Indications for organ removal
Surgical removal of a kidney is used when organ-sparing procedures are impossible or impractical. The main pathologies requiring a radical approach include malignant tumors, severe forms of renal tuberculosis, as well as advanced stages of hydronephrosis and pyonephrosis, in which the renal parenchyma is irreversibly destroyed. In addition, the intervention is indicated for massive traumatic injuries that leave no chance of restoring the organ's integrity. The surgery is always performed under endotracheal anesthesia.
Surgical approach and kidney mobilization
To ensure adequate exposure, surgeons use an oblique lumbar incision. The Fedorov or Bergmann approaches are the most common. During the approach, all layers of the abdominal wall are sequentially incised, followed by the posterior layer of the renal fascia. At this stage, the adipose capsule of the organ is exposed. The most important anatomical landmark here is the 12th rib, near which the subcostal vessels and nerve pass.
The next step is the mobilization of the organ. The surgeon carefully separates the surrounding adipose tissue, dissecting existing adhesions and scar tissue. After this, so-called mobilization (delivery) is performed: the kidney is physically brought out into the surgical wound. To ensure clean subsequent manipulations, the adipose tissue is completely cleared from the organ.
Technique of managing the renal pedicle
Working with the vascular pedicle is the most delicate stage. The elements are isolated in a strict sequence: first the renal vein, then the renal artery, followed by the posterior wall of the renal pelvis, and finally the ureter (which is isolated as far down as possible).
A specialized instrument, the Deschamps needle, is used to ligate the vessels. It is used to pass two strong silk ties under the vessels. The distance between the applied ligatures must be exactly 1 cm.
The order of tying the ligatures is of critical importance:
- The ligatures located medially (closer to the spine) are always tied first. The surgeon must exercise extreme care to avoid accidentally catching the wall of the inferior vena cava (v. cava inferior) in the ligature.
- Only after this are the second, distal ligatures tied.
To transect the vessels between the distal ties and the renal hilum, a Fedorov renal clamp is applied. The vessels are transected strictly between the clamp and the hilum. An important rule: the artery is transected first, followed by the vein.
After transection, hemostasis must be checked. For this purpose, the blades of the Fedorov clamp are very carefully spread apart. If there is no bleeding from the resulting stump, the clamp is completely removed, and the long ends of the silk ligatures are trimmed.
Transection of the ureter and completion of the surgery
The ureter requires separate management. A clamp is applied 2–3 cm below its junction with the renal pelvis. Below this clamp, the ureter is ligated with catgut. Transection is performed between the clamp and the ligature, after which the kidney is finally removed from the wound.
The cut surface of the ureter stump must be treated with an alcoholic iodine solution for disinfection and then buried in the surrounding soft tissues. It is worth noting that in the presence of specific indications, the ureter is not left as a short stump, but is removed entirely, down to the bladder wall.
At the final stage, the surgeon thoroughly checks for hemostasis in the empty renal bed. To ensure fluid drainage, a rubber drain is placed down to the bed. The surgical wound is closed strictly layer by layer.
Briefly: answers to topical questions
What surgical approaches are used for surgical exposure of the kidney?
Lumbar incisions are used for surgical exposure of the kidney. Most commonly used are:
- Fedorov incision — an oblique lumbar incision from the angle between the 12th rib and m. erector spinae downward toward the umbilicus.
- Bergmann incision — made along the bisector of the angle between the 12th rib and the lateral border of m. erector spinae.
- Israel incision — a modification of the Bergmann incision extended downward parallel to the inguinal ligament.
Which muscles of the anterolateral abdominal wall are sequentially incised during the Fedorov approach?
During the Fedorov approach, the muscle layers are incised in the following order:
- First layer — m. latissimus dorsi (superiorly) and m. obliquus externus abdominis (inferiorly).
- Second layer — m. serratus posterior inferior and m. obliquus internus abdominis.
- Third layer — m. transversus abdominis.
- Deep layers — m. quadratus lumborum (incised together with the fascia thoracolumbalis).
If necessary, the rectus abdominis muscle (m. rectus abdominis) is additionally transected up to the linea alba.
In what specific pathologies is complete removal of the ureter down to the urinary bladder indicated?
When indicated, the ureter can be completely removed down to the urinary bladder. Specific pathologies serving as indications for such removal are not specified in the cited sources.
Which nerves run in the lumbar region and are at risk of injury during lumbotomy?
The sources mention the subcostal nerve along with the subcostal vessels near the 12th rib as an anatomical landmark during the approach. There is no direct indication of the risk of its injury during lumbotomy in the provided materials; information regarding other nerves of the lumbar region is also not provided.
Rule of transecting renal pedicle vessels: alphabetically. First, the artery is transected, and then the vein.
Class and exam questions
What instrument is used to pass threads under the renal vessels?
Deschamps needle is used for the safe placement of silk ligatures beneath the elements of the vascular pedicle.
In what order are the ligatures tied on the renal vessels?
The ties located medially (closer to the spine) are always tied first. Only after this are the second, distal ligatures tied.
What is used to treat the ureter stump after organ removal?
The cut surface of the ureter stump must be treated with an alcoholic iodine solution, after which it is buried in the surrounding soft tissues.
What else to study on this topic
- Topographic anatomy of the renal fascia and adipose capsule.
- Comparative characteristics of the oblique lumbar approaches according to Fedorov and Bergmann.
- Topographical features of the inferior vena cava in the context of right-sided nephrectomy.
- Technique of applying the Fedorov renal clamp and potential errors during hemostasis control.
- Indications for total ureterectomy down to the urinary bladder wall.
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