Method for left partial nephrectomy

FIELD: medicine.

SUBSTANCE: peritoneum and mesocolon tissues of a descending colon are incised above an involved region and above a vascular renal pedicle to perform a left partial nephrectomy. Through the local mesocolon incision above the vessels, a renal artery is filopressed and compressed for thermal ischemia. A new growth is incised and evacuated through the mesocolon incision made above the involved region of the kidney.

EFFECT: method provides the ergonomic approach through a minimum thickness of the mesocolon tissues, minimises the risk of intestinal and splenic injuries and development of complications, ensures the fast postoperative intestinal functional recovery.

2 cl, 2 ex

 

The invention relates to medicine and can be used in urology.

The most effective treatment of renal cell carcinoma is operational, and organ-preserving intervention is considered a priority [the Summary of recommendations of the European Association of urology / edited by M. Kogan. - Rostov-on-don: OOO "omega-Print", 2009. - 317 p.]. Evolution of laparoscopic technologies in urology has led to the almost total abandonment of traditional interventions in localized tumors of the kidney. So, laparoscopic partial nephrectomy recognized by the European Association of urology the method of choice in the treatment of renal cell carcinoma in stages Τ1[Clinical guidelines of the European Association of urology / Resp. edited by T. V. Lukovkin, N. In. Chernozhukov, A. G. Shegai. - M.: OOO "ABC-press", 2010. - 1031 p.].

Algorithm traditional laparoscopic partial nephrectomy provides a broad mobilization of the colon with the intersection of the colon-splenic and splenic-phrenic ligament to expose the retroperitoneal space and the vascular pedicle of the kidney. The kidney is excreted in the fascia of Gerota so widely, as needed, to expose the tumor. Then dissected adipose capsule of the kidney to the healthy parenchyma. The allocation of the renal artery during W is carried out after�ROCA mobilization of the colon. Only after that carry out temporary clamping for the formation of thermal ischemia. On the background of the last tumor excised within healthy tissue, and the integrity of the anatomical structures is restored seam [Puchkov K. V. Laparoscopic surgery for kidney cancer / K. V. Puchkov, A. A. Krapivin, V. B. Filimonov. - M.: publishing house "medical practice-M, 2008. - S. 123-139 (the prototype of the present invention) Stolzenburg J-U. Laparoscopic and robot-assisted surgery in urology. Atlas of standard procedures / J-U. Stolzenburg, LA. Turk, E. N. Liatsikos. - Springer Heidelberg Dordrecht London New York, 2011. - 79-85].

The stage of mobilization of the colon and secretion of the renal artery is at least one third of operational time and is accompanied by some risk of iatrogenic intraoperative complications, such as injury of the bowel wall and damage to the spleen arising from the mobilization of the descending part of the colon in 1% and 1.2% respectively [Popov S. V. computer assisted surgery in the treatment of patients with renal tumors / S. V. Popov, A. I. Novikov, O. N. Skryabin, D. V. Zaitsev. - SPb.: Maps, 2011. - 224 p.].

This has been a cause of the development of an alternative method transtentorial partial nephrectomy without mobilization of the descending colon.

The problem solved in the present invention is to develop a method of partial nephrectomy to minimize the risk of complications

Achievable technical results due to the implementation of the developed method are:

- ergonomic access to the surgical area of interest (the area of the kidney, the tumor) using a minimum thickness of tissue of the mesocolon, without resorting to broad mobilization of the colon with the intersection of the colon-splenic and splenic-phrenic ligament. This minimizes the risk of injury of the intestine and spleen, and therefore, eliminates the complications associated with these lesions;

- optimization of the operation caused, including by reducing the duration of the operation, because it eliminates the need for the mobilization of the colon that? in addition to reducing the risk of complications, leads to the most rapid recovery of bowel function in the postoperative period.

The method is as follows.

Local dissection of the peritoneum and tissues of the mesocolon of the descending colon just above the vascular pedicle of the kidney, in the direction of the vessels, and over the tumor area of the kidney, thereby forming a "window" to access the affected area of the kidney. Optimal is making a cut so that the length of the defect in the mesocolon exceeded tumor diameter not less than 25%. Through a local incision mesocolon over the vessel�and is a limited selection of the main or segmental renal artery, which is fixed in the turnstile for subsequent transient clamping to ensure total or segmental thermal ischemia, respectively. Excised tumor cold shears within the healthy tissue together with fatty tissue, and covered her. A remote part of the kidney with tumor evacuated through a "window" mesocolon into the abdominal cavity, and then out. The wound of the kidney sutured in layers, and then sutured the window in the mesocolon.

Clinical example No. 1

Patient F., aged 65, was hospitalized with complaints of recurrent back pain on the left. When examined in the clinic, ultrasound data, revealed a tumor of the left kidney. According to the control CT revealed a tumor of the lower segment of the left kidney up to 3 cm, located on the border of lower and middle thirds of the anterior surface of the left kidney; the pathology of regional lymph nodes were found. Clinical diagnosis defined as "Cancer of the left kidney c T1N0M0". In this connection, we carried out laparoscopic transtentorial partial nephrectomy.

