EA035811B1 - Renal transplantation method - Google Patents

Abstract

The invention relates to medicine, in particular, to transplant surgery, and proposes a method of kidney transplantation through a limited incision without the use of surgical drainage. The objective of the invention is to prevent the initial renal allograft dysfunction and to reduce the rate of early surgical complications in kidney recipients. The essence of the invention is as follows: Retroperitoneal approach is provided from a mini-incision (5-6 cm long) in the iliac region. The region of iliac vessels and the apex of urinary bladder are mobilized, a bed for kidney allograft is prepared between m. iliopsoas and anterior abdominal wall. The renal transplant is placed in the prepared bed so that it is completely hidden in the iliac fossa, and in the area of the surgical wound only the renal vein and artery are located, which are anastomosed from this mini-incision with the iliac vessels mobilized for 3-4 cm. The sequence of applying anastomoses is changed: first arterial anastomosis is formed, then venous anastomosis is formed. The next step is performance of ureteroneocystoanastomosis with antireflux protection, which is also performed through mini-incision. The final stage of the operation is suturing of the wound without surgical drainage, which is not necessary due to the low invasiveness of the intervention.

Description

The invention relates to medicine, namely to transplant surgery, and presents a method of kidney transplantation from a mini-access without the use of surgical drainage.

The known method of robotic kidney transplantation [1].

The operation with the da Vinci Robot surgical system is performed by a transplant surgeon. Through incisions on the anterior abdominal wall 8 mm long, 4 ports are installed through which instruments for manipulation are inserted into the abdominal cavity. By operating the instruments, the surgeon mobilizes the iliac vessels, preparing them for the formation of anastomoses. Through the vagina in women, the renal graft is placed into the iliac fossa and the sequential anastomoses are started: the renal vein - the external iliac vein, the renal artery - the external iliac artery. Then, after the kidney graft is included in the bloodstream, an anastomosis is formed between the bladder and the ureter. At the final stage, the vagina is sutured and the surgical site is drained with a tube. The stitches on the skin are sutured.

In the known method, the cosmetic effect, good initial function of the renal graft, and a small number of postoperative complications are evident.

The disadvantage of this method is low functionality due to the high cost of robotic operating equipment, consumables, and this does not allow the use of this technique with a large number of transplants. The time interval for performing the operation up to 7 hours also does not allow us to speak about the positive side of using this technique. The cosmetic effect of the operation is only achievable in women, since the renal graft is placed in the iliac fossa through the vagina.

The closest in technical essence and the achieved positive result (prototype) to the claimed one is the method of classical kidney transplantation, in which a club-shaped incision with a length of 15-20 cm is used, access to the retroperitoneal space is provided [2].

The external iliac artery and vein are isolated over 7-8 cm. The kidney graft is removed from the preservative solution and placed in a specially prepared four-layer 40x40 cm napkin. A wedge-shaped cutout is made in the center of the napkin for the vascular pedicle of the graft. The graft is covered with melting sterile ice and begins with the formation of a venous anastomosis between the renal vein and the external iliac vein of the recipient in an end-to-side manner. An arterial anastomosis is most often placed between the renal artery (or arteries) and the external iliac artery, also of the end-to-side type. After control of hemostasis, the formation of ureterocystoneoanastomosis is performed. Upon completion of the formation of all anastomoses, the retroperitoneal space is drained with a tube to control early postoperative complications. The wound is sutured in layers.

The disadvantage of this method is the unsatisfactory cosmetic effect after a lengthy incision on the anterior abdominal wall, the constant presence of the renal allograft in an open position, the risk of infection of the area of the operation when draining and frequent pain syndromes associated with it.

The objective of the invention is to prevent the initial dysfunction of the renal allograft and reduce the incidence of early surgical complications in kidney recipients.

The task is achieved due to the fact that in the method of kidney transplantation, including access to the retroperitoneal space by performing an incision, mobilization of the iliac vessels, preparation of the bed for the kidney allograft and placing it in the prepared bed in the iliac fossa, the formation of vascular anastomoses, ureteroneocystoanastomosis and wound closure, new is that access to the retroperitoneal space is carried out by a mini-incision 5-6 cm long, mobilization of the external iliac vessels is carried out for 3-4 cm, after which the allograft of the kidney is placed in a prepared bed so that it is completely hidden in the iliac fossa , and in the area of the operating wound there was a renal vein and an artery, while first an arterial and then a venous anastomosis is formed with a portion of the external iliac vessels mobilized by 3-4 cm, then ureteroneocystoanastomosis is performed with antireflux protection from a mini-incision.

The essence of the invention is as follows.

Access to the retroperitoneal space is provided from a mini-incision (length 5-6 cm, depending on the anatomical features of the recipient) in the iliac region.

A short section of the external iliac vessels is mobilized for 3-4 cm (depending on the anatomical features of the recipient) and the apex of the bladder, a bed for the kidney allograft is prepared between the m.iliopsoas and the anterior abdominal wall. The renal graft is placed in the prepared bed so that it is completely hidden in the iliac fossa, and only the renal vein and artery are located in the area of the surgical wound, which from this mini-access are anastomosed with the mobilized short section of the external iliac vessels. With this technique, the sequence of the anastomoses is changed. First of all, arterial, and then - venous anastomosis is formed.

