RU2569719C2 - Method for nephrectomy according to single retroperitoneoscopic approach technique in children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: nephrectomy is performed from a single retroperitoneoscopic approach. Elastic SILS port with three working passages are inserted by means of Farabeuf dilators into a retroperitoneal space, through a skin incision 2.5-3 cm long along a midaxillary line between the XI and XII ribs at 1-1.5 cm in the caudal direction from a conventional line connecting the ribs. Oblique abdominal muscles are separated apart along the fibres; Gerota fascia is opened. A kidney is endoscopically separated; a vascular pedicle and ureter are transected. The organ is removed together with the port.

EFFECT: method enables reducing invasiveness of the surgical intervention and shortening a rehabilitation period when removing the kidneys in the children suffering multicystic renal dysplasia, terminal hydronephrosis, renal hypo- and aplasya, or nephrosclerosis, eliminating intra- and postoperative complications by an adequate approach with minimum tissue involvement.

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Description

The invention relates to medicine, in particular to pediatric surgery, and can be used in the surgical treatment of children with kidney removal.

In the global practice, various endovideosurgical techniques for removing kidneys in children are described. However, at present, pediatric surgeons continue to search for improvement of methods for a single endovideo surgical treatment of children with non-functioning kidneys.

A known method of nephrectomy, including retroperitoneal access to the kidney. Cut the skin with a length of 2-3 cm along the mid-axillary line in parallel and below 12 ribs. Stupidly, in layers, intramuscularly expose retroperitoneal space. A retroperitoneoscope is inserted into the retroperitoneal space. Set his mirror at the back of the kidney. Allocate the posterior surface of the kidney and the posterior surface of the vascular renal pedicle. Allocate the front surface of the kidney and vascular renal pedicle. Perform aspiration of the kidney. Tighten a collapsed kidney into the surgical wound. Ligated and cross the vascular renal pedicle. Draw a kidney into the wound. Allocate, ligate and cross the ureter. The kidney is removed (Zhuravlev V.N., Bazhenov I.V., Zyryanov A.V. Method of nephrectomy // Patent for invention RU 2173963 C2. Published: 09.27.2001). The method is not widespread when performing a ureteronephrectomy due to the inability to allocate the distal ureter and the difficulty of manipulating in a small "workspace".

The laparoscopic nephrectomy method according to the single-instrument port technique essentially describes a two-trocar retroperitoneoscopic nephrectomy (Garg S., Gundeti Μ., Mushtaq I. The single instrument port laparoscopic (SIMPL) nephrectomy // Journal of Pediatric Urology. - 2006. - No. 2. P. . 194-196). The original method has a lot of disadvantages. To create a “working space” in the retroperitoneal region, the authors install a Gaur′a balloon, which can lead to complications at the initial stage of the operation in the form of bleeding from ruptured vessels and the formation of hematomas that impair visualization in the “working space”. In addition, manipulations on the kidney, vascular pedicle of the kidney and ureter using one instrument are extremely difficult and in some cases impossible. Therefore, this method is not applicable in wide practice.

Also known is a method of single-port nephrectomy in infants (Barbancho DC, Fraile AG, Vazquez FL and Bramtot AA Single-port nephrectomy in infants: Initial experience // Journal of Pediatric Urology. - 2011. - No 7. - P. 396-398) . The method proposed by the authors describes a general technique for nephrectomy and ureteronephrectomy in infants. When performed through a 2.5 cm infra-umbilical incision, ASC TriPort (Advanced Surgical Concepts, Dublin, Ireland) is placed in the abdominal cavity. ASC TriPort - is a multi-channel access system that allows you to simultaneously install multiple (3-4) laparoscopic instruments through a single incision. For visualization using a 5 mm 30 ° telescope. As working tools use a clamp-rotator 5 mm (EndoMiniDissect, Covidien, USA) and a vessel sealing system 5 mm (LigaSure, Covidien, USA). The subsequent stages of the operation are similar to conventional laparoscopic nephrectomy, after which the kidney is removed through an infraumbilical wound. However, this method is not reproducible due to the high cost of consumables and the possibility of intra-abdominal complications during or after an operation on a kidney located in the retroperitoneal space.

