ANTERIOR TRANSPERITONEAL APPROACH FOR REMOVAL OF RENAL STONES C. A. LINKE,
M.D.
C. L. LINKE,
M.D.
R. S. DAVIS, M.D. Z. BARBARIC,
M.D.
From the Departments of Surgery (Urology), Anesthesiology, and Radiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
ABSTRACT - An anterior transperitoneal approach was used fn- removal of stones from 15 kidneys in 13 patients. Exposure of the anterior portion of the pelvis was readily accomplished making excellent exposure of the interior of the kidney possible. Minimal urinary drainage was noted postoperatively. The operative procedures done with the patients in the supine position were well tolerated.
anterior pelvis posterior to the renal vessels. The ureter is deliberately not mobilized. An incision is made from upper to lower pole infundibulum. The infundibula, into the various segments of the kidney, are often best visualized from the opposite side of the patient. Intraoperative roentgenograms are obtained beginning with a scout film obtained prior to induction of anesthesia to check stone location and x-ray technique. Recently developed fast filmscreen combinations allow use of lower kilovolt peak (improving contrast) without prolonging exposure time. Roentgenogram quality is further improved by use of a crisscross grid with 8:l ratio taped to the film cassette, and improved collimation achieved by a 10 by 30-cm. collimator extension tube. Exact perpendicular placement of x-ray beam to film plane is necessary when the grid is used to insure proper exposure and proper roentgenogram detail. Respiration may be suspended during the x-ray exposure to avoid motion on intraoperative films. By attention to the foregoing details, adequate intraoperative roentgenograms can be obtained by exposure of the minimally mobilized in situ kidney using film placed beneath the patient. If these are found inadequate, the kidney can be mobilized completely and films can be placed
An anterior transperitoneal approach has been used in removal of stones from 15 kidneys in 13 patients (2 bilateral) reviewed herein. Surgical Considerations The patient is placed on the operating room table in the supine position with a padded x-ray cassette holder beneath the kidney area. An anterior subcostal incision is made through all layers of the anterior abdominal wall including the peritoneum (Fig. 1). Abdominal exploration is carried out after which the ipsilateral colon is mobilized from the posterior peritoneal attachments and retracted medially. On the right side, the duodenum is mobilized exposing the vena cava and right renal vein. On the left, greater mobility of the left renal vein may be obtained by division of the spermatic vein and occasionally the adrenal vein. The renal artery is isolated with an umbilical tape permitting temporary arterial occlusion if needed during the procedure for better visualization or palpation of the renal substance. The lower pole of the kidney is mobilized so that it can be elevated and rotated anteriorly. Beginning at the renal hilum, a plane is developed into the renal sinus directly along the
UROLOGY
/ OCTOBER
1976 / VOLUME
VIII,
NUMBER
4
DUOD.
LINE OF INCISION
TAPE ON RENAL ARTERY
FIGURE 1. (A) Anterior subcostal incision is made with patient in supine position. (B) Peritoneum incised lateral to colon. (C) Colon (and duodenum on right) reflected to expose kidney pelvis and vessels. (D) Vessels retracted and incision made in pelvis from upper to lower infundibulum. (E) Visualization into kidney is often best from opposite side. (F) Stones removed from kidney pelvis and infundibula.
directly behind the kidney and exposed in this location. ’ When stone removal has been judged complete, the pyelotomy is closed. In many cases removal of the retractors results in immediate apposition of the cut edges of the renal pelvis covered by the renal substance. If approximation of the edges of the renal pelvis appears good, no sutures are used in the closure of the pyelotomy. If there appears to be some irregularity in the apposition of the edges, two or three interrupted 5-O chromic sutures are used to direct the apposition more appropriately. In no case was extensive suturing of the pyelotomy incision necessary. Two Penrose drains (0.75 inch diameter) are placed in the retroperitoneal area and are
330
brought out through a large stab wound in the lateral abdominal wall beneath the rib cage. The colon is placed back over the retroperitoneal drains without suturing, and omentum is used to separate small intestine from the wound area. The wound is closed using chromic sutures in the peritoneal layer and lateral muscle layers and generally using interrupted wire sutures in the anterior rectus fascia. Clinical
Features
Figure 2 illustrates clinical features encountered and tracings of preoperative x-rays of 15 (consecutive) kidneys in which the anterior transperitoneal approach was used for removal of renal stones. Three kidneys (1, 2, and 15) had
UROLOGY
/ OCTOBER1976
/ VOLUMEVIII,
NUMBER4
been previously operated on by flank approach for stone disease. Preoperative percutaneous nephropyelostomy tubes were used to drain infected kidneys (3, 15) in 2 septic patients. In 1 patient, stones were removed from both kidneys (8, 9) during the same operative procedure. Preoperative and one-week postoperative x-ray
RIGHT
KIDNEY
LEFT KIDNEY
Results
Stone removal was complete in all but three kidneys (2, 8, 12). Exposure of the intrarenal
Ii RIGHT
COMMENTS PREVIOUS
films of this patient are shown in Figure 3. Temporary postoperative nephrostomy tube drainage was used in 3 cases (1, 2, 3).
