RU2134548C1 - Method of nephroptosis treatment - Google Patents

Abstract

FIELD: medicine, more specifically, surgery. SUBSTANCE: method includes making on abdominal wall of four incisions sizing from 0.5 to 2.0 cm; installation of trochars for introduction of laparoscope and tools; taking aside right portion of liver; dissection of peritoneum up to 10 cm in projection of right kidney; separation of anterior surface, upper pole and kidney rib; introduction into abdominal cavity of prolen net sizing 2 x 2.5 cm with vicryl thread and straight needle; fixation of prolen net to kidney; introduction of needle holder through subcostal trochar; catching of straight needle; bringing of needle through thickness of abdominal wall; making incision up to 10 cm in point of needle appearance; suturing through incision to fascia of vicryl thread; tying of vicryl threads and pulling of kidney to its physiological position; peritonizing of kidney region by application of continuous endosuture. EFFECT: reduced injury caused by intervention.

Description

 The invention relates to medicine and will find application in the treatment of nephroptosis and kidney rotation.

 Nephroptosis, a fairly common urological pathology, covering almost all age groups, is the cause of disability, the development of pyelonephritis, arterial hypertension, often leads to asthenization of the patient.

 Conducted research on the medical-scientific and patent literature revealed a number of methods for the treatment of nephroptosis.

 So, by the copyright certificate N 542514, BI N 2, 1977, IPC A 61 B 17/00 the "Method for the treatment of nephroptosis" is protected, which provides for the selection of the upper pole of the kidney and its fixation to the diaphragm.

 Author's certificate N 545339, BI N 5, 1977, IPC A 61 B 17/00 protects the "Method for the treatment of a movable kidney", which includes stitching the kidney to the diaphragm on a fascial-diaphragmatic flap.

 Copyright certificate N 588977, BI N 3, 1978, IPC A 61 B 17/00 protects the "Method of Nephropexia", which provides for the fixation of the kidney with allogeneic wide fascia of the thigh, from which a triangular flap is cut out and sutured to dense peritoneal tissues.

 Patent certificate N 1662513, BI N 26, 1991, IPC A 61 B 17/00 protects the "Method for the treatment of a movable kidney", which involves cutting a fascial flap from the posterior leaf of the renal fascia with one base directed to the dome of the diaphragm and suturing the lower segment of the kidney to a split flap.

 Patent certificate N 1690703, BI N 42, 1991, IPC A 61 B 07/00 protected "Method for the treatment of nephroptosis", providing for longitudinal incision on the front and rear surfaces and fascioplication at the mid-transverse axis of the displaced kidney simultaneously with supracapsular fixation of the kidney to the final fascia at the incision site.

 Author's certificate N 1801373, BI N 10, 1993, IPC A 61 B 17/00 protects the "Nephropexy method on the right", which involves cutting a flap from the parietal peritoneum in the region of the lower surface of the kidney with the base to the dome of the diaphragm 6-7 cm long and fixated.

 Copyright certificate N 1804801, BI N 12, 1993, IPC A 61 B 17 \ 00 protected "Method of nephropexia", which involves dissecting the front flap of the renal fascia at the border with the parietal peritoneum in the longitudinal direction for 8-9 cm, retreating outwards on 2-3 cm, make a parallel incision and form a U-shaped fascial flap, which is sewn to the fibrous capsule of the front surface of the kidney.

 Author's certificate N 1827184, BI N 26, 1993, IPC A 61 B 17/00 protects the "Method for the treatment of nephrolithiasis", which involves puncture of the lower calyx, and after removal of calculi, fixation of the movable kidney using rigid drainage with a balloon for at least 20 days.

 Author's certificate N 2012245, BI N 9, 1994, IPC A 61 B 17/00 protects the "Method for the treatment of nephroptosis", which involves cutting out an aponeurotic flap from the transverse abdominal muscle, after isolation and movement of the kidney, three U-shaped sutures are placed between the renal fascia the fibrous capsule of the kidney along its front surface and the nodal joints between the formed flap and the fibrous capsule of the kidney along its outer edge.

 The disadvantages of these methods is the high invasiveness of surgical intervention (the need for lumbotomy 12-15 cm long), the occurrence of postoperative complications, the relatively long healing time of the operating room.

 The closest analogue taken as a prototype is the "Method of nephropexy", protected by the patent of the Russian Federation N 2029506, BI N 6, 1995, IPC A 61 B 17/00.

