RU2367368C1 - Nephroptosis therapy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to urology, can be used in treatment of pathological renal mobility. Video-assisted endosurgical correction of nephroptosis is performed. Peritoneum is dissected together with nephritic fascia in a distal direction from lower renal pole. With a needle introduced through an endoport, upper edge of peritoneal flap is fixed along with a renal fascia at the right or renal fascia at the left to psoas with 4-5 ligatures along the edge of bottom renal pole. Free peritoneal bottom with fascia at the right or fascias at the left is duplicated to peritoneal top with 2-3 interrupted sutures.

EFFECT: method provides renal fixation reliability, technical simplicity, and minimal operative invasiveness, eliminates complications caused by open intervention, keeps renal mobility, and does not require foreign materials to be used.

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Description

The invention relates to medicine and, in particular, to urology, and can be used in the treatment of patients with omission of the kidneys (nephroptosis).

Today, there are many different methods for the treatment of nephroptosis, which are carried out both in an open (tomic) manner and through the use of modern medical technologies through laparoscopic or lumboscopic access. However, the disadvantage of open surgery is the high morbidity resulting from performing surgical access, a long rehabilitation period, the need to use narcotic analgesics in the postoperative period, the high probability of developing postoperative hernias, and the possibility of suppuration of a postoperative wound. A disadvantage of endovideo surgical interventions is their long duration, especially with lumboscopic approaches, the use of foreign material implants to fix the kidney in physiological position. In addition, a number of methods of nephropexy lead to a restriction of the respiratory mobility of the kidney.

An analogue - the prototype is nephropexy using laparoscopic access, in which the kidney is fixed by means of a prolene mesh, which in the form of "pants" is fixed in the retroperitoneal space like a hammock. The back surface of the mesh can be attached to the lumbar muscles by means of a special needle, which together with the thread is carried out percutaneously through punctures in the lumbar region, or by a herniostapler [1,2].

The disadvantages of this method are the long duration of surgery, and when using a herniostapler, insufficient reliability of fixation of the mesh to the lumbar muscles and kidney and the likelihood of a relapse of the disease, restriction of kidney mobility by the mesh during a respiratory excursion, the need for foreign material.

The closest analogue to the prototype is the method of V. A. Gorash [3]. The usual oblique lumbar incision exposes the retroperitoneal space. Open the general renal fascia. In a blunt way, the kidney is freed from adhesions, adhesions and the fat capsule, after which it is lifted in the hypochondrium and held in this position. Then above the ureter on the front and rear fascia leaves top-down welded sutures are placed at a distance of 3-4 cm from each other. After this, the seams are tightened and tied. From the bottom up impose the second floor of the welded seams. Next, the entire capsule in the form of a fat swab is placed under the lower pole of the kidney and 3-4 sutures are put together to tighten the fascial bag. The sutured fascial sac is fixed with two sutures to the periosteum of the XII rib. The wound is sutured in layers tightly. The patient should spend 18-21 days in bed.

The disadvantages of this method are the need for open surgery, a long rehabilitation period in the postoperative period, access injuries, a high probability of developing lumbar hernias, severe pain and the need for narcotic analgesics in the postoperative period.

The technical result to which the invention is directed is the development of a method for endovideo surgical nephropexy that meets the following requirements: anatomy, physiology, fixation reliability, short duration of intervention, simplicity of technical performance, minimally invasiveness.

The method is as follows.

Standard transperitoneal access is made in the supine position, with varying degrees of table tilt.

In Fig. No. 1 shows the establishment in the abdominal cavity of the following endoports:

- 10 mm above the navel - for a laparoscope,

- 5 mm in the right hypochondrium and - 5 mm in the left hypochondrium along the midclavicular line for holding a needle for nephropexy,

- 5 mm under the sternum in the midline or (and) a 5 mm trocar in the iliac region on the right with nephropexy on the right (left with nephropexy on the left).

After the endoports are installed, gas is insufflated into the abdominal cavity. The ascending and colon move down and medially.

In Fig. No. 2, it is shown how the kidney, by means of traction with the instruments, is set into a fixed physiological position 1. During surgery on the right, the peritoneum is dissected together with the prerenal fascia for about 5-6 cm, distal to 1.5 cm of the lower pole of kidney 2.

In Fig. No. 3 shows the exposure of the lower pole of the kidney. During an operation on the left, to access the kidney, the splenic angle of the colon is initially mobilized; later, the operation is carried out similarly, using the prerenal fascia as a strengthening material.

In Fig. 4,5, a special needle is shown, and Fig. 6 shows how an injection is made using a special needle inserted through the endoport over the sternum or in the right (during surgery on the right) or the left hypochondrium (during surgery on the left) through the peritoneum and the renal fascia (right) or the renal fascia (left), and the needle (1) below the pole of the kidney, through the lumbar muscles is carried out to the lumbar region, where the thread is inserted into it (2).