KIDNEY
LEFT KIDNEY
COMMENTS
SURGERY
IGHT
MULTIPLE
STONES
KIDNEY
PRE-OP PERCUTANEOUS NEPHROS2ND
INCISION
FOR
FIGURE 2. Clinical features and tracings of preoperative r-ray films of 15 kidneys in 13 patients by anterior transperitoneal approach fbr removal of stones.
UROLOGY
/ OCTOBER
1976 / VOLUME
PASS
VIII,
NUMBER 4
operated
on
331
FIGURE 3. Bilateral renal stones in twenty-eight-year-old man, who previously had total colectomy for Crohn’s disease. (A and B) Preoperative scout and intravenous pyelographyfibns; bilateral pyelolithotomy was done by anterior approach through two separate subcostal incisions. (C and D) Scout and intravenous pyelography films taken seven days postoperatively.
structures of the kidney has been considered to be at least as good by other approaches in all cases, and superior to more conventional exposure techniques in most instances. Significant urinary drainage from the drain sites was noted in only 2 instances (10, 12) in both of which there was considerable edema at the site (ureteropelvic junction) of impacted stones. In both of these cases, drainage ceased by three days postoperatively. In all other cases there was no significant postoperative urinary drainage. Postoperative nephrostomy tube drainage of the kidney in those instances (1, 2, 3) in which it was used was discontinued by ten days postoperatively. Comment Although the anterior transperitoneal approach has been used by others2 review of the present series of patients was considered ap-
332
propriate since most renal stones are still removed by the flexed lateral or prone position approach.3-5 The natural posterior angulation of the lateral part of the kidney in the renal fossa is a natural advantage for the anterior approach allowing excellent vision into the internal structure of the kidney without need for extensive mobilization of the kidney or ureter (Fig. 1B). The transperitoneal incision is considered important to allow adequate mobilization of the colon (and duodenum on the right side) away from the medial portion of the kidney. The extended pyelotomy through the anterior wall of kidney pelvis has been easy to accomplish even in those patients previously operated on through flank incisions. The generally stated advantage of posterior pyelotomy is that there are fewer vessels overlying the pelvis in this area. We have, however, found no real difficulty in exposing the anterior
UROLOGY
/ OCTOBER1976 / VOLUMEVIII, NUMBER4
portion of the kidney pelvis by the simple traction and rotation maneuvers described. The plane between the anterior wall of kidney pelvis and the hilar vessels is developed easily. Developing the plane on the pelvis itself leaves a thin layer of fatty areolar tissue around the vessels. At times a dusky appearance of the kidney in that portion which is being retracted occurs, but this is easily relieved by removal of the traction for a few moments. Stone fragments were retained in 3 patients (Fig, 2). We do not believe that this is a limitation of the approach itself, but rather points to the need for further refinements in technique such as the use of a nephroscope or other instruments to gain better visualization within the infundibula. 6,7 Intraperitoneal drainage of urine postoperatively has not been a complication in any of the aforementioned patients. Several features are probably responsible for the minimal drainage noted, including the tendency for the pyelotomy to reapproximate itself, the natural covering of the pyelotomy by the anterior portion of the kidney and by the colon, and the additional protection offered by the omentum near the drain sites. Since the exposure of the pelvis is very direct, the ureter remains in its usual location without need for traction or distortion of this structure. This probably is important in early recovery of efficient peristaltic activity in the ureter which likewise may