RU2800246C1 - Method of retroperitoneoscopic access when performing one-stage nephrectomy in case of purulent processes in the kidney and perirenal tissue - Google Patents

Abstract

FIELD: medicine, urology.

SUBSTANCE: in the position of the patient on a healthy side under ultrasound control, a purulent area is punctured. The wound is expanded, an electric pump is introduced into it and the purulent contents of the retroperitoneal space is evacuated. The purulent cavity is washed. Then the electric pump is removed, a 10 mm trocar with a laparoscope is inserted in its place, and a retropneumoperitoneum is created by insufflation of CO2. Additional trocars are introduced along the anterior and middle axillary lines, revision and sanitation of the retroperitoneal space are carried out. Further along the lumbar muscle, the posterior surface of the kidney, renal vessels with bipolar tissue coagulation are exposed, the kidney is mobilized along the posterior surface and renal vessels, and nephrectomy is performed. A circular polyvinylchloride drainage is installed in the retroperitoneal space and in the postoperative period the retroperitoneal space is irrigated with an antiseptic, an aqueous solution of chlorhexidine for 2 days.

EFFECT: method allows to perform nephrectomy in one stage, improves visualization of the surgical field, improves the efficiency of treatment of patients with purulent-inflammatory diseases of the kidneys and retroperitoneal space, reduces the risk of dissemination of the purulent process, eliminates the risk of infection of the abdominal organs, creates adequate access to the kidney and vascular pedicle, prevents intraoperative wound complications and the occurrence of postoperative complications.

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Description

SUBSTANCE: invention relates to medicine, namely to video endoscopic operative urology, and can be used in video endoscopic operations for purulent-inflammatory diseases of the kidneys and limited purulent paranephritis in somatically intact patients for one-stage nephrectomy.

Under purulent-inflammatory lesions of the kidneys and retroperitoneal space, it is customary to understand conditions characterized by the development in the focus of inflammation (kidney or perinephric tissue) of a purulent-destructive process, accompanied by clinical and laboratory manifestations, purulent infections [Lopatkin N.A., 2013; Sinyakova L. A., 2010; Colgan R., 2011]. This group includes all forms of purulent pyelonephritis (apostematous pyelonephritis, abscess and carbuncle of the kidney), suppurated renal cysts and hematomas, pyonephrosis, perirenal abscesses and purulent paranephritis [Ayvazyan A.V., Voyno-Yasenetsky A.M., 1985]. Purulent inflammation of the kidneys and retroperitoneal tissue are classified as complicated urinary tract infections. They represent an urgent clinical problem associated with the difficulty of diagnosis, the complexity of the optimal choice of treatment tactics and the subsequent management of the postoperative period [Goncharova Yu.M., 2012; Scholes D. et al., 2005; Nicolle L., 2008; Tanagho E., 2008; ShoffW. H., 2010].

In some cases, morphological changes in secondary purulent pyelonephritis significantly change the conditions for the further course of an acute inflammatory process or its next exacerbation. In the vast majority of cases, with timely and proper treatment, this pathological process is reversible due to the reserve nephrons of the kidneys and the reverse development of retention changes in the urinary tract. In the case of prolonged obstruction, untimely drainage, a virulent infectious agent, pyonephrosis develops and often pus breaks into the perirenal tissue (PC) with the development of purulent paranephritis [Styazhkina S.N., 2015; Eslievsky Yu.N., 2007; Rossleigh M.A., 2007; Ribun V.V., 2017].

Among the above purulent forms of lesions, the most difficult group are patients with combined purulent lesions of the kidneys and perirenal tissue.

Treatment of purulent-inflammatory diseases of the kidneys and perirenal tissue remains a difficult problem, in particular in terms of choosing a method of treatment and its timely provision. The nature of the operation performed depends on the severity of the condition of the patients: with severe intoxication and a serious condition of the patients, percutaneous or endoscopic drainage of the purulent focus is performed with simultaneous drainage of the kidney and paranephria, and after stabilization of the condition, nephrectomy is performed [Teodorovich O.V. 2002; Gadzhiev A.N. 2006; Ribun V.V. 2017]. On the other hand, an extensive purulent zone of paranephria cannot always be adequately drained percutaneously, even if there are several drains, which significantly lengthens the time, cost of treatment, and patient rehabilitation.

