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The steps of the periumbilical incision for anterior lumbar interbody fusion (ALIF). The thick white arrows point cephalad. A, A 270-degree semicircle is drawn centered on the umbilicus with a diameter of about 6 cm. B, The skin of the 270-degree semicircle is cut. C-E, Once the skin has been transected and thus subcutaneous fat is encountered, the dissection continues radially at a 45-degree angle until the anterior sheath is encountered. A yellow dotted line demonstrates where a counterincision can be made partway through the case to expand the field of view if the initial incision is made with too small of a diameter. F, The anterior sheath is cut at its medial attachment to the linea alba. G, The rectus abdominis is retracted laterally, revealing the posterior sheath. H, The posterior sheath is incised laterally at the arcuate line. I and J, Retractors are placed such that a single spinal level is exposed, then repositioned without modifying the original incision to expose other levels. K, The dermis is closed with buried interrupted polyglactin stitches, and the epidermis is closed with buried interrupted poliglecaprone stitches. Dermabond is applied on top of the closure. L, This photograph shows a different patient 3 weeks after the original procedure. In the case pictured here, a small counterincision had been made during the operation to increase the size of the exposure as highlighted by the bident. Only one patient (3%) had to have such a counterincision made.