The next stage is to perform ureteroneocystoanastomosis with antireflux protection, which is also performed from a mini-access. The final stage of the operation is wound suturing without a surgical drill, which is unnecessary due to the low trauma of the intervention.

The main result of the application of minimally invasive kidney transplantation technique was the improvement of the initial function of the graft. In the comparison group, a decrease in the frequency of initial dysfunctions, a statistically significant increase in the volume of daily urine output, and an improvement in creatinine levels, starting from the first day after surgery, throughout the early postoperative period were achieved.

The novelty of the proposed method is as follows.

1) Using a mini-access (incision length 5-6 cm) for kidney transplantation.

2) Lack of drainage due to low invasiveness of the operation.

3) The reverse sequence of the formation of vascular anastomoses (first arterial, then venous).

4) Closed position of the renal graft during the formation of vascular anastomoses.

The essence of the invention is illustrated by a clinical example.

Recipient 1, 45 years old, female, was admitted to the transplantation department with a diagnosis of chronic glomerulonephritis with an outcome in nephrosclerosis, chronic renal failure, terminal stage. For the patient, the kidney donor was her own sister. The kidney graft was explanted by hand-port in an assisted manner, and on January 31, 2017, the recipient underwent transplantation.

After preoperative preparation, the patient was taken to the operating room of the republican transplant center. Under general anesthesia in the iliac region on the left, an open access was made to the retroperitoneal space from a mini-access 5 cm long, the external iliac vessels were mobilized for 3 cm.After preparation of the vessels, the renal graft was placed retroperitoneally in the left iliac region. Anastomoses were sequentially superimposed between the renal artery and the external iliac artery of the end-to-side type and the renal vein and the external iliac vein of the end-to-side type. After recirculation, the renal graft acquired a pink color and satisfactory turgor. The bladder was filled with a solution of 0.9% NaCl 150 ml through the urinary urethral Foley catheter No. 16Fr. The detrusor of the bladder was dissected in an oblique-longitudinal direction along the apical-lateral wall of the bladder to the mucous layer for 2 cm. The graft ureter was processed along its length. The distal end is dissected along the posterior surface by 5 mm. The mucous membrane of the bladder was opened up to 10 mm. The suture located at the distal end of the graft ureter was sutured in the distal angle of the mucosa incision from the inside out. Then, the proximal angle of the bladder mucosa incision with the graft ureter was sutured with a similar thread. Further suturing was carried out with a thread from the proximal angle of the anastomosis, and then its second half was sutured with a thread from the distal angle, towards the middle of the anastomosis. Then the medial part of the ureterocystoneanastomosis was similarly sutured. Detrusor around the anastomotic area is sutured. Drainage of the retroperitoneal space and anastomoses with a safety PVC tube was not performed, since a thorough hemostasis was performed intraoperatively. Layer-by-layer wound closure. Local anesthesia of the surgical wound with Bupivacaine solution. In the postoperative period, the function of the renal graft is immediate, the diuresis is sufficient. The patient spent 1 bed-day in the surgical intensive care unit, then transferred to the transplantation unit. By the 7th day after surgery, the patient's blood creatinine was 105 μmol / l, the glomerular filtration rate was 102 ml / min. There were no complications after surgery. The use of analgesics was not required.

The patient was discharged in satisfactory condition for outpatient treatment. After 6 months, the patient was examined - the renal graft function is satisfactory, the postoperative scar on the anterior abdominal wall is 5 cm, pink, mobile, without signs of inflammation.

The inventive method is applicable to kidney transplant recipients and allows the operation to be performed with little trauma, with a good cosmetic effect, does not require the administration of analgesics in the postoperative period, and reduces the number of renal dysfunctions.

The claimed method in comparison with the prototype provides:

1) cosmetic effect (the operation is performed from a mini-access 5-6 cm long);

2) constant presence during the operation of the kidney transplant in a closed position (in the retroperitoneal space);

3) reduction or absence of pain syndrome in patients in the postoperative period due to the small size of the postoperative wound and the lack of safety drainage;

4) improving the function of the renal graft in the postoperative period;

5) decrease in the incidence of early surgical postoperative complications.

Sources of information

1. Wagenaar S., Nederhoed J.H., Hoksbergen A.W.J., Bonjer H.J., Wisselink

IW., Van Ramshorst G.H. Minimally invasive, laparoscopic, and robotic-assisted techniques versus open techniques for kidney transplant recipients: a systematic review. Eur Urol 2017; 72: 205-17.

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2. Breda A., Territo A., Gausa L., et al. Robotic kidney transplantation: one year after the beginning. World J Urol. In press, https: //dx.doi. org / 10.1007 / s00345-017-2006-8.

Claims (1)

CLAIM A method of kidney transplantation, including access to the retroperitoneal space by making an incision, mobilizing the iliac vessels, preparing a bed for a kidney allograft and placing it in a prepared bed in the iliac fossa, forming vascular anastomoses, ureteroneocystoanastomosis and wound suturing, characterized in that the space provides access to the retroperitoneal a mini-incision in the iliac region 5-6 cm long, mobilization of the external iliac vessels is carried out for 3-4 cm, after which the allograft of the kidney is placed in a prepared bed so that it is completely hidden in the iliac fossa, and in the area of the operating wound are located a renal vein and an artery, while first forming an arterial and then a venous anastomosis with a 3-4 cm section of the external iliac vessels mobilized, then a ureteroneocystoanastomosis with antireflux protection is performed from the specified mini-incision.