Most often, the main method of surgical treatment for a massive purulent-destructive process of the kidney and paranephria is lumbotomy with a revision of the kidney and retroperitoneal space (RP) with excision of purulent foci and affected perinephric tissue, and in some cases, depending on the condition of the patients, simultaneous nephrectomy is performed [Pytel A.Ya., Zolotarev I.I., 1975; Ayvazyan A.V., Voyno-Yasenetsky A.M., 1985; Ribun V.V., 2017].

On the other hand, the discovery of surgical interventions due to trauma and a large percentage of complications have become less common. The widespread use of video endoscopic methods has opened up the possibility of retroperitoneoscopic access in the treatment of purulent-inflammatory diseases of the kidneys and retroperitoneal space [Rublevsky B.V., 2010; Kadyrov Z.A. 2012; Neimark A.I. 2015]. However, the use of retroperitoneoscopy is controversial due to the lack of experience and a sufficient number of operations and the possibility of the method.

In addition, often after performing a nephrectomy in the postoperative period, doctors are faced with the development of suppuration of the postoperative wound, which significantly lengthens the process of recovery and recovery of patients [Styazhkina S.N., 2015; Eslievsky Yu.N., 2007; Rossleigh M.A., 2007; Ribun V.V., 2017].

From the prior art, a method is known for creating access and exposure of the organs of the retroperitoneal space by the extraperitoneal route according to S.P. Fedorov. Operative urology / Ed. acad. ON THE. Lopatkin and prof. I.P. Shvetsov. - L .: "Medicine", 1996 - p. 95-96]. The method is performed by a wide incision with a dissection in an oblique transverse direction between the costovertebral angle and the navel of the skin of the subcutaneous fat, superficial fascia, external internal oblique and transverse muscles and transverse fascia. The edges of the wound are bred with a retractor. The peritoneal fold is exfoliated anteriorly with a tupfer. In a blunt way, the retroperitoneal tissue itself is stratified. Open the renal fascia. A kidney with a vascular pedicle is bluntly isolated from the perirenal fatty tissue surrounding it.

However, due to trauma and a high percentage of complications, the use of standard surgical approaches to the organs of the retroperitoneal space in surgical practice is minimized [Shan-Sin V.M. Retroperitoneoscopy in surgery of the retroperitoneal space in children. Dissertation abstract. Kemerovo, 2000, pp. 1-2.].

A known method of nephroureterectomy for pyonephrosis, where an extraperitoneal lumbar incision is performed according to Bergman-Israel about 35 cm, exposes the retroperitoneal space. After the kidney is isolated from the surrounding tissues, the ureter is mobilized in a blunt way up to the bladder. At the bladder, the ureter is slightly stretched, ligated and cut off. Sometimes the stump of the ureter is immersed with a purse-string suture into the bladder wall. The kidney is taken out into the wound, its vessels are bandaged and cut off. A rubber tube is brought to the bed of the kidney, and a rubber strip is brought to the stump of the ureter. The wound is sutured in the usual way (Operative urology: //Guide/ Edited by N.A. Lopatkin, I.P. Shevtsov. - L .: Medicine, 1986. -780 s).

The disadvantages of this method are that traditional open surgeries require large incisions, which increases trauma, the risk of bleeding from surrounding tissues increases significantly due to severe infiltration of surrounding tissues, which can subsequently cause suppuration and prolonged wound infection.

A method for creating retroperitoneoscopic retroperitoneal access to the kidney and retroperitoneal space was developed and described in 1992 by D.D. Gaur access technique using balloon insufflation [Gaur D.D. Laparoscopic operative retroperitoneoscopy: use of a new device // J. Urol. - 1992 - vol/148 p.1137; F. Hinman. Operative urology. / Under. ed. SOUTH. Alyaeva, V.A. Grigoryan, Moscow. Ed. House "GEOTAR-MED", 2001, pp. 1016-1017].