 The method is as follows: after a lumbotomy, the lower pole of the kidney is freed of paranephric tissue and half of the front surface. Then, subcapsular tunnels and a tunnel in the paranephric tissue along the anterior surface to the upper pole of the kidney are formed on the mobilized surface of the kidney. A flap on the leg is cut out from the parietal peritoneum, the base to the diaphragm at the level of 12 thoracic vertebra. The flap is passed through the tunnel in the paranephric tissue from the upper pole to the mobilized surface and then laid in subcapsular tunnels along the front surface and on the lower plus of the kidney. After this, the flap is sutured to the kidney capsule. The method allows to maintain the physiological mobility of a fixed kidney and the physiological blood and lymph circulation of the kidney. Despite the good results of treatment, this method has the following disadvantages: greater trauma, the need for wide surgical access with an operating wound length of up to 12-15 cm, the risk of developing postoperative complications, the length of hospital stay 10-15 days after surgery.

 The aim of the present invention is to reduce the morbidity, achieve a cosmetic effect, reduce the patient’s hospital stay, reduce the number of postoperative complications. This goal is achieved in that the surgical intervention is carried out using laparoscopic techniques.

 The method is as follows.

 Under general anesthesia with the use of muscle relaxants, after preliminary processing of the surgical field, an umbilical incision of up to 3 mm is performed. A Veress needle is inserted through the incision, after conducting samples, pneumoperitoneum up to 3.5 liters is created. In a closed way, a 10 mm trocar is inserted 3 cm higher and to the right of the navel through an incision on the anterior abdominal wall of 1 cm. A laparoscope is inserted and the abdominal cavity is examined to exclude damage from the introduction of the troacap and exclude other abdominal pathology. Three additional trocars are introduced into the epigastrium (10 mm trocar), the right hypochondrium along the anterior axillary line 5 cm below the right costal arch (10 mm trocar), along the right parasternal line under the costal arch (12 mm trocar). The right lobe of the liver is removed by the organ manipulator through the epigastric trocar. A cut up to 10 cm dissect the peritoneum in the projection of the ribs of the right kidney. The front surface, the upper pole and the edge of the right kidney, the transverse fascia in the projection of the 10th, 11th, 12th ribs along the posterior axillary line are isolated, freeing it from the paranephral tissue, the prolene mesh, most often used in laparoscopic, is introduced through the upper hypochondria surgery, 2 x 2.5 cm in size with a 12 cm long tied to its small side with a straight atraumatic needle. The prolene mesh with the small side, free of thread, is fixed to the kidney in the region of its upper pole, closer to the rib of the kidney with a reusable ETHICON form herniostapler inserted through the upper hypochondrium trocar, with 3-4 brackets. To do this, traction of the upper pole of the kidney is preliminarily carried out ventrally and caudally, a needle holder is inserted through the upper hypochondrium trocar, a straight needle is taken and drawn through the entire thickness of the abdominal wall in the 10th, 11th intercostal space along the posterior axillary line, in the place of needle puncture through the skin do an incision up to 1 cm, through which additional vicryl filament is sutured to the nearby fascia and tied with a thread removed from the abdominal cavity, while the latter moves the kidney to its physiological position, providing it with a physiological mobility, lymph and blood circulation, the area of the kidney is peritonized by the application of a continuous endosw.

 Example 1. Patient Semenchenko G. G., 50 years old, was admitted to the clinic "Health" on 12/20/95 (medical history 201629) with a diagnosis of Right-sided nephroptosis of the 2nd degree. 12/21/95, Laparoscopic nephropexy.

 Under endotracheal anesthesia, after preliminary processing of the surgical field, an umbilical incision of up to 0.3 cm was made. A Veress needle was inserted through the incision, and pneumoperitoneum up to 3.5 l was created after the tests. A 10 mm trocar was inserted in a closed manner 4 cm higher and to the right of the navel through a 1 cm incision on the anterior abdominal wall. The abdominal cavity was examined with a laparoscope and no abdominal pathology was revealed. 3 additional trocars were introduced in typical places (epigastrium, right hypochondrium along the anterior axillary line 5 cm below the right costal arch, along the right parasternal line under the costal arch). The right lobe of the liver was taken away with an organ manipulator inserted through the epigastric trocar, and a peritoneum was dissected up to 8 cm in the projection of the rib of the right kidney. The front surface, the upper pole, the rib of the right kidney, the transverse fascia in the projection of the 10th and 12th ribs along the posterior axillary line are highlighted, a 2 x 2.5 cm prolene mesh was introduced through the upper hypochondrium trocar with a length of vicryl thread movable to its small side 12 cm with a straight atraumatic needle. The prolene mesh was fixed to the kidney in the region of its upper pole closer to the edge of the kidney with a reusable ETHICON herniostapler inserted through the upper hypochondrium with 4 staples. A needle holder was inserted through the upper hypochondrium trocar, by which a straight needle was drawn through the entire thickness of the abdominal wall in the 10th intercostal space along the posterior axillary line, a 1 cm incision was made through the skin at the site of the needle puncture, through which a free vicryl thread was sutured and tied with a thread removed from the abdominal cavity to the skin, pulling the right kidney to the physiological position, the area of the kidney is peritonized by the application of a continuous endo suture. Control of places of introduction of trocars. Hemostasis. Gas from the abdomen removed. Stitches to the skin. Aseptic dressing.

