RU2503420C1 - Method of laparoscopic nephropexy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to urology. 0.5 cm long skin cut is made under twelfth rib. First injection needle is introduced into wound and directed under lower end of kidney 1.5-2.0 cm more medially than its longitudinal axis. Second injection needle is introduced near first injection needle and directed under lower end of kidney 1.5-2.0 cm more laterally than its longitudinal axis. Ligature is placed into abdominal cavity through instrumental port. Ends of ligature are inserted into needle holes. Needles are extracted through wound of lumbar area. Ends of ligature are tightened and ties up by surgical knot.

EFFECT: method of laparoscopic nephropexy reduces probability of nephroptosis recurrence, restricts supermobility of organ, prevents rotational displacements of kidney in post-operative period.

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Description

The invention relates to medicine, namely to urology, and can be used in the surgical treatment of nephroptosis.

There is a method of treating nephroptosis based on the principle of Rivoir surgery, which includes the following operation technique: a flap of the psoas major muscle is cut out, it is subcapsular along the posterior surface of the kidney and the caudal end is fixed to the twelfth rib (Pytel A.Ya., Lopatkin N.A. “On the Rivoir operation and its modifications as the most physiological method of nephropexy.” J. “Urology and Nephrology. M.,“ Medicine, 1996, No. 21, pp. 3-7.)

The disadvantage of this method is that the aforementioned nephropexy prevents the physiological mobility of the kidney and gives a large number of complications.

A known method of treating nephroptosis, including lumbotomy, opening the renal fascia, reposition of the kidney, suturing the renal fascia, while it is hemmed with mattress stitches in a checkerboard pattern, through 1-1.5 cm to the fibrous capsule of the kidney (RF Patent No. 2284159 "Method of nephropexy ”, September 27, 2006, BI No. 6, 2006).

The known operation contradicts modern principles of minimally invasive surgery, since it is carried out by lumbomy.

The closest technical solution chosen as a prototype is an endoscopic method for the treatment of nephroptosis - laparoscopic nephropexy, including the creation of pneumoperitonium under general endotracheal anesthesia: a trocar for a telescope and a trocar for introducing instruments are introduced into the abdominal cavity; on the right or left side channel, the peritoneum is dissected and the colon moves downward and medially; then the peritoneum and prerenal fascia are dissected at the lower end of the kidney, the kidney is mobilized from perinephral fiber; distal to the lower pole of the kidney using a needle inserted through the endoport, fix the upper edge of the peritoneal flap together with the renal fascia to the lumbar muscles with 4-5 ligatures along the edge of the lower pole of the kidney, and the free lower edge of the peritoneum to the upper type of duplicate (RU 2367368, C1 09/20/2009 description s.4).

The disadvantages of this method are that the well-known laparoscopic nephropexy does not provide anatomical and physiological fixation of the kidney, as it is performed by dissecting the peritoneum and renal fascia and their duplicate suturing to the lumbar muscles, moreover, the nephrofixation zone is injured when the muscles of the lumbar region are contracted, t .e. the position of the kidney is determined by the tone and activity of muscle tissue; the technical stages do not provide damping, and therefore renoprotective, mechanisms of nephropexy, since heterogeneous tissues of the perinephric space are connected.

The objective of the invention is to prevent relapse.

This task is achieved in that the method of laparoscopic nephropexy includes the creation of pneumoperitoneum, insertion of trocars for the telescope and instruments into the abdominal cavity, reposition of the kidney overlaying nephrofixation sutures, characterized in that under the twelfth rib of the affected lumbar region, a skin incision of 0.5 cm is performed, the first injection needle is inserted into the resulting wound and the abdominal cavity is punctured, the needle is directed under the lower end of the kidney medial to its length 1.5-2.0 cm, next to the first injection needle they tear the abdominal cavity with a second needle and direct it under the lower end of the kidney laterally 1.5–2.0 cm laterally through the instrument port, a ligature is prevented through the instrument port into the abdominal cavity, one end of which is inserted into the lumen of the first needle and the other end into the lumen of the second needle , the needles are removed through the wound of the lumbar region, and the ends of the ligature are pulled and tied with a surgical knot, thereby performing nephropexy.

The method of laparoscopic nephropexy is as follows.