As the closest analogue, the method of single-port laparoscopic nephrourerectomy in children of all age groups is adopted (Luithle T., Szavay P., Fuchs J. Single-incision laparoscopic nephroureterectomy in children of all age groups // Journal of Pediatric Surgery. - 2013. - Vol. 48. P. 1142-1146). The essence of the invention lies in the fact that in the method of a single-port laparoscopic nephrourerectomy in children of all age groups, patients were differentiated into two groups according to their weight. In children weighing less than 10 kg, the so-called Manhattan technique was performed. Those. Nephrourerectomy was performed using one 5 mm and two 3 mm trocars placed through a transumbilical incision. In patients weighing more than 10 kg, the operation was performed using the X-Cone metal reusable port (Karl Storz Endoskope, Tuttlingen, Germany) with the possibility of using laparoscopic instruments of various diameters of 3-12.5 mm. The method was carried out as follows. The patient was placed in supine position with the operated side elevated by 30–40 °. In patients with a body weight of less than 10 kg, a transumbilical incision was performed along the lower semicircle of the umbilical ring, which was extended to the contralateral side of the operated kidney. A 5 mm trocar was placed in the abdominal cavity at right angles and pneumoperitoneum was created. Then a 5 mm 30 ° laparoscope was installed and two 3 mm standard working ports were placed through separate fascial punctures. Used the usual 3 mm straight tools. After mobilization of the peritoneum and dissection of the fascia, Gerota exposed the kidney. The ureter was mobilized to the level of the bladder. After isolation of the renal pedicle, the laparoscope was replaced from 5 mm to 3 mm in order to clip the vessels of the kidney using metal clips from a 5 mm clip applicator. The kidney and ureter were isolated using an electrocautery hook. After complete isolation of the kidney and intersection of the ureter, the peripheral end of the ureter was ligated using PDS-endoloops (Ethicon, Cincinnati, Ohio, USA). The kidney was removed after the expansion of the surgical wound by combining fascial punctures. The surgical wound was sutured in layers tightly. In patients with a body weight of more than 10 kg, a skin incision was performed along the lower semicircle of the umbilical ring from 3 hours to a 9-hour position. Then, at a right angle, the Χ-Cone port was placed in the abdominal cavity and pneumoperitoneum was created. To exclude the collision of the instruments with each other, we used a long 5 mm 30 ° telescope, a bending tool 5 mm and a clamp 5 mm. Mobilization was performed using either a harmonic scalpel or an electrocauterisadion hook. The kidney leg was crossed after treatment with a harmonic scalpel or clipping. The peripheral end of the ureter was also ligated using PDS-endoloops. The kidney was removed via X-Cone.

Elegant in its design, the method of single-port laparoscopic nephrourerectomy in children of all age groups is a differentiated choice of surgical access when removing the kidney in children, but has some drawbacks. First, in children with a body weight of up to 10 kg, the surgical wound was widened before the kidney was removed, which could have been avoided by setting up the Χ-Cone port initially, thereby providing the surgeon with comfortable conditions for manipulation, excluding the use of direct tools. Secondly, the authors do not discuss retroperitoneoscopic access, as the most appropriate for manipulation in the retroperitoneal space, especially when removing a multicystic dysplasized kidney, in which removal of the ureter to the level of the bladder is not necessary. Thirdly, this method of differentiating surgical access for nephrectomy in children is not based on nosology, and both endovideo surgical methods of kidney removal presented with success can be used in patients of different age groups.

The objective of the invention is to perform a surgical operation through adequate endovideo surgical access, which will reduce the invasiveness of the surgical procedure, the length of hospital stay of patients with the least number of complications of the disease with a shortened rehabilitation period and improved cosmetic results.

The problem is solved by the proposed method of nephrectomy according to the technique of a single retroperitoneoscopic access in children, based on endovideosurgical removal of the kidney in children, the distinctive features of which are that after diagnosis, children with multicystic kidney dysplasia, terminal hydronephrosis, hypo-, aplasia of the kidney and / or nephrosclerosis perform a nephrectomy video endoscopy through a single retroperitoneal access, by installing an elastic SILS port with three working channels in the abdominal space from the side of the removed organ through a skin incision 2.5-3 cm long along the middle axillary line between the XI and XII rib, departing 1-1.5 cm in the caudal direction from the conditional line connecting the ribs, oblique muscles of the abdomen are bred along the fibers, the fascia Gerota is opened, then using the Farabeff retractors, the port is installed in the retroperitoneal space, after which, using endoscopic instruments, the kidney is excised, the vascular pedicle, ureter is intersected and the organ is removed together with the port.