The basis of this method is the exfoliation of retroperitoneal tissue and tissue using a balloon dissector in order to create a cavity for performing operations. An incision of about 2 cm is made with the patient in the lateral position, through all layers of the abdominal wall at the edge of the erector spinae muscle, 2 cm above the iliac crest. Next, the transverse fascia is opened, the index finger enters the retroperitoneal space and forms a gap between the renal and transverse fascia, where a balloon dissector is installed (a rubber catheter with a finger attached to its end from a No. 7 surgical glove or a latex balloon). Depending on the localization of the process, the dissector balloon is directed to the navel - if it is necessary to expose the upper ureter, to the McBurney point - if intervention is expected on the lower ureter, to the epigastrium - to isolate the kidney. The balloon is filled by forcing air into it with a special tip until the anterior abdominal wall bulges. The pressure in the balloon is controlled using a sphygmomanometer through a T-shaped adapter (50-110 mm Hg). For the purpose of hemostasis, the balloon is left inflated for 5 minutes, then the contents are released from it and the balloon is removed. A 10 mm laparoscopic port of the Hasson type is inserted into the resulting space and the wound is sutured with a mattress suture. Carbon dioxide is insufflated through the port, maintaining the pressure in the retroperitoneal space at the level of 12-15 mm Hg. Additional ports of working trocars are installed under video surveillance strictly extraperitoneally.

The disadvantage of this method is a wide incision and loss of tightness around the trocar during manipulation, which complicates the operation. Another disadvantage of it is the risk of using this method in patients with poorly developed perirenal tissue and cicatricial process in the paranephria, since excessive stretching of the balloon can damage the peritoneum. In addition, this method was used in standard situations and was not used for pyoinflammatory diseases of the kidneys and retroperitoneal space [Gaur. D.D., Rathi S.S., Ravandale A.V. and Gopichand M. A single-centre experience of retroperitoneoscopy using the balloon technique // BJU International (2001), 87, P. 602-606].

A known method of creating access when performing retroperitoneoscopic surgery on the organs of the retroperitoneal space, including an incision of the skin and muscle layer, perforation of the aponeurosis of the transverse abdominal muscle, the installation of trocars in the retroperitoneal space and the supply of carbon dioxide, characterized in that the perforation of the aponeurosis is carried out by a trocar with a stylet, which is inserted at an angle oriented into the iliac region, after which the trocar stylet is removed, and the tube is deepened by 1-2 cm into the retroperitoneal space and carbon dioxide is injected through it under the control of optics (Patent RU No. 2578185, dated 2016.03.20).

However, this method was mainly used to perform the operation in standard situations and normal physiological arrangements of the retroperitoneal organs. And it was not used for purulent-inflammatory diseases of the kidneys and purulent paranephritis.

Known surgical access to the kidney with pyonephrosis, through retroperitoneoscopic access, allows you to mobilize the kidney and its vessels (Ribun V.V. Retroperitoneoscopic operations for purulent-inflammatory diseases of the kidneys and retroperitoneal space. Diss.. Cand. Med. Sciences. - 2017) . By creating a retropneumoperitoneum, the posterior surface of the kidney with perirenal tissue is mobilized and moved medially. Next, the renal pedicle (artery and vein) is mobilized, a clip is placed on them and crossed. After isolation and transection of the ureter, the kidney is removed with perirenal tissue in a single block from the mini-access.

This method is used by single urologists only for pyonephrosis due to space limitations and lack of experience. In addition, the lack of preoperative diagnosis of the state of the kidneys and surrounding tissues does not provide an adequate approach to the kidney and vessels of the renal pedicle and does not always allow the operation to be completed successfully and the risk of conversion is high. With this method, the kidney is not emptied intraoperatively, most often only the kidney is isolated, and Gerota's fascia is not excised or removed, and the perinephric tissue is not always removed, which can be a source of infection and cause postoperative complications, which is a significant drawback of the method.

