Method for left total nephrectomy

FIELD: medicine.

SUBSTANCE: left total nephrectomy is performed. A kidney is approached by forming an oval window into a mesocolon of a descending colon. The window area is limited by: v. mesenterica inf, arcus Riolani, a. colicae sin and a tail of pancreas. A ligament of Treitz, a peritoneum and mesocolon tissues are incised. A free oval area of the mesocolon and peritoneum are left on the kidney. The kidney is evacuated through the mesocolon window. The mesocolon is left open. A strand of a greater omentum is placed into a retroperitoneal cavity formed after the kidney has been removed. In specific case, the kidney is mobilised together with an adrenal gland.

EFFECT: method enables optimising the surgical procedure by eliminating the stage of intestinal mobilisation, leads to the fastest postoperative intestinal functional recovery.

3 cl, 2 ex

 

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

The most effective treatment for renal cell cancer remains operational. Evolution of laparoscopic technologies in urology has led to the almost total abandonment of traditional interventions in localized tumors of the kidney. So, laparoscopic nephrectomy recognized by the European Association of urology the method of choice in the treatment of renal cell carcinoma in stage T1-T2[The summary of recommendations of the European Association of urology. Edited by M. Kogan. - Rostov-on-don: OOO "omega-Print", 2009. - 317 C].

Any standard algorithm laparoscopic nephrectomy provides a broad mobilization of the colon with the intersection of the colon-splenic and splenic-phrenic ligament to expose the retroperitoneal space [Puchkov, K. V. Laparoscopic surgery for kidney cancer / K. V. Puchkov, A. A. Krapivin, V. B. Filimonov. - M.: publishing house "medical practice-M, 2008. - Pp. 94-111 (prototype developed method) 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. - 52-57].

This stage rarely takes less than a third operational time and is accompanied by some risk of iatrogenic intraoperative complications, such as wound wall �lshka and damage to the spleen, occur during 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 / C. B. 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 nephrectomy through a "window" in the mesocolon of the descending colon, without the mobilization of the last.

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

Achievable technical results are provided in the implementation of the developed method are:

- ergonomic access to the surgical area of interest 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 injuries.

- 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 fu�functions of the intestine in the postoperative period.

- developed access provides fast identification and secure precise dissection of the great vessels. The latter due to the minimal thickness of the tissue of the mesocolon, covering the vascular pedicle of the kidney, where Vienna Shine through the mesentery of the colon.

- used anatomical landmarks forming an oval "window" guarantee optimal extraction of the kidney within the fascia Gerota through this doorway. Creating a window of smaller size will not allow to evacuate through him a kidney. The formation of a wider "window" is impractical and fraught with risk of injury of the left colon vessels or the inferior mesenteric vein.

- leave mesocolon on the kidney, eliminates the risk of damage to the fascia Gerota and bleeding from underlying blood vessels.

The method is as follows.

Carry out the dissection of the ligament of Treitz, peritoneum and tissues mesocolon widely to form an oval "window" in the mesocolon of the descending colon, the top of which is limited by v. mesenterica inf, arcus Riolani, a. colicae sin and tail of the pancreas, and received a free oval part of the mesocolon and peritoneum leave on the kidney.

Using the generated access is made to the allocation of the abdominal aorta, renal and adrenal vessels (artery� and veins).

Produces a wide selection of the artery and vein of the kidney during. In accordance with the requirements of the first stage ablation ligated (legasuite/cleroidea) and intersects the renal artery at the site of its confluence with the abdominal aorta. Then ligated (legasuite/cleroidea) and renal vein intersects together with its tributaries (adrenal, gonadal, and lumbar veins). After the treatment of renal vascular organ megascale emit from all sides without compromising the integrity of the fascia Gerota and adipose capsule, complete with the adrenal or without. After mobilization of the ureter to the level of the common iliac vessels of his tie (be ligated/ kopiruyut) and cross. The body is evacuated through a "window" mesocolon into the abdominal cavity, and then out. The window in the mesocolon not sutured. In formed after removal of the kidney cavity in the retroperitoneal space is placed a strand of greater omentum.

Clinical example No. 1.

Patient X., 38 years. Hospitalized with complaints of recurrent back pain on the left. Outpatient ultrasound examination revealed a tumor of the left kidney. MRI - a solid education to 7 cm is located on the border of lower and middle third of the posterior-lateral surface of the left kidney with the signs of infestation pelvis; data for pathology of lymph node not�. On the survey results, the clinical diagnosis was verified as "Cancer of the left kidney cT1N0M0"in this connection we carried out laparoscopic transtentorial nephrectomy.

