non-atrophic nephrolithotomy

The renal artery trunk is divided into the anterior and posterior branches at the renal hilum or the renal sinus. After entering the renal parenchyma, each branch lacks mutual collateral circulation. The distal end of the anterior and posterior branches of the renal artery forms a relatively avascular anterior-posterior segment about 1 cm at the back of the kidney arch, which is called the Brodel line. Cutting the renal parenchyma along this line can reduce the amount of bleeding and avoid renal ischemic atrophy. However, the lines between the anterior and posterior segments vary from person to person, and the curves are curved. Most of them are not in a straight line. It is often impossible to draw the exact position according to the fixed anatomical landmark of the surface. If the posterior branch of the renal artery is temporarily blocked, the line between the segments can be clearly displayed. Cutting the renal parenchyma along this plane can avoid damage to the main branches of the renal artery, less bleeding, and no ischemic renal atrophy. Treatment of diseases: kidney stones Indication Non-atrophic nephrolithotomy is suitable for large staghorn kidney stones, multiple pyelone stones, and small renal pelvis. It is difficult to remove or remove stones with other kidney or pelvis. Contraindications The kidney has a serious infection or has no function. Preoperative preparation 1. Adequate treatment of existing urinary tract infections, the application of broad-spectrum antibiotics should be strengthened 48 hours before surgery. 2. Prepare blood for 600ml. 3. Prepare local cooling supplies during surgery. Surgical procedure 1. Determining the plane of the relatively avascular zone: The eleventh intercostal incision is generally used to reveal the kidney. The entire kidney and renal pedicle blood vessels should be fully dissociated to enable the incision to be made. The most common method for determining the plane of the avascular area (Brodel line) is to block the pulsating posterior renal artery with a finger at the posterior lip of the renal hilum. If the finger cannot accurately block the posterior artery, it must be separated for noninvasiveness. When the vascular clamp temporarily blocks the posterior branch of the renal artery, there is no arterial blood perfusion in the blood supply area of the artery. The color of the kidney tissue in the ischemic area rapidly changes to pale, forming a sharp boundary with the renal tissue of the anterior branch of the renal artery. The markers are sutured on the renal capsule. In order to enhance the tolerance of renal tissue to ischemia, clamping the renal artery can cool the ice in the kidney. The relative avascular zone can also be measured using a Doppler ultrasound stethoscope. 2. Incision of the kidney: Temporary blockage of renal blood supply with a non-invasive vascular clamp, local cooling of the kidney. The renal parenchyma is cut longitudinally along the relatively avascular plane of the marker. The length of the incision depends on the size of the stone, but generally 3 to 4 cm is sufficient. Use a sharp blade to cut the kidney neatly and directly against the stone to avoid blunt dissection and severe contusion of the kidney tissue. 3. Remove the stone: Hold the stone with a stone pliers, gently shake it and remove the stone in the direction of the incision. If the stone and the renal pelvis and renal pelvis adhesion, use the handle to remove, avoid violent sputum. If the stone is too long to be removed, it can be removed in the middle of the stone with a clamp. After the stones are removed, the renal pelvis and renal pelvis are thoroughly rinsed with a fine catheter to remove stones and clots. 4. Hemostasis: The renal parenchyma is cut, and there is a large vascular end near the renal pelvis. The 4-0 absorbable line is used for suturing. The arcuate vascular end of the renal cortex and medulla junction is also sutured with a 4-0 absorbable line, and the suture is knotted at the medulla to avoid splitting the fragile kidney cortex. 5. Suture the renal pelvis and renal pelvis: insert a baby catheter or ureteral catheter from the kidney incision, pass the renal pelvis to the bladder, confirm the ureter without obstruction, and use the 4-0 absorbable line to suture the incision of the renal pelvis and renal pelvis continuously. The renal incision is completely separated from the renal pelvis and renal pelvis. 6. Suture the renal parenchyma: wear a 2-0 absorbable line interrupted or sutured renal parenchyma with a large curved round needle, knot the kidney section close together, in order to make the renal parenchyma not be separated by the suture, free adipose tissue or muscle can be used. The tissue pad is tied under the suture and knotted, and the kidney capsule is sutured with a thin wire. After the kidney is sutured, the renal pedicle clip is removed. If there is still bleeding, it can be filled or pressed to stop bleeding. 7. Close the incision and place the drainage.