, safe, and efficient when performed by a trained spine surgeon. This approach offers potential strategic benefits as a primary alternative to the conventional left-sided route, especially in stand-alone L5-S1 procedures.