Operations on the kidneys

Surgery on the kidney carried out in various accesses: vnebrachnyi, razbrosannye or razgromnym. The most often used vnebrachnyi access through the exposure of the retroperitoneal space - lumbotomy. The cut if lumbotomy produce in the lumbar region.

Fig. 3. Operative access to the kidney: 1 - section Fedorov; 2 - section Simon 3 - section of Bergmann of Israel; 4 - section mobiles; 5 - cut Piana.

The most common are cut Fedorov and a cut of the Bergmann - Israel (Fig. 3).
With large tumors, kidney, when difficult approach to the upper pole of the kidney, use a combination of approaches: the thoraco-abdominal vnebrachnyi and abdominal razbrosana-vnebrachnyi.
Most operations on the kidneys produce currently under endotracheal anesthesia with the use of muscle relaxants, which greatly facilitates the access retroperitoneal space to the kidneys.
Patient is placed on the operating table on the healthy side. The nature of the operation is dictated by the disease and the patient.
When paranemia produce opening retroperitoneal space and purulent with the subsequent draining of his rubber drainage and gauze tampons. When acute pyelonephritis, aposematism nephritis produce decapsulation kidneys. Often this operation is accompanied by another operation - neprostaia (see) or pyelostomy.
When multiple stones of kidneys or during Staghorn calculi stones produce nephrotomy, combining it with pallidotomy (operation dissection pelvis to remove stones). More often make a cut on the back or bottom surface of the renal pelvis, to which access is freer and safer. At the back pielokamie dissection of its produce in a longitudinal direction, after which a special tool to remove from the section kidney stone. If kidney stones was infected, then the surgery is completed drainage pelvis rubber drainage - pyelostomy, if secondary pyelonephritis was not, then cut pelvis can impose several ketotofin seams and drain perinephral space.
For tumors of the kidneys, with large degenerative changes in it, make a removal of kidney - nephrectomy.
In pathological mobility of the kidneys produce fixing in renal bed - nephropexy, when hydronephrosis often produce plastic operations on renal pelvis and pelvis-ureter fistula.
At a tuberculosis of the kidneys, with traumatic its damage, at stones of kidneys produce the removal of the kidney, typically of one of the poles - resection of the kidney.
In polycystic kidney patients produce an operation that combines the emptying of cysts of kidneys with improving blood circulation in her due to sewing in the renal parenchyma packing - amandarenee. When hypertensioncaused by narrowing of the renal artery, produced on her plastic surgery.
Nursing - see the Postoperative period.

Operational approaches to the kidney, revealing her and intervention it is carried out in various accesses: vnebrachnyi, razbrosannye (abdominal) and razgromnym (thoracic). In some cases, for example when large kidney tumors, use the combined access to the kidney - thoracoabdominal. Most operations on the kidneys produce from vnebrachnogo approach by exposure retroperitoneal space - lobotomie. Lumbotomy can be made of various sections of the lumbar region. The most common sections Fedorov, Bergmann of Israel; rarely used sections of Simon, Piana, mobiles (Fig. 35).
When very large kidney tumors and tumors of the adrenal gland use section on Nagamatsu: vertical incision on the edge of straight back muscles with a continuation of the front abdominal wall along the bottom edge of the XII ribs with subperiosteal resection near vertebrae X, XI and XII of the ribs.
During operations on kidney patient is placed on the operating table on the opposite surgery side, put a cushion, which facilitates access to Petrograd After the incision of the skin and cellular tissue cut muscle naked and retroperitoneal space. The peritoneal bag pushed inwards. Reveal behind the renal capsule and perirenal fat of the kidneys secrete. Intermuscular accesses without dissection of muscles, by expanding lengthwise, became possible with the use of modern types of anesthesia with the use of muscle relaxants.