In Fig. No. 7, it is shown how the thread along the channel of injection with a needle is carried out into the abdominal cavity, where the second needle injection is made, retreating 2 cm and parallel to the edge of the kidney. The ligature is displayed on the lumbar region, near the site of the first puncture. The thread is tightened subcutaneously.

In Fig. No. 8.9, conducting 4-5 ligatures (2) according to the scheme until the fixation of the kidney. At the same time, a sheet of peritoneum fixed to the lumbar muscles with renal fascia or renal fascia (left) forms a physiological “hammock”, eliminating excess and maintaining physiological mobility of the kidney.

The free lower edge of the peritoneum or renal fascia (left) (1) is sutured with 2-3 interrupted sutures to the upper, forming a duplicate.

Example:

Patient M., 21 years old, medical history No. 17362. Diagnosis: Nephroptosis on the right, secondary chronic pyelonephritis, recurrent course, renal failure 0.

Complaints: for aching pains in the right lumbar region, aggravated in the evening and after exercise. Anamnesis of the disease - sick for five years, pyelonephritis attacks up to 4 times a year.

According to excretory urography, a pathologically mobile kidney is determined within 2.5 vertebrae (signs of nephroptosis of the II degree). Ultrasound examination of the kidneys: left - without pathology, pelvis not expanded, calyx up to 6 mm. Right 10.6 × 4.9 cm, upper pole lower by 9 cm from the dome of the diaphragm, pelvis 2.2 × 1.8 cm, calyx 0.6-0.7 cm. Ultrasound Dopplerography - the increase in vascular resistance indices of arteries II is determined -III order on the right. Clinical blood counts are normal. Urea 4.5 mmol \ l, creatinine 60 μmol \ l. General urine analysis, urine analysis according to Nechiporenko, urinalysis according to Zimnitsky - without pathology. Urine culture on microflora - E. Coli 10,000 microbial bodies.

The indication for surgery was the presence of a pain syndrome, a recurring course of pyelonephritis.

Operation No. 208: Under endotracheal anesthesia, gas was insufflated into the free abdominal cavity, 8 mm Hg. Revision of the abdominal cavity. At the level of the lower third of the right kidney, after its elevation to the physiological position, the parietal peritoneum was opened for 5 centimeters, the capsule of the kidney was mobilized from perinephral fiber and prerenal fascia. Using a trocar needle inserted through the endoport, the upper edge of the dissected parietal peritoneum was fixed together with the renal fascia to the lumbar muscles along the edge of the kidney pole, 4 interrupted sutures. The nodes are tied subcutaneously from the lumbar region, through the puncture site. The lower edge of the parietal peritoneum, together with the renal fascia, is fixed to the upper by separate interrupted sutures. Desufflation, seams on the skin, aseptic sticker.

The postoperative period was uneventful. Activated on the second day after surgery. Discharged home on the fifth day, with recommendations for wearing a bandage for a month and a half.

During the follow-up examination, one year after the operation, there is no pain, no pyelonephritis attacks per year, blood and urine tests are normal. Ultrasound examination in the standing position of the right kidney in a typical place, while maintaining a respiratory excursion. Excretory urography - the position of the right kidney is typical, is shifted by ^1/2 _{of the} body of the lumbar vertebra, the urodynamics are not broken. With ultrasound dopplerography - vascular resistance indices in the right kidney are within normal limits. The advantages of the proposed method:

- minimally invasive due to the use of laparoscopic access;

- anatomy of surgery;

- the method of nephropexy is simple in technical execution, does not require the use of foreign materials;

- the nephropexy method is available in any institutions that have endovideo surgical equipment;

- short duration of the operation;

- the method allows you to activate the patient in the early stages after surgery (after 1-2 days);

- preservation of the mobility of the kidney (physiological respiratory excursion);

- reduction of postoperative hospital bed and rehabilitation period;

- a good cosmetic result.

Literature:

1. Antonov A.V. Endovideourology. Upper urinary tract and pelvis. SPb .; 2005.

2. Puchkov KV, Filimonov VB, Vasin RV, Vasin IV Nephropexy using a polypropylene implant with laparoscopic access: a clinical and experimental study. - Urology, 2008. - No. 2. - C.3-8.

3. Chukhrienko D.P., Lyulko A.V. Atlas of operations on the organs of the genitourinary system. - M: Medicine, 1972. - 375 p.

Claims (1)

The method of endovascular surgical correction of nephroptosis, characterized in that after dissection of the peritoneum together with the renal fascia distal to the lower pole of the kidney using a needle inserted through the endoport, the upper edge of the peritoneal flap is fixed with the renal fascia on the right or renal fascia on the left to the lumbar muscles 4-5 ligatures along the edge of the lower pole of the kidney, and the free lower edge of the peritoneum with fascia on the right or fascia on the left is sutured with 2-3 interrupted sutures to the upper one according to the type of duplication.

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