Closest to the claimed method is a method of retroperitoneoscopic single-stage nephrectomy in pyonephrosis, including retroperitoneoscopy, mobilization of the posterior surface of the kidney with perinephric tissue, exposure and mobilization of the vessels of the renal pedicle and removal of the kidney with perinephric tissue, characterized in that at the preoperative stage, the patient's condition of the kidneys and surrounding tissues is assessed according to ultrasound and MRI, the absence of severe infiltration and perinephritis is established, after then retroperitoneoscopy is performed, then, under combined endoscopic and ultrasound control, a pyonephrosis puncture is performed and the puncture site is expanded to 1 cm with an electric knife, then purulent contents are evacuated from the cavitary system of the kidney with a 10 mm electric suction, which is washed with an antiseptic solution to clean water with the retroperitoneal space; the lumbar muscle is exposed, the vascular pedicle of the kidney is isolated along its course, which is clipped and crossed; produce a phased mobilization of the kidney with perirenal tissue within the fascia of Gerota and the ureter; the affected kidney with retroperitoneal perirenal tissue and Gerota's fascia is removed as a single block with a ligated and transected ureter; after control for hemostasis, the kidney bed is drained, the median wound is sutured [Patent RU 2795838 dated 12.05.2023].

This method was chosen by us as a prototype

The disadvantages of this method is that it is used only in patients with no combined purulent lesions of the kidney and perinephric tissue and, thus, there is no need for intraoperative sanitation of purulent areas of the retroperitoneal space.

The objective of the claimed invention is to increase the effectiveness of the treatment of patients with purulent-inflammatory diseases of the kidneys and retroperitoneal space, reduce the risk of dissemination of the purulent process, create adequate access to the kidney and vascular pedicle, and prevent postoperative wound complications.

The problem is solved by the method of retroperitoneoscopic access when performing a one-stage nephrectomy in case of purulent processes in the kidney and perirenal tissue, in which the degree of purulent damage to the kidney and purulent areas in the paranephria is preliminarily diagnosed according to ultrasound and MRI data, in the position of the patient on the healthy side under ultrasound control, the purulent area is punctured, the wound is expanded, an electric suction is introduced into it and the purulent contents of the retroperitoneal space are evacuated, the purulent the cavity, then the electric suction is removed, a 10 mm trocar with a laparoscope is inserted in its place and a retropneumoperitoneum is created by CO2 insufflation; additional trocars are introduced along the anterior and middle axillary lines, revision and sanitation of the retroperitoneal space is carried out, then along the lumbar muscle, the posterior surface of the kidney, renal vessels with bipolar tissue coagulation are exposed, the kidney is mobilized along the posterior surface and renal vessels, and nephrectomy is performed; a circular PVC drainage is installed in the retroperitoneal space and in the postoperative period for 2 days the retroperitoneal space is irrigated with an antiseptic - an aqueous solution of chlorhexidine.

The technical result of the claimed invention is the ability to perform nephrectomy in one stage due to the preoperative assessment of the condition of the kidney and surrounding tissues, the creation of adequate access to the kidney and renal vessels, the reduction of the risk of dissemination of the purulent process, the prevention of postoperative wound complications.

This technical result in purulent-inflammatory lesions of the kidneys and limited purulent paranephritis in somatically intact patients is achieved due to the fact that one-stage nephrectomy and rehabilitation of the retroperitoneal space are used. The presence of this pathology determines further tactics with operational access, namely: accurate diagnosis of purulent areas in the kidney and paranephria using ultrasound and MRI at the initial stage, puncture of the purulent focus under ultrasound control, evacuation and washing of the purulent cavity with saline for better visualization by introducing an electric suction. The evacuation of the purulent focus creates an adequate cavity to create a working space. Creation of a retropneumoperitoneum by the introduction of a laparoscope and CO2 insufflation under optical control, as well as the installation of additional trocars, provides adequate access to the kidneys and blood vessels, which reduces the risk of bleeding, blood loss, and simplifies surgical intervention. Processing of the renal pedicle and mobilization of the kidney along the posterior surface reduces trauma, the risk of bleeding and damage to the peritoneum, which eliminates the risk of dissemination of the purulent process into the abdominal cavity. The kidney with perirenal tissue within the fascia of Gerota with the ureter is removed from the mini-access, which also simplifies the operation and reduces trauma.