Decapsulation kidney - removal of the fibrous capsule is used for acute pyelonephritis, perinephric, sometimes kidney failure. In result of this operation is possible to reduce the increased vnutripolostnoe pressure and improve the blood circulation and lymph circulation in the kidney. After display buds on its lateral edge produce longitudinal section of the fibrous capsule (Fig. 36). In the section introducing globality probe and through it, occasionally lifting the capsule, dissect it. Then the edge capsules prepare the chin from renal parenchyma down to the gate P. Dissect the fibrous capsule is not necessary. Often decapsulation kidney combined with other operations, such as neprostaia.
Nephrotomy - section renal parenchyma - produced with the purpose of removal of kidney stones, foreign bodies, to perform nephrostomy, and sometimes and diagnostic purposes. Longitudinal sectional nephrotomy is used to remove large Staghorn calculi stones. Cut renal parenchyma produce longitudinally along the line of Condesa, some distance of 0.5 cm posterior to the convex region kidneys. Sectional nephrotomy should be made after a preliminary temporary decrease vascular legs P. For this purpose it is necessary to mobilize P. and on the vascular pedicle to impose soft clip. In addition sectional longitudinal nephrotomy, apply cross nephrotomy. Time of termination of blood flow to the kidneys should not exceed 30 minutes Local hypothermia - cooling P. to a temperature of 14-16 OC allows to switch off the circulation in the kidney for a longer time, reduce the renal bleeding from wounds and improves healing of wounds and the postoperative period. Often used in renal surgery partial nephrotomy by dissection renal parenchyma over a Cup or pole P. for extraction of a stone. After nephrotomy stop bleeding carried out by the imposition ketotofin seams on the wound (Fig. 37). The imposition of large mattress, the U-shaped tightening of seams on the renal parenchyma is not justified, as this occurs ischemia kidney to the development of heart attacks and secondary bleeding. Extensive nephrotomy must be combined with neprostaia.
Nephrostomy - the imposition of renal fistula; provides drainage Cup-pelvis system, is in acute inflammatory processes of kidneys, hydronephrosis, calculous anuria, etc. In the case of thinning renal parenchyma is enough to make nephrotomy length of 2 cm, and after renal wound to enter into the pelvis rubber drainage. If you have a large number of renal parenchyma for correct installation renal drainage it is necessary to make a cut in the pelvis (pilotami), then through one of the calices to punch parenchyma clip Fedorov, and, taking them drainage tube, enter it into the sack. Drainage should be recorded by a fibrous capsule kidney ketotofin seam (Fig. 38).
Pyelostomy - imposition of the fistula to the pelvis. This operation make less than nephrostomy. On the dissection of the renal pelvis into it enter rubber drainage tube, which is fixed ketotofin seam to the edges of the pelvic wounds (Fig. 39). Nephrostomy circle drainage, consisting in carrying out drainage tube through wounds pelvis and kidneys, has not justified itself, as it causes severe complications until the eruption of the drainage tube through the renal parenchyma.
Pelotonia - dissection of the renal pelvis. This operation is usually used to extract stones from the kidney and cups. Depending on the location of the incision pelvis distinguish front, the lower back and upper pilotami. Front pelotonia dangerous because of possible damage to the renal vessels; it is used when you have a large vnepochechny pelvis, and more often abnormal kidney (u, dystopic kidney), in which the pelvis is located in the front, away from large vessels. Much more likely to have to make a back Palotai (Fig. 40).
In allocating the back surface of the kidney from pelahenko fat free up the rear wall of the pelvis and dissect it. When vnutripuzarnom type pelvis should push outwards rear lip P. finger or a hook that can usually easily with well-developed renal sinus. Hook lift renal lip, therefore exposing the back surface of the pelvis (Fig. 41). On the inner surface of renal lips, and sometimes on its lower edge are a. et v. retropyelica, injury should be avoided. A cut in the wall of the renal pelvis produce longitudinal or transverse directions. When removing large and especially Staghorn calculi concretions have to cut not only
the sack, but a Cup; this operation is called calicotome.