The essence of the proposed method of laparoscopic nephropexy is illustrated in the figure, where 1 is the kidney, 2 are injection needles, 3 is the fascia-peritoneal U-shaped suture.

The operation is carried out from two 5 mm punctures. The central trocar is installed in a standard umbilical point in the midline of the abdomen. The manipular trocar is installed under the control of optics in the left mesogastric region at the level of the navel. After the diagnostic stage, instrumental reposition of the kidney is performed. Next, the patient is turned on his side and under the twelfth rib of the affected lumbar region, a 0.5 cm long skin incision is made. The first injection needle is inserted into the wound and the abdominal cavity is punctured, with the needle directed under the lower end of the kidney 1.5-2 times more medial than its length, 0 cm, next to the first injection needle, the abdominal cavity is punctured with the second needle, and it is directed under the lower end of the kidney laterally 1.5–2.0 cm lateral to the kidney. A ligature is placed in the abdominal cavity through the instrument port, one end of which is inserted into the lumen of the first needle, and the second end into the lumen of the second needle. The needles are removed through the wound of the lumbar region, and the ends of the ligature are pulled and tied with a surgical unit, thereby performing nephropexy by partially closing the subrenal fascial space. Cosmetic sutures are placed on the puncture wounds of the anterior abdominal wall and lumbar region.

The method of laparoscopic nephropexy is confirmed by an example of a specific implementation.

Example. Patient A., 16 years old. Diagnosis: Right-sided nephroptosis of the 3rd degree. Chronic pyelonephritis. Under general anesthesia, an operation was performed: laparoscopic nephropexy on the right. Progress of the operation: a central 5 mm trocar is installed in a standard umbilical point along the midline of the abdomen. A manipulative 5 mm trocar is installed under the control of optics in the mesogastric region at the level of the navel. After the diagnostic stage, an instrumental reposition of a lowered kidney was performed. Then the patient was laid on his side and a skin incision 0.5 cm long was made under the twelfth rib of the affected lumbar region. The first injection needle was inserted into the resulting wound and the abdominal cavity was punctured, with the needle directed 1.5-2 to the lower end of the kidney, 0 cm; the abdominal cavity is punctured next to the first injection needle with the second needle, and it is directed under the lower end of the kidney laterally 1.5–2.0 cm laterally of its kidney. A ligature is placed in the abdominal cavity through the instrument port (prolene 3-00), one end of which is tucked into the lumen of the first needle, and the second end into the lumen of the second needle. The needles were removed through the wound of the lumbar region, and the ends of the ligature were stretched and tied with a surgical unit, thereby nephropexy was achieved by partially closing the subrenal fascial space. Cosmetic sutures were placed on the puncture wounds of the anterior abdominal wall and lumbar region.

The postoperative period was uneventful. Wound healing by primary intention. Suppressive antibacterial and anti-inflammatory therapy was carried out for a week. A follow-up examination after 6 months noted the elimination of nephroptosis on the right and improvement of renal function according to dynamic gamma scintigraphy. No urinary infection detected, no complaints.

The proposed method of laparoscopic nephropexia allows you to: reduce the likelihood of recurrence of nephroptosis, since an optimal anatomical and functional configuration of the fascial-peritoneal bed of the kidney is formed, and partial closure of the subrenal fascial space limits the organ mobility; this prevents the rotational displacement of the kidney in the postoperative period, since nephropexy is performed symmetrically to the length of the organ.

Claims (1)

A method of laparoscopic nephropexy, including the creation of pneumoperitoneum, introducing trocars for a telescope and instruments into the abdominal cavity, reposition of a kidney for applying nephrofixation sutures, characterized in that a skin incision of 0.5 cm is performed under the twelfth rib of the affected lumbar region, the first injection needle is inserted into the resulting wound and the abdominal cavity is punctured, the needle is directed under the lower end of the kidney medial of its length 1.5-2.0 cm, the abdominal cavity is punctured near the first injection needle with the second needle and n they rule it under the lower end of the kidney laterally 1.5-2.0 cm lateral than its length, a ligature is prevented through the instrument port into the abdominal cavity, one end of which is inserted into the lumen of the first needle and the other end into the lumen of the second needle, the needles are removed through the wound lumbar region, and the ends of the ligature are pulled and tied with a surgical node, thereby performing nephropexy.

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