The technique of operation. The position of the patient on the back". Optical trocar in umbilically area. After inspection of the abdomen 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. Formed transtentorial access to the left kidney. Why cut the ligament of Treitz, the peritoneum and tissues mesocolon widely to form an oval "window" of the mesentery of the descending colon, the top of which is limited by v. mesenterica inf, arcus Riolani, a. colicae sin and tail of the pancreas. Part of the mesocolon and of the peritoneum on the left kidney. Using the generated access selected the mouth of the left renal artery, which is the hour be ligated the abdominal aorta and the cross. Then Legerova and crossed renal vein tributaries. Megascale, the left kidney was mobilized within the fascia Gerota whole, without adrenal gland. The ureter is mobilized to the level of the iliac vessels, where Legerova and crossed. The drug is extracted through a window in the mesocolon and evacuated from the abdominal cavity in the plastic container. Through a "window" in the mesentery of Obodo�Oh bed of excised intestine kidneys are filled with the lock of the greater omentum. Deathplace. Suture wounds.

The operation lasts for 55 minutes. The volume of blood loss of 50 ml.

The postoperative period is smooth. The patient became active in the first day. At the same time marked the restoration of bowel function (stool within 12 hours after surgery). Need narcotic analgesics, and blood transfusion was not. In a satisfactory condition the patient was discharged under the supervision of a urologist clinic on the fifth day after surgery. At the control examination after a month of being patient is good, works at the same place, leads a normal lifestyle. According to the control ultrasound surgery area of pathology. The blood and urine tests within normal limits.

Clinical example No. 2.

Patient L., 72 years of age. Hospitalized at the urology center of the Gorky railway with complaints of recurrent nagging pain in your lower back on the left and increased blood pressure up to 190/110 mm Hg ultrasound examination revealed a tumor of the upper pole of the left kidney up to 7 cm According to the control MSCT with contrast, heterogeneous verified tumor of the upper pole of the left kidney up to 6.5 cm in maximum dimension, densely adjoining to the adrenal gland. Education is uneven contrast; of signs of involvement of regional lymph nodes were found. Based on the survey results, the diagnosis veri�econovan as "Cancer of the left kidney cT 1N0M0". The latter was an indication for surgical treatment in the amount of laparoscopic nephrectomy.

The technique of operation. The position of the patient on the back". Optical trocar in umbilically area. After inspection of the abdomen 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. Formed transtentorial access to the left kidney. Why cut the ligament of Treitz, the peritoneum and tissues mesocolon to form a "window" to the mesentery of the descending colon of oval form, the top of which is limited by v. mesenterica inf, arcus Riolani, a. colicae sin and tail of the pancreas. A fragment of the mesocolon and of the peritoneum on the left kidney. Using the described access selected the mouth of the left renal artery, which is patched up and crossed to the confluence of the abdominal aorta. Then kopirovane and crossed renal vein tributaries. Megascale, the left kidney was entirely mobilized together with the adrenal gland, without compromising the integrity of the fascia Gerota. Ureter allocated to iliac vessels. There is crossed after clipping. Body extracted through a window in the mesocolon and evacuated from the abdominal cavity in the plastic container. Through a "window" in mesocolon colon in the box remote kidneys failed� the lock of the greater omentum. Deathplace. Suture wounds. The operation lasts for 45 minutes. Blood loss volume of 70 ml. Postoperative period without complications. Patient activated on the day of surgery. Recovery of bowel function observed after 10 postoperative hours was held self-formed stools). Blood transfusion and narcotic analgesia was not used. The patient was discharged for outpatient monitoring in a residence on the fifth day after surgery. Control examination after 2 months. According to the ultrasound area surgery without pathology; blood and urine tests within normal limits. The patient feels satisfied, socially and professionally rehabilitated completely.

1. A method for performing a total left nephrectomy, including the implementation of the access to the left kidney, isolation and ligation of the vessels of the kidney, the kidney allocation without compromising the integrity of the fascia Gerota and adipose capsule, the mobilization of the whole kidney and ureter to the level of the common iliac vessels, the ureter is ligated and cut, it is removed, characterized in that the access to the kidney perform by forming an oval window in the mesocolon of the descending colon, the top of which is limited by v. mesenterica inf, arcus Riolani, a. colicae sin and tail of the pancreas, which carried out the dissection of the ligament of Treitz, peritoneum and tissues mesocolon, and the received�th free oval part of the mesocolon and peritoneum leave on the kidney, the body is evacuated through a "window" of the mesocolon, a "window" in mesocolon are not sutured, and the resulting after removal of the kidney cavity in the retroperitoneal space is placed a strand of greater omentum.

2. A method according to claim 1, characterized in that the kidney is mobilized together with the adrenal gland.

3. A method according to claim 1, characterized in that the kidney is mobilized without adrenal gland.



 

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