When vnutripuzarnom type pelvis in the case of location of concrements in the pelvis and the lower Cup apply lower pilotami. After highlighting the lower pole of the kidney and upper third of the ureter produce mobilization pelvic-ureteric segment, usually covered with renal parenchyma. Prepare the chin lower pole of the kidney from pelvis and pushed his hook towards the outside; as a result, exposing the lower surface of the pelvis, which is cut longitudinally. Producing lower pilotami, you should not hurt himself pelvis-ureter segment, as if his wound may subsequently develop stricture.
To remove large stones from the top of the Cup used upper pilotami. The technique of this operation is similar to the lower pilotami, but is more difficult and requires pre-mobilization of the entire P. with the dislocation it in the wound. After pielokamie preferably take the wound pelvis thin kedgotoline seams. If it is technically not possible, well enough to drain renal injury.
All operations on the kidneys is associated with the opening of the urinary tract, require good drainage of the wound. For this purpose apply a rubber-gauze, cellophane-gauze graduates or thin drainage tube inserted to the place of opening of the pelvis and cups, and in the bottom corner of the wound.
Resection of the kidney - removal of the kidney - produce tuberculosis, traumatic injuries, gidrokalikoz, nephrolithiasis, solitary Kista, tornakalna-channel Cup, manifested bleeding, sometimes with the tumor only P. Often repetiruyut one of the poles of the kidneys, rarely middle part. It is necessary to mobilize vascular stem, so that, if necessary, to impose on vessels soft clip and thus to perform an operation is bloodless. Sometimes this can be achieved by compression of the kidney fingers or soft clip imposed centrally repetiremos renal segment. If you have a separately running blood vessel to the pole P. subject resection, his tie, which greatly facilitates the operation. After excision pole P. produce the dressing and suturing renal calyx and pelvis (Fig. 42).
Crossed and bleeding in the kidney wound vessels sheathe kedgotoline seams and bandaged. Renal wound sutured hub kedgotoline seams. Tamponade of the wounds of the kidneys when resection muscle or fat tissue does not currently produce. If resection of the kidney was a wide opening Cup-pelvis system, you need to make nephrostomy. When the disease is one-half of abnormal doubled P. apply gaminiratne, which differs little from resection P. Abnormally positioned vessels tied up in close proximity to remove the part of the kidney.
When cavernous tuberculosis, along with resection P. apply cavernicoli. The cut on the outside surface P. open purulent cavity located in the parenchyma, and then remove cheesy mass and sometimes pyogenic shell.
In certain indications governatore has the advantage before resection P., because it is a large part of the functioning of the parenchyma.

Nephrectomy - kidney - produced in malignant tumors, hydronephrosis, large damage to the kidney, in advanced stages of the inflammatory (purulent) diseases P., when nephrogenic hypertension and other Kidney separated from the surrounding tissues, mobilize the vascular pedicle, which impose kedgotoline ligatures. Vascular leg bandaged closer to main line vessels. Higher (centrally) ligatures impose on foot clip Fyodorov, then vascular leg crossing. The ureter is tied up in the upper third of the cross between two ligatures. Deleting P. vascular leg centrally imposed on her clip additionally be stitched and bandaged with catgut (Fig. 43).
With extensive sclerotic peri - and parametrico, janefrose when you cannot distinguish a kidney from surrounding tissues, apply subcapsular nephrectomy by Fedorov (Fig. 44).
This operation dissect sklerozirovanie perirenal fat and with it the fibrous capsule. Kidney decapsulator. Front and rear gate P. produce semilunar bordering cuts through debonded from renal parenchyma
fibrous capsule and together with it sklerozirovanie perinephral fatty tissue. Through these incisions are able to mobilize and tie renal vascular leg.
With papillary tumors of the renal pelvis along with nephrectomy, you should always make ureterectomy (see the Ureter, operations) with resection of the bladder, respectively location ureter mouth same side. Would such an operation to make two incisions in the abdominal wall: from lumbar - nephrectomy and inguinal-iliac - ureterectomy with resection of the bladder.