Installing a circular PVC drainage into the retroperitoneal space and postoperative rehabilitation of the retroperitoneal space by irrigating antiseptics significantly reduces the risk of postoperative wound complications. Thus, carrying out the main stages of the operation under ultrasound and optical control is very important in terms of achieving the claimed technical result: a significant improvement in visualization, adequate sanitation of the purulent cavity and a reduction in the risk of dissemination of the purulent process, prevention of intraoperative wound complications and the occurrence of postoperative complications.

Detailed description of the method and examples of its clinical application .

The method is carried out as follows. At the preoperative stage, the condition of the kidneys and surrounding tissues is assessed in the patient, an objective diagnosis of a purulently affected kidney and purulent areas in the paranephria is carried out using ultrasound and MRI. Under endotracheal anesthesia, in the position of the patient on a healthy side, a puncture of the purulent area is performed under ultrasound control, then expanding the wound to 1 cm, an electric pump is introduced at the same place and the purulent contents of the retroperitoneal space are evacuated. The evacuation of the purulent focus creates an adequate cavity to create a working space. Then the cavity is washed and the electric pump is removed. A 10 mm trocar with a laparoscope is inserted at the injection site of the electric pump and a retropneumoperitoneum is created by CO2 insufflation. Under optical control, additional 5 and 10 mm trocars are inserted along the anterior and middle axillary lines. Revision of the retroperitoneal space and sanitation of existing purulent foci is carried out by periodic irrigation of the cavity with saline for better visualization, and further along the lumbar muscle, the posterior surface of the kidney, renal vessels with bipolar coagulation of tissues are exposed. After ligation and transection of the vascular pedicle, the kidney is mobilized with perirenal tissue with Gerota's fascia.

The affected kidney with perirenal tissue and Gerota's fascia is removed as a single block with the ligated and transected ureter. After monitoring for hemostasis, the kidney bed is drained. A circular polyvinyl chloride drainage is installed in the retroperitoneal space. The wound is sutured. In the postoperative period, in order to prevent suppuration of the wound, the retroperitoneal space is constantly irrigated with an aqueous solution of chlorhexidine for 2 days.

The performance of the proposed method is confirmed by the following clinical examples.

Example 1. Patient A-ova, age 44, was admitted with complaints of pain in the lumbar region on the left, hyperthermia up to 38.8°C, weakness, nausea, decreased performance. The general condition at admission is of moderate severity. BP - 115/70 mm Hg. Heart rate - 85 in 1 min. According to a comprehensive clinical and laboratory study, ultrasound and CT, a clinical diagnosis was established: Urolithiasis. Coral stone of the left kidney. Terminal pyonephrosis, purulent paranephritis. Right kidney cyst.

Given the safety of the somatic condition, ultrasound and MRI data on the presence of purulent kidney damage and limited purulent paranephritis, it was decided to perform a one-stage nephrectomy by the claimed method. Under endotracheal anesthesia, in the position of the patient on a healthy side, under ultrasound control, a puncture of the purulent site was performed, the wound was expanded to 1 cm, and an electric suction was introduced into it, and about 100 ml of purulent contents of the retroperitoneal space were evacuated. The electric pump has been removed. A 10 mm trocar with a laparoscope was introduced at the injection site of the electric suction and a retropneumoperitoneum was created by CO2 insufflation. Under optical control, additional 5 and 10 mm trocars were introduced along the anterior and middle axillary lines. The revision of the retroperitoneal space and the sanitation of purulent foci were carried out by periodic irrigation of the retroperitoneal space with saline. Further along the psoas muscle, the posterior surface of the kidney and renal vessels were exposed. After ligation and transection of the vascular pedicle, the kidney was mobilized with perirenal tissue with Gerota's fascia, which were removed from the mini-access as a single block.

After monitoring for hemostasis, the kidney bed was drained. A circular polyvinyl chloride drainage was installed in the retroperitoneal space. The wounds are sutured. In the postoperative period, in order to prevent suppuration of the wound, the retroperitoneal space was irrigated with an aqueous solution of chlorhexidine for 2 days.

In the postoperative period, active antibacterial, detoxification and anti-inflammatory therapy was carried out. The postoperative wound healed by primary intention. Ultrasound control revealed no pathological formations in the area of the kidney bed. In a satisfactory condition, the patient was discharged on the 7th day after surgical treatment under the supervision of a urologist at a polyclinic at the place of residence.

Example 2. Patient P-s, age 38, was admitted with complaints of pain in the lumbar region on the right, hyperthermia up to 39.1°C, chills, weakness, nausea, lack of appetite. The general condition at admission is of moderate severity. BP - 110/75 mm Hg. Heart rate - 89 in 1 min. According to a comprehensive clinical and laboratory study, ultrasound and CT, a clinical diagnosis was established: Acute hematogenous purulent pyelonephritis. Multiple abscesses of the right kidney. Purulent paranephritis.

Considering the total damage to the kidney by a purulent process with a breakthrough of the purulent process into the paranephria according to ultrasound and MRI data, the preservation of the somatic condition, it was decided to perform a one-stage nephrectomy by the claimed method. Under endotracheal anesthesia, in the position of the patient on a healthy side, under ultrasound control, a puncture of a purulent site was performed into the paranephria, the wound was expanded to 1 cm, an electric suction was introduced into it, and about 55 ml of purulent contents of the retroperitoneal space were evacuated. The electric pump has been removed. A 10 mm trocar with a laparoscope was introduced at the injection site of the electric suction and a retropneumoperitoneum was created by CO2 insufflation. Under optical control, additional 5 and 10 mm trocars were introduced along the anterior and middle axillary lines. The revision of the retroperitoneal space and the sanitation of purulent foci were carried out by periodic irrigation of the retroperitoneal space with saline. Further along the psoas muscle, the posterior surface of the kidney and renal vessels were exposed. After mobilization, ligation and transection of the vascular pedicle, the kidney was mobilized with perirenal tissue with Gerota's fascia, which were removed from the mini-access as a single block.

After monitoring for hemostasis, the kidney bed was drained. A circular polyvinyl chloride drainage was installed in the retroperitoneal space. The wounds are sutured. In the postoperative period, in order to prevent suppuration of the wound, the retroperitoneal space was irrigated with an aqueous solution of chlorhexidine for 2 days.

In the postoperative period, antibacterial, detoxification and anti-inflammatory therapy was carried out. The wound healed by first intention. In a satisfactory condition, the patient was discharged on the 5th day after surgical treatment under the supervision of a urologist at the polyclinic at the place of residence.

The method developed by us proved to be effective in the treatment of 8 patients with purulent-inflammatory diseases of the kidneys and retroperitoneal space. He made it possible to improve the quality of the treatment process, to save patients from the disease in a short time. The operation meets the requirements of purulent surgery.

Advantages of the method of retroperitoneoscopic access when performing a one-stage nephrectomy in case of purulent processes in the kidney and perirenal tissue:

- the ability to perform a nephrectomy in one stage,

- creation of adequate access to the kidney and renal vessels,

- reducing the risk of dissemination of the purulent process,

- prevention of postoperative wound complications.

- exclusion of the risk of infection of the abdominal cavity.

Claims (1)

A method for retroperitoneoscopic access when performing a one-stage nephrectomy with purulent processes in the kidney and perinephric tissue, including at the preoperative stage an assessment of the condition of the kidneys and surrounding tissues according to ultrasound and MRI data, characterized in that they diagnose the degree of purulent damage to the kidney and purulent areas in the paranephria, in the position of the patient on a healthy side under ultrasound control, a purulent area is punctured, the wound is expanded, an electric suction is introduced into it and the purulent contents of the retroperitoneal space are evacuated, the purulent cavity is washed, then the electric suction is removed, a 10 mm trocar with a laparoscope is inserted in its place and a retropneumoperitoneum is created by insufflation of CO2 ; additional trocars are inserted along the anterior and middle axillary lines, revision and sanitation of the retroperitoneal space is carried out, then along the lumbar muscle, the posterior surface of the kidney, renal vessels with bipolar tissue coagulation are exposed, the kidney is mobilized along the posterior surface and renal vessels, and nephrectomy is performed; a circular PVC drainage is installed in the retroperitoneal space and in the postoperative period for 2 days the retroperitoneal space is irrigated with an antiseptic - an aqueous solution of chlorhexidine.