minimize postoperative urinary extravasation. The supine position is well tolerated by the anesthetized patient whereas the flexed lateral and prone positions are the most poorly tolerated.8,g Venous return in the flexed lateral and prone position is significantly decreased by the dependent posture of the lower half of the body, favoring development of systemic hypotension. The myocardial depression of halothane, the curarized muscle paralysis of the legs, and vena cava compression are all factors which further decrease venous return. If hypotension occurs in the flexed lateral or prone position, the most physiologic approach to restore cardiac output is to elevate the legs by decreasing the flexion. This, however, may be incompatible with maintaining adequate surgical exposure. Despite mechanical ventilation, intrapulmonary shunting occurs in the lateral positions. The upper lung receives most of the ventilation but
UROLOGY /
OCTOBER 1976 /
VOLUME VIII, NUMBER 4
the least circulation, while the dependent lung receives the greatest circulation and the least ventilation. The ventilation-perfusion relationship is thereby disturbed and arterial oxygen tension is decreased. This can cause significant hypoxia, seen most commonly in the aged and in emphysematous patients. The supine position also permits better management of other specifically difficult patients such as the quadriplegic patient in the present group. The anterior approach is particularly advantageous in those patients having “malrotation” of the kidney and in those requiring other procedures such as removal of ureteral stones. The ability to check the intraperitoneal structures for evidence of other pathology is of potential importance. In 2 patients in this group, appendectomy and cholecystectomy were considered indicated and were accomplished through the same operative exposure. Bilateral kidney stone removal is likewise more easily accomplished with this approach (Fig. 3). X-ray control during the procedure is possible by exposure of the films placed beneath the patient or placed under the kidney itself. University of Rochester School of Medicine and Dentistry Department of Surgery (Urology) Rochester, New York 14642 (DR. C. A. LINKE) References 1. LINKE, C. A., ROGOFF, S. M., LIND, B., and FRIDD, C. W. : Intraoperative roentgenograms of kidney, Urology 3: 28 (1974). 2. POUTASSE, E. F.: Anterior approach to upper urinary tract surgery, J. Urol. 85: 199 (1961). 3. GIL-VERNET, J.: New surgical concepts in removing renal calculi, Urol. Int. 20: 255 (1965). 4. BOYCE, W. H.: Surgery of renal calculi, in Glenn, J. F., and Boyce, W. H., Eds.: Urologic Surgery, New York, Harper and Row, 1969, chap. 3, p. 88. ANDALORO,V. A., and LILIEN, 0. M. : Posterior approach to the kidney, Urology 5: 600 (1975). HERTEL, E.: Intraoperative nephroscopy, ibid. 4: 13 (1974). CLARK, P.: Nephroscopy, Br. J. Urol. 47: 599 (1975). DON, H. F., CRAIG, D. B., WAHBA, W. M., and CouTURE, J. G.: The measurement of gas trapped in the lungs at functional residual capacity and the effects of posture, Anesthesiology 35: 582 (1971). 9. MARSH, H. M., REHDER, K., SESSLER, A. D., and FOWLER, W. S.: Effects of mechanical ventilation, muscle paralysis, and posture on ventilation-perfusion relationships in anesthetized man, ibid. 38: 59 (1973).
333
M.D.
C. L. LINKE,
M.D.
R. S. DAVIS, M.D. Z. BARBARIC,
M.D.
From the Departments of Surgery (Urology), Anesthesiology, and Radiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
ABSTRACT - An anterior transperitoneal approach was used fn- removal of stones from 15 kidneys in 13 patients. Exposure of the anterior portion of the pelvis was readily accomplished making excellent exposure of the interior of the kidney possible. Minimal urinary drainage was noted postoperatively. The operative procedures done with the patients in the supine position were well tolerated.
