KIDNEY SURGERY

KIDNEYSURGERY

Site hosted by Dr Taj Uddin Qadri FCPS FRCS

Assistant Professor of Surgery Baqai Medical University Karachi Pakistan

SURGICAL APPROACH TO THE KIDNEY

ANTERIOR APPROACH
Position - supine

Incision

Paramedian/Kocher's subcostal on the appropriate side
Full laparotomy

Procedure

1. Divide peritoneal reflection lateral to colon and mobilise the colonic flexure

2. Beware
a. On right

• Hepatic flexure

• Duodenum

• Gonadal vessels

b. On left

• Splenic flexure

• Spleen

• Tail of pancreas

• Gonadal vessels

3. Mobilise the colon medially to display the perinephric fascia which is opened to display the kidney

4. Structures at the hilum

a. Renal vein is most anterior

b. Renal artery

c. Ureter is deep to the artery

Postoperatively ileus common

POSTERIOR APPROACH

Position lateral, with a renal bridge on the operating table under the opposite loin

Incision

1. Either supracostal or subcostal, following the line of the 12th rib; commencing 6 cm lateral to the mid-line and finishing in the posterior axillary line

2. Deepen by dividing
a. Latissimus dorsi
b. External oblique
c. Internal oblique/quadratus lumborum in the line of the incision to display the perinephric fascia
d. Identify the ureter

3. Open the perinephric fascia to display the kidney

4. Structures at the hilum
a. Ureter is most posterior
b. Renal artery
c. Renal vein deep to the artery

5. Beware pneumothorax

6. Ileus common with retroperitoneal trauma

NEPHRECTOMY

Indications

1. Malignant tumour arising within the kidney

2. Chronic pyelonephritis complicated by hypertension, recurrent infection

3. Transitional cell carcinoma of the ureter treated by nephro-ureterectomy

Preoperative management

1. Examine and mark the side

2. Investigations

a. MSU and treat concurrent urinary tract infection
b. IVP/ultrasound/CT

• Delineate pathology

• Confirm the presence of opposite kidney
c. Adenocarcinoma

• Arteriography ± embolisation

• Consider cavagram to exclude venous extension

d. Transitional cell carcinoma - cystoscopy to exclude co- existing bladder tumours

e. Urine cytology

3. Antibiotic prophylaxis to Gram-negative bacteria

4. IVI

5. Catheterise

Pre-incision

General anaesthetic with endotracheal intubation

Procedure

1. Use anterior approach but do not open perinephric fascia when operating for cancer

2. Clamp the renal artery

3. Ligate and divide in continuity

a. Renal vein (oversew the short right renal vein)
b. Renal artery

4. Adenocarcinoma of the kidney/chronic pyelonephritis – ligate and divide ureter at an accessible point. Remove kidney for histological examination

5. Transitional cell carcinoma of the renal pelvis - needs a complete ureterectomy with excision of the vesico-ureteric junction and formal closure of the bladder

Closure

1. Large suction drain to the renal bed

2. Close in layers

Postoperative management

Investigation

1. MSU

2. Histological examination of specimen

3. Transitional cell carcinoma - needs long-term cystoscopic follow-up

Complications

1. Early

a. Infection

• Urine

• Wound

• Septicaemia

b. Haemorrhage - reactionary at renal pedicle
c. Ileus
d. DVT
2. Late

Tumour recurrence, new primary with transitional cell carcinoma

PYELOLITHOTOMY/URETEROLITHOTOMY

Preoperative management

1. Examine and mark the side

2. Investigations

a. MSU, treat pre-existing urinary tract infection

b, IVP

c. Those for renal calculi (24 h urine for calcium, oxalate, urate, xanthine, cysteine analysis)

d. Renal function (electrolytes, clearance studies)
e. Plain abdominal X-ray en route to the operating theatre to see if the stone has moved

3. Broad spectrum antibiotic prophylaxis

4. IVI

Pre-incision

1. General anaesthetic with endotracheal intubation

2. Position - lateral for pyelolithotomy, supine for ureterolithotomy

PYELOLITHOTOMY
(Stone in pelvis/upper ureter)

Incision

Posterior approach

Procedure

1. Assess and gently mobilise the kidney (beware perinephric inflammation and fibrosis)

2. Controlling the stone with the left hand retract the renal sinus with a Gilvernet retractor

3. Incise the renal pelvis over the stone in its long axis and remove the stone with Desjardins forceps. Wash out pelvis

4. On table pyelogram

5. Close the renal pelvis with interrupted absorbable sutures

6. Send the stone for biochemical analysis

Closure

1. Drains

a. One to the renal pelvis
b. One to the wound

2. Close in layers

URETEROLITHOTOMY
(Stones in middle third of ureter)

Incision

1. Extended grid iron in iliac fossa

2. Do not open peritoneum

Procedure

1. Sweep the peritoneum medially and locate the ureter

2. Place slings around the ureter above and below the stone

3. Gently milk the stone proximally as there may be ulceration/fibrosis of the ureter where it has impacted

4. Incise onto the stone and remove it for biochemical analysis

5. Pass a ureteric catheter distally to exclude distal obstruction

6. Close the ureter with absorbable suture

Closure

1. Drain the retroperitoneal space

2. Close in layers

Postoperative management

1. Remove the drain when drainage is minimal

2. Investigations

a. Biochemical analysis of stones
b. MSU

Complications

1. Early

a. Infection

• Urine

• Septicaemia
b. Stone fragmented during removal

• Small (<1 cm) fragments should pass spontaneously

• Larger irretrievable fragments, refer to specialist centre
c. Hydronephrosis

• Ureteric oedema

• Residual calculous obstruction

2. Late

a Recurrent calculi

b Hydronephrosis

• Ureteric stricture

• Recurrent calculi

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