URO / Open simple nephrectomy (신장절제술)

 

 

 

 

 

 

 

Open simple nephrectomy 

/kidney tumor 신장암

 

 

URO Major + 소방 10개 + OMNI ret 

-OMNI Ret : 짧고 얇은 ㄱ자 -> mayo type 2개 -> malleable 

foley 는 pre-op 준비 

 

<부속>

Lg needleholder 4ea

hemolok 2/2

hemoclip small / medium

 

 

<P.R.N>

Rasp, vein ret, Lg pott's, pott's fcp, rib set (Rm1), bone file (RM4)

 

 

<준비물품>

Glove

4x8 gz 4개 

mess 15 & 20

bovie tip (small /large)

수세미

spoid 

펜&자

hemolok (초/보)

surgicel 1901 (4등분)

nylon tape 1ea - ureter 

JP 100L 

sling

 

 

<suture>

black silk 1/3/7호 긴실

1/0 vicryl 2개 : fascia

2/0 catgut 1+ : bleeding control

2/0 vicryl 2개 : peritoneum, subcu

3/0 nylon 1개 : tagging

skin stapler 

 

 

<prn>

surgiclip L - lymph node dissection 시 

Deaver cover 

 

 

 

 

 

 

 

 

 

1.incision & approach

position : lateral 

marker design : 10th intercoastals 12cm 

​flank 11th 12th rib supracostal - good renal and retroperitonea expose , caution : pleural injury  

incision #20 mess - flank incision, access to the retroperitoneal cavity is obatained 

subu, muscle 은 short allis 2ea 로 잡고 bovie 로 cutting 

baby richadson 으로 retaction 

kelly + stick으로 fascia 벗겨낸다

 

 

2.peritoneum opening (Retroperitoneal cavity)

allis 2ea 잡고 20mess incision 후 bovie cutting 후 열리면 Lg 기구로 바꿈

bovie tip , Lg mixter, Lg pin, Lg debakey, metz 등 

 

 

 

 

3.Perirenal fat dissected , Gerota's fascia opened

anterior layer of renal fascia 가 열리면 kidney, colonic mesentery, peritoneum 이 보이면 omni를 건다.

omni set에서 mayo retractor , 얇은 ㄱ자 deaver, malleable 주로 사용 

(omni 걸 때 4*8 gz는 펴지 말고 반만 접어서 준다) 

fascia아래 kidney, adrenal gland는 주변 perirenal fat 으로 둘러 쌓여 있는데 

perirenal fat 을 kidney 로 부터 분리 하기 위해 suction tip과 bovie, gause 로 분리

 

4.Renal arteries , vein, uretre were dissected & ligated 

-debakey, mixter, bovie로 renal artery와 vein 주위를 박리한 후 

-Ureter 는 U-Tape으로 걸어 놓는다 + mosquito 

-adrenal, gonadal vein 을 Lg rt angle 이나 mixter로 박리 후 5호 tie silk (hemolok M/L) 로 2번씩 Ligation 한 후 metz cut

prn. artery 는 7호

-​renal artery 는 1개 총 2개 branch 로 분화하여 renal vein 바로 뒤에 붙어서 주행

Renal vein 고 함께  silk tie 1회 시행한 후 추가로 각각 1회씩 silk tie 시행 hem-o-lock apply 하였음

 

 

5.Perirenal connective tissue dissection 

 

6.Radical nephrectomy was done 

 

7.kindney 가 나오면 Irrigation 

->JP Drain + 3/0 nylon tagging 

 

8.bleeding control 

surgiel 5*35 (4등분) 

prn) spongostan 4등분

 

9.close

peritoneum : 2/0 vicryl

muscle : 1/0 vicryl *2 

prn) 5호 silk 로 fascia interrupt

subcutaneous : 3/0 vicryl

skin : stapler 

sorbact 10*15, 8*10 으로 dressing + 복대 

 

 

 

 

 

 

 

 

 

 

Using one of the incisions described above, typically a flank incision, access to the retroperitoneal cavity is obtained. A self-retaining retractor (Finochietto, Bookwalter, or Omni-Tract retractor) is used to expose the visceral organs. The posterior layer of the renal fascia is bluntly dissected from the muscles of the posterior abdominal wall. The anterior layer of renal fascia is dissected from the colonic mesentery and peritoneum, leaving a fascial compartment in which the kidney, adrenal gland, and perirenal fat lie. The renal fascia is incised and the perirenal fat is separated from the kidney using a combination of blunt dissection and electrocautery. Improper entry into the subrenal capsule must be avoided as this can lead to additional bleeding and difficulty in identifying the appropriate surgical planes. The surgeon must beware of aberrant vessels, typically found near the poles and in areas resistant to blunt dissection. In cases in which posterior dissection is difficult because of adherence of the kidney to the psoas muscle, inclusion of the psoas fascia in the dissection may be helpful and necessary. In cases of a large hydronephrotic kidney, in which exposure can be difficult, puncture and aspiration of the renal pelvic contents may decompress and aid mobilization of the kidney. Next, the adrenal gland is dissected from the upper pole of the kidney by maintaining the dissection plane directly on the renal capsule. The superior attachments of the kidney to the spleen, pancreas, and liver are freed to allow safe caudal retraction of the kidney.

Next, the lower pole of the kidney is mobilized and the ureter isolated, and the gonadal vein, usually found adjacent to the ureter, is identified. Care should be taken to mobilize the gonadal vein medially in order to avoid traction injury and avulsion of the vein. Once the inferior pole is mobilized, the ureter can be divided in between surgical clips or 2-0 silk ties. Division of the ureter provides access to the posterior part of the kidney and better exposure of the renal hilar structures. From a caudocranial approach, the renal vein is usually identified after division of the ureter. Combination of blunt and sharp dissections will allow identification of the renal artery posterior to the renal vein 

 

 

google 그림 : http://patients.uroweb.org/fileadmin/eau_images/images_full/rad_neph.jpg