Nephropexy - commit operation kidney - shows when nephroptosis. Many of the proposed operations for treatment of nephroptosis manufactured using Homo - or alloplastic materials. Various methods of nefropatii using synthetic materials has not justified itself. When these methods, fixed to the ribs kidney deprived of their physiological mobility, and therefore significantly impaired renal hemodynamics. The same lack of suffering and nephropexy by Fedorov, and its various modifications commit kidney for fibrous capsule. The operation of Horasa (suturing dispersed sheets renal fascia) does not provide sufficient commit P.
Lately most widespread methods of nefropatii muscular flap, taken on the leg of lumbar muscles. Frequently used operation Rivoira consisting in selection of muscle a flap of lumbar muscles, holding it under the fibrous capsule kidney and fixation of the flap to the free end of the XII ribs. This operation, as mentioned above, significantly limits the physiological mobility P. Best results nephropexy on Rivoire in modification of the urological clinic of the 2nd Moscow medical Institute. Muscle flap spend subkapsuliarna on the back surface of the kidney and, going around the lower pole of it, fix the end of the flap on the front surface of the body. This is achieved by raising P. in their bed in the normal position with preservation of physiological its longitudinal axis. Muscle flap lumbar muscles lock node with the silk sutures to the fibrous capsule P. (Fig. 45). This operation allows you to save physiological respiratory mobility of kidney and does not allow it to drop below the normal position.
Intergewestelijke kidney aims to create a roundabout blood flow to the kidneys and is used in nephrogenic hypertension due to chronic pyelonephritis. The resected segment jejunum with its feeder mesentery cut in length, excised mucosa and submucosa of the shell and the flap is stitched to the kidney on the whole of its surface devoid of fibrous capsule (Fig. 46).
With renovascular hypertension caused stenotic lesions of the renal artery and its branches, used plastic, reconstructive operations on renal artery: resection of the narrowed segment of the artery with the connection ends artery end-to-end, endarterectomy (excision of atheromatous plaque from the artery walls with the restoration of its clearance), bypass artery to the aorta, splenomegaly arterial anastomosis and other
Operations on the kidneys should include renal biopsy. A biopsy may be performed percutaneous puncture method or by using lumbotomy. For renal biopsy using a special needle, allowing to get out of renal parenchymal piece of tissue for histological examination.
Plastic surgery used in the treatment of hydronephrosis,see Hydronephrosis.

Fig. 35. Operative access to the kidney: 1 - section Fedorov; 2 - section Simon 3 - section of Bergmann of Israel; 4 - section mobiles; 5 - cut Piana.
Fig. 36. Decapsulate kidney (1 and 2 - step).
Fig. 37. Sectional nefrologii. By removing calculus impose mattress seams, hinges are fixed loose pieces of muscular tissue.
Fig. 38. Nephrostomy: 1 - pre-made pelotonia and with a probe entered in the buckets and then at the bottom of the Cup, in the sack held drain pipe; 2 - drainage tube is fixed to the fibrous capsule kidneys.
Fig. 39. Pyelostomy. A drainage tube is introduced into the pelvis. On the edge of the pelvic wound stitched up for fixing tubes.
Fig. 40. Back pelotonia.
Fig. 41. Exposure hooks renal sinus.
Fig. 42. Resection of upper pole of the kidney.
Fig. 43. Nephrectomy: 1 - the ureter tied up and crossed; the imposition of a common ligatures on the vessels of the kidney renal stem; 2 - overlay clips on renal stem; 3 - kidney removed, flashing renal vascular for subsequent bandaging.
Fig. 44. Subcapsular nephrectomy by Fedorov: 1 - allocating kidneys from thickened fibrous capsule; 2 - kidney selected, renal leg covered turned capsule in the field gate kidney capsule circular podselitsya; 3 - capsule shifted, renal leg exposed.
Fig. 45. Nephropexy on Rivoire (scheme). Cut from muscle flap is recorded lower pole of the kidney. The distal end of the muscle flap is fixed to the free end of the XII ribs.
Fig. 46. Intergewestelijke kidneys (scheme): 1-4 consistent stages of the operation.