Nephrectomy according to the proposed methodology for a single retroperitoneoscopic access is as follows. The operation is performed under general anesthesia. The patient is on the operating table in a supine position, opposite the area of surgical interest. A skin incision for the SILS-port installation (Covidien, USA) 2.5-3 cm long is carried out along the middle axillary line between the XI and XII rib, departing 1-1.5 cm in the caudal direction from the conditional line connecting the ribs. The oblique muscles of the abdomen are bred along the fibers, and the fascia Gerota is opened. Then, with the help of Farabef expanders, a SILS-port is installed in the retroperitoneal space, which has three 5 mm working trocars and a cannula for supplying carbon dioxide. Create pressure in the retroperitoneal space 12-16 mm RT.article A laparoscope with a diameter of 5 mm 30 ° is installed in one of the working trocars, two other trocars are used for working flexible and direct instruments: a dissector-rotator with a diameter (5 mm), a clamp-rotator (5 mm), a scissor-rotator (5 mm), an endoclipator (5 mm), ultrasonic scissors (5 mm). Allocate the front and back surface of the kidney and the vascular pedicle of the kidney. The vascular leg of the kidney is either clipped, or intersected with ultrasound scissors, or tied with an extracorporeal nodal suture with non-absorbable suture depending on the diameter of the vessels, the ureter is crossed with ultrasound scissors, the kidney is removed together with the port.

Clinical example of the method

Patient G., 12 years old, was hospitalized in the urology department of the GAUZ DRKB MH RT with a direct diagnosis: Multicystic dysplasia of the left kidney. An examination was performed in the form of an ultrasound examination of the kidneys: the left kidney is represented by cystic formations with a diameter of 10-40 mm, a total size of 65 × 37 mm, there is no parenchyma, the blood supply to the kidney is poor, it is represented by a renal artery with a diameter of 2 mm and a renal vein with a diameter of 2.5 mm, peripheral vessels kidneys are not visualized. According to X-ray computed tomography, multicystic dysplasia of the left kidney was confirmed, the dimensions of which were 68 × 40 × 32 mm, the kidney does not gain contrast. The child underwent surgery: ureteronephrectomy according to the technique of a single retroperitoneoscopic access described above. The operation was performed under general anesthesia. The patient was on the operating table in a supine position, opposite the area of surgical interest. A skin incision was made along the mid-axillary line between the XI and XII rib, 1.5 cm departing in the caudal direction from the conditional line connecting the 3 cm long ribs. The oblique muscles of the abdomen were bent along the fibers and the Gerota fascia was opened. Then, with the help of Farabef expanders, SILS-port was installed in the retroperitoneal space. They created a pressure in the retroperitoneal space of 14 mm Hg. The kidney, vascular pedicle, and ureter were isolated in stages using 5 mm rotator tools (dissector rotator, clamp rotator, scissor rotator). The vascular pedicle of the kidney was ligated with metal clips using an endoclipplicator. The ureter is highlighted over 10 cm, where it is crossed by Harmonic ultrasound scissors. The kidney was removed along with the port. The postoperative wound was sutured in layers by internal interrupted sutures. The duration of the operation was 55 minutes. The day after the operation, the child began to walk independently. On the fifth day after the operation, the patient was discharged home in satisfactory condition. Complications and relapses of the disease in the early postoperative period and in terms of up to 1 year were not observed in the child. Parents of the child were satisfied with the results of surgical treatment (Fig. 1).

In FIG. 1 - postoperative photograph of Patient G. with nephrectomy performed according to the technique of a single retroperitoneoscopic access 1 year after the operation.

Thus, in contrast to the previously proposed methods, nephrectomy using the single retroperitoneoscopic approach through one surgical incision allows to reduce the invasiveness of surgical access, to eliminate intra-abdominal intraoperative and postoperative complications during nephrectomy, has an excellent cosmetic result, due to adequate access to the removed organ with minimal damage. tissues, which accelerates the rehabilitation period. The reproducibility of the method is possible if you have knowledge of the anatomy of the child's body and the skills of endoscopic surgery.

Claims (1)

Nephrectomy method according to the method of single retroperitoneoscopic access in children, based on endovideosurgical removal of the kidney in children, characterized in that after the diagnosis is established for children with multicystic kidney dysplasia, end-stage hydronephrosis, renal hypo-, aplasia and / or nephrosclerosis, a nephrectomy is performed through a single video retroperitoneal access, by installing an elastic SILS port with three working channels in the retroperitoneal space from the side of the removed organ through a skin incision of length 2, 5-3 cm along the mid-axillary line between the XI and XII rib, departing 1-1.5 cm in the caudal direction from the conditional line connecting the ribs, the oblique muscles of the abdomen are stretched along the fibers, the fascia Gerota is opened, then with the help of Farabef expanders into the retroperitoneal space establish a port, after which, using endoscopic instruments, carry out the selection of the kidney, the intersection of the vascular pedicle, ureter and organ removal together with the port.

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