The technique of operation. The position of the patient on the back". Through a puncture in umbilically region is a trocar with laparoscope. During the audit the abdominal cavity revealed no pathology. The patient was transferred to the operating table in the Trendelenburg position (10°) and the "healthy" side (30°). Working trocars installed� in the epigastrium and along the lateral edge of the rectus abdominis. On the border of lower and middle third of the posterior-lateral surface of the projection of the left kidney, through the mesocolon, visualized a tumor, protruding above the surface of the kidney. Through the mesocolon, visualized renal vein. Along the course of the last made a linear incision of the peritoneum and tissues mesocolon with denudation of the vascular pedicle of the kidney. Renal artery locally allocated, fixed in the turnstile. Linear mesocolon dissection of tissue over the tumor, accessed fascia Gerota. On the background of thermal ischemia, which lasted 15 minutes, the tumor is excised with cold scissors within the healthy tissue together with fatty tissue, and covered her. The integrity of the anatomical structures of the kidney restored intracorporeal suture. Upon restoration of renal blood flow produced by the control of hemostasis. The surgery area drained through a separate puncture in the lumbar region. The drug is evacuated from the abdominal cavity in the plastic container. "Window in the mesocolon sutured. Deathplace. Suture wounds. The operation lasts for 75 minutes. Blood loss volume of 70 ml.

The postoperative period without complications. The patient became active on the day of surgery. After 8 hours was the first after the surgery chair. Conducted prevention of thromboembolic and infectious complications, the differential treatment. Need to�narcotic analgesics, and blood transfusion was not. In a satisfactory condition the patient was discharged under the supervision of a urologist clinics on the fourth day after the operation. At the control examination after a year of feeling satisfied patient, works, leads his normal life. According to the control MSCT data for the progression of the disease there. Blood tests and urine without pathology.

Clinical observation No. 2.

Patient I., aged 45, was hospitalized at the urology center of the Gorky railway without complaint. With ultrasound during a routine medical examination revealed a tumor of the left kidney. According to the control MRI with contrast defined tumor of the anterior surface of the lower segment of the left kidney to 3.7 cm Clinical diagnosis defined as "Cancer of the left kidney c T1N0M0". In this connection, we carried out laparoscopic transtentorial partial nephrectomy.

The technique of operation. The position of the patient on the back". Through a puncture in umbilically region is a trocar with laparoscope. During the audit the abdominal cavity revealed no pathology. The patient was transferred to the operating table in the Trendelenburg position (10°) and the "healthy" side (30°). Working trocars are installed in the epigastrium and along the lateral edge of the rectus abdominis. On the border of lower and middle third on the anterior surface of the projection of the left kidney, through the mesocolon, thick�that tumor formation, protruding above the surface of the kidney. Through the mesocolon visualized renal vein. Along the course of the last made a linear incision of the peritoneum and tissues mesocolon with denudation of the vascular pedicle of the kidney. Selected segmental renal artery, pityusa the lower pole of the left kidney. Artery is fixed in the turnstile. Linear mesocolon dissection of tissue over the tumor accessed fascia Gerota. On the background of segmental thermal ischemia, which lasted 10 min, the tumor is excised with cold scissors within the healthy tissue together with fatty tissue, and covered her. The integrity of the anatomical structures of the kidney restored intracorporeal suture. Upon restoration of renal blood flow produced by the control of hemostasis. The surgery area drained through the trocar wound in the iliac region. The tumor was evacuated from the abdominal cavity in the plastic container. "Window in the mesocolon was usualis. Deathplace. Suture wounds. The operation lasts for 80 min. Volume of blood loss of 40 ml.

The postoperative period was uneventful. The patient became active on the day of surgery. After 10 h after the operation was the first independent chair. Narcotic analgesics, and blood transfusion was not used. On the fifth day after the operation the patient was discharged to outpatient stage of treatment. Six months later, produced by the audit inspection: �alob no, feeling pleased to be working at the same place, leads a normal life. According to the MRI control area operations without pathology, no signs of progression. Clinical blood and urine without pathology.

1. A method for performing partial nephrectomy on the left, including the implementation of the access to the left kidney, excision of the tumor, the restoration of the anatomical integrity of the structures, characterized in that the access to the affected area of the kidney are performed by local dissection of the peritoneum and tissues of the mesocolon of the descending colon over the affected area of the kidneys and over the vascular pedicle of the kidney, then through a local incision mesocolon over the vessels that carry a limited selection of the main or segmental renal artery, which is fixed in the turnstile for subsequent transient clamping, thereby achieving total or segmental thermal ischemia, respectively, excised the tumor within healthy tissue together with fatty tissue, it covered, in a remote part of the kidney with tumor evacuated through the slit in the mesocolon is made over the affected area of the kidneys in the abdominal cavity, and then out, the wound of the kidney is sutured in layers.

2. A method for performing partial nephrectomy on the left according to claim 1, characterized in that the optimal size of the cut tissue of the mesocolon is�the looks of the incision is greater than the diameter of the tumor by at least 25%.



 

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