anterior pelvis posterior to the renal vessels. The ureter is deliberately not mobilized. An incision is made from upper to lower pole infundibulum. The infundibula, into the various segments of the kidney, are often best visualized from the opposite side of the patient. Intraoperative roentgenograms are obtained beginning with a scout film obtained prior to induction of anesthesia to check stone location and x-ray technique. Recently developed fast filmscreen combinations allow use of lower kilovolt peak (improving contrast) without prolonging exposure time. Roentgenogram quality is further improved by use of a crisscross grid with 8:l ratio taped to the film cassette, and improved collimation achieved by a 10 by 30-cm. collimator extension tube. Exact perpendicular placement of x-ray beam to film plane is necessary when the grid is used to insure proper exposure and proper roentgenogram detail. Respiration may be suspended during the x-ray exposure to avoid motion on intraoperative films. By attention to the foregoing details, adequate intraoperative roentgenograms can be obtained by exposure of the minimally mobilized in situ kidney using film placed beneath the patient. If these are found inadequate, the kidney can be mobilized completely and films can be placed
An anterior transperitoneal approach has been used in removal of stones from 15 kidneys in 13 patients (2 bilateral) reviewed herein. Surgical Considerations The patient is placed on the operating room table in the supine position with a padded x-ray cassette holder beneath the kidney area. An anterior subcostal incision is made through all layers of the anterior abdominal wall including the peritoneum (Fig. 1). Abdominal exploration is carried out after which the ipsilateral colon is mobilized from the posterior peritoneal attachments and retracted medially. On the right side, the duodenum is mobilized exposing the vena cava and right renal vein. On the left, greater mobility of the left renal vein may be obtained by division of the spermatic vein and occasionally the adrenal vein. The renal artery is isolated with an umbilical tape permitting temporary arterial occlusion if needed during the procedure for better visualization or palpation of the renal substance. The lower pole of the kidney is mobilized so that it can be elevated and rotated anteriorly. Beginning at the renal hilum, a plane is developed into the renal sinus directly along the
UROLOGY
/ OCTOBER
1976 / VOLUME
VIII,
NUMBER
4
DUOD.
LINE OF INCISION
TAPE ON RENAL ARTERY
FIGURE 1. (A) Anterior subcostal incision is made with patient in supine position. (B) Peritoneum incised lateral to colon. (C) Colon (and duodenum on right) reflected to expose kidney pelvis and vessels. (D) Vessels retracted and incision made in pelvis from upper to lower infundibulum. (E) Visualization into kidney is often best from opposite side. (F) Stones removed from kidney pelvis and infundibula.
directly behind the kidney and exposed in this location. ’ When stone removal has been judged complete, the pyelotomy is closed. In many cases removal of the retractors results in immediate apposition of the cut edges of the renal pelvis covered by the renal substance. If approximation of the edges of the renal pelvis appears good, no sutures are used in the closure of the pyelotomy. If there appears to be some irregularity in the apposition of the edges, two or three interrupted 5-O chromic sutures are used to direct the apposition more appropriately. In no case was extensive suturing of the pyelotomy incision necessary. Two Penrose drains (0.75 inch diameter) are placed in the retroperitoneal area and are
330
brought out through a large stab wound in the lateral abdominal wall beneath the rib cage. The colon is placed back over the retroperitoneal drains without suturing, and omentum is used to separate small intestine from the wound area. The wound is closed using chromic sutures in the peritoneal layer and lateral muscle layers and generally using interrupted wire sutures in the anterior rectus fascia. Clinical
Features
Figure 2 illustrates clinical features encountered and tracings of preoperative x-rays of 15 (consecutive) kidneys in which the anterior transperitoneal approach was used for removal of renal stones. Three kidneys (1, 2, and 15) had
UROLOGY
/ OCTOBER1976
/ VOLUMEVIII,
NUMBER4
been previously operated on by flank approach for stone disease. Preoperative percutaneous nephropyelostomy tubes were used to drain infected kidneys (3, 15) in 2 septic patients. In 1 patient, stones were removed from both kidneys (8, 9) during the same operative procedure. Preoperative and one-week postoperative x-ray
RIGHT
KIDNEY
LEFT KIDNEY
Results
Stone removal was complete in all but three kidneys (2, 8, 12). Exposure of the intrarenal
Ii RIGHT
COMMENTS PREVIOUS
films of this patient are shown in Figure 3. Temporary postoperative nephrostomy tube drainage was used in 3 cases (1, 2, 3).
KIDNEY
LEFT KIDNEY
COMMENTS
SURGERY
IGHT
MULTIPLE
STONES
KIDNEY
PRE-OP PERCUTANEOUS NEPHROS2ND
INCISION
FOR
FIGURE 2. Clinical features and tracings of preoperative r-ray films of 15 kidneys in 13 patients by anterior transperitoneal approach fbr removal of stones.
UROLOGY
/ OCTOBER
1976 / VOLUME
PASS
VIII,
NUMBER 4
operated
on
331
FIGURE 3. Bilateral renal stones in twenty-eight-year-old man, who previously had total colectomy for Crohn’s disease. (A and B) Preoperative scout and intravenous pyelographyfibns; bilateral pyelolithotomy was done by anterior approach through two separate subcostal incisions. (C and D) Scout and intravenous pyelography films taken seven days postoperatