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3.1. Surgical methods of treatment of tumours of kidneys

Resections of kidneys 185 (76 %) by the patient, 45 (19 %) - nefrekto - my with normally functioning opposite kidney, 12 (5 %) the patient - rentgenoendovaskuljarnaja an occlusion of vessels of a tumour of kidneys are executed.

The tumour location makes the big impact on possibility definition organosohranjajushchej operations. The most simple situation develops at tumour localisation in the bottom and top segment as at the given localisation technically easier to execute organosohranjajushchuju operation and to take in a wound of the operated organ. Also favorable localisation on an external contour of an average part of a kidney is represented. Neoplasms even the small size, the kidneys localised on a medial surface, located near to hiluses, can be near to the basic vessels and CHLS, that does performance of operation rather labour-consuming.

In this connection, we had been used access: high slanting ljumboto - mija with resection ХІ of a rib (a drawing 19-20) for the purpose of reduction travmatichno - sti, allocation completely kidneys (a drawing 21) together with a renal leg for maintenance of its local hypothermia (a drawing 22).

Advantage of the given method is smaller travmatichnost for the account of absence of necessity of opening of a pleural cavity and a diaphragm section; possibility of full allocation of a kidney that allows to dilate possibility of the indication of performance of a nephrectomy at various localisation of a tumour.

Optimum position of the patient - curved on an operating table so that the angle between its body and an operating table made nearby 30-45 °. During the given access a dermal cut made over ХІ a rib, beginning from a back axillary line in a direction to a belly-button to lateralnogo edges of a direct muscle of a stomach. We dissect a skin, a hypodermic fat, and a superficial fascia. Then wound edges it is widely planted aside and dissected an external slanting muscle of a stomach. Then we start a resection of distal third XI rib, for this purpose we cross a periosteum on a forward surface of a rib, and the cut edge is bordered by an additional cross-section. Raspatory Farabefa we separate a periosteum from a forward surface of a rib, then under a back leaf of a periosteum it is got a costal forceps and we cross a rib. After that the cut extremity of a rib we grasp a Kocher's forceps, we delay it up and an electrocoagulator we separate a periosteum from a back surface of a rib. Thus opening of a pleural cavity does not occur. By a following stage it is crossed an internal slanting muscle of a stomach, a deep leaf of a pojasnichno-back fascia and a cross-section muscle, providing with that access to retroperitoneal space. Then we dissect a back leaf of a renal fascia and it is bared a fatty capsule of a kidney then it is established 4 retractors of retractor Sigala: by two of them it is fixed a costal arch - an upper edge of an operational wound, and the third and the fourth - a wound bottom edge. For allocation of a kidney from a fatty capsule, last on one of sites of a back surface it is dissected and consistently allocated a back surface of a kidney, the bottom segment, a forward surface with abduction of descending department of a colonic intestine if operation is carried out on the left side, or ascending department of a colonic intestine and a duodenum if operation is carried out on the right.

In last turn it is started remission of the top segment of an adrenal adjoining to it for what we spend a ligation of all fine adrenal vessels.

Further removing a peritoneum and a kidney, we provide access to an aorta and on - chenym to vessels and it is bared the top third of ureter (a drawing 21). We allocate a kidney stupid and acute by from a perinephric fat, except for a part, prilezhashchej to a tumour. Further we press a renal leg a clamp Satinsky; we carry out a kidney hypothermia by obkladyvanija round it ice crumbs (a drawing 22) for the purpose of reduction of ischemic damages (a drawing 22-23).

Drawing 19. Position of the patient and a projection of a dermal cut at a high slanting lumbotomy with a resection of XI rib.

Drawing 20. A subperiostal resection of XI rib to a back axillary line.

Drawing 21. An ureter capture on derzhalku

Drawing 22. The kidney allocated completely.

Drawing 24. Crossclamping by a clamp Satinsky a renal leg.

The anatomic estimation of applied access specifies on small travmatichnost as does not damage large nerves and vessels. The analysis of objective parametres of an operational wound specifies in sufficient accuracy of a projection of a cut over an operation zone. The presented access frames a sufficient surgery field, allows to manipulate under a constant direct vision, to bare all surface of a kidney, and renal vessels are projected practically in the wound centre. The digital estimation of parametres of a wound specifies for sufficient width 15,3±0,8 sm and small depth 7,4±0,6 the Angle of an inclination of an axis of operational action to renal vessels see is peer 84,8±1,20.

For prevention of development of renal insufficiency conservation of the maximum volume of a renal parenchyma in the conditions of minimum time of an ischemia is required. In our cases has on the average made 20-30 minutes after clamp applying on a renal leg against protivoishemicheskoj protection, namely obkladyvanie "crumbs" of ice of all kidney, leaving only area of an operational intervention (a drawing 23). By means of the given technique we have achieved timely restoration of function of a kidney after a declamping Satinsky from a renal leg and in 90 % of cases of good functional ability of a kidney after its resection.

Nephrectomy carried out always within a healthy tissue, not receding from wound edge. In case of opening of collective system of a kidney made its tight ushivanie (a drawing 26). Defect of a kidney is taken in by returnable haemostatic seams with fatty tissue use (a drawing 27, 29-30).

Clamp from a renal leg took out and any more did not close, since it can lead reperfuzionnomu to kidney damage (to Ljubarskaja J.O., 2006). A wound drainage carried out through a counteropening below the basic cut.

Drawing 25. The Nephrectomy within healthy tissues. Obkladyvanie "crumbs" of ice of all kidney, except area of an operational intervention.

Drawing 26. Tight ushivanie kidney calyxes.

Drawing 27. Defect of a kidney is taken in by returnable haemostatic seams with fatty tissue use.

Intraoperatsionnyh complications, lethal outcomes were not. To three patients the resection of a unique kidney more than 2/5 is executed, that has led to transfer into a program hemodialysis of one patient and two 7 and 10 sessions of a program hemodialysis, with the subsequent constant level of a creatinine of blood of 200 mkmol/l and urea of 15 mmol/l in a current of three years are executed.

Till now the resection of kidneys concerning a tumour is an effective method of treatment of patients with a kidney tumour.

Timeliness and radicalism of performance of operation predetermines the further destiny of the patient. Therefore it is necessary, that each operation, made to the patient with a kidney tumour, it has been carried out especially carefully, with the maximum radicalism.

Such technics organosohranjajushchej operations at RP has allowed to reduce probability of a recurrent tumour to a minimum, to reduce quantity of complications.

3.1.1

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A source: Hamitov Denis Dinarovich. Tactics of surgical treatment of patients with bilateral tumors of the kidneys, a tumor of a single kidney and patients with a kidney tumor in combination with chronic kidney diseases on the opposite side. Thesis for the degree of candidate of medical sciences. Kazan 2014. 2014

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