 The postoperative course is smooth, bed rest for 7 days.

 The patient was examined after 3 months, does not show complaints, on an excretory urography in a standing position, the kidney is in a physiological position.

 Example 2. Patient Tarasova L. N., 20 years old, was admitted to the clinic "Health" 18.12.95. (medical history 400381) with a diagnosis of Right-sided nephroptosis of the 2nd degree. 11.28.95 g. Laparoscopic nephropexy.

 Under endotracheal anesthesia, after preliminary processing of the surgical field, an incision was made up to 1 cm, 4 cm higher and to the right of the navel, a Verash needle was inserted through the incision, and pneumoperitoneum up to 3.5 l was created after the tests. A closed method introduced a 10 mm trocar. A laparoscope performed an audit of the abdominal cavity, damage and pathology of the abdominal cavity were not detected. 3 additional trocars were introduced in typical places (epigastrium, right hypochondrium along the anterior axillary line 5 cm below the right costal arch, along the right parasternal line under the costal arch). The right lobe of the liver was taken away by the organ manipulator through the epigastric trocar, the peritoneum in the projection of the rib of the right kidney was dissected up to 10 cm. The front surface, the upper pole, the rib of the right kidney and the transverse fascia in the projection of the 10th to 12th ribs along the posterior muscular line are highlighted, a 2 x 2.5 cm prolene mesh was introduced through the upper hypochondrium trocar with a vikril thread tied to one of its sides 12 cm long with a straight atraumatic needle. The prolene mesh was fixed to the kidney in the region of its upper pole closer to the edge of the kidney with a reusable ETHICON herniostapler inserted through the upper hypochondrium with 3 staples. A needle holder was introduced through the upper hypochondrium trocar, with which a straight needle was drawn through the entire thickness of the abdominal wall in the 11th intercostal space along the posterior axillary line, at the site of the needle piercing through the skin, an incision of up to 1 cm was made, through which a free vicryl thread was sewn to the nearby fascia and tied to a thread brought to the skin from the abdominal cavity, while the right kidney is pulled up in a physiological position and fixed, the region of the kidney is peritonized by the application of a continuous endo suture. Control of places of introduction of trocars. Hemostasis. Gas from the abdomen removed. Stitches to the skin. Aseptic dressing.

 The postoperative course is smooth, bed rest for 6 days.

 The patient was examined after 3 months, no complaints, with excretory urography in a standing position, the kidney is in a physiological position.

 The presented laparoscopic nephropexy technique was used in 27 patients with right-sided nephroptosis, in all patients the postoperative period was uneventful, and in the control study of the kidneys by ultrasonography and excretory urography 3 and 6 months after the operation, the physiological position of the right kidney was noted.

 Compared to the prototype, the claimed method is less traumatic, the patient’s hospital stay is reduced, the risk of postoperative complications is reduced, a good cosmetic effect is achieved, as incisions for introducing trocars 1-2 cm heal almost without scarring.

 The method was tested in the medical diagnostic center "Health" for 27 patients. The results of its use are positive, as confirmed by examples.

Claims (1)

 A method of treating nephroptosis, which involves fixing the kidney in a physiological position, characterized in that the surgical intervention is carried out using laparoscopic techniques, for which 4 cuts from 0.5 to 2 cm in size are made on the abdominal wall, trocars are inserted for the introduction of a laparoscope and instruments, with an organ manipulator the right lobe of the liver is removed, the peritoneum is cut up to 10 cm in the projection of the right kidney, the front surface, upper pole, kidney rib, transverse fascia in the projection of the 10th, 11th and 12th ribs are isolated of the posterior axillary line, a 2 × 2.5 cm prolene mesh is inserted into the abdominal cavity, with a 12 cm long acrylic thread tied to its small side with a straight atraumatic needle, the prolene mesh with the small side free from the thread is fixed to the kidney in the region of its upper pole closer to the rib of the kidney, the needle holder is inserted through the upper thigh trocar, they grab a straight needle and pass it through the entire thickness of the abdominal wall in the 10th and 11th intercostal space along the posterior axillary line, make an incision up to 1 cm through the skin through the skin, through which it is close to the lying fascia is sutured with a vikril thread and tied with a vikril thread removed from the abdominal cavity, while the latter pulls the kidney into the physiological position, the region of the kidney is peritonized by the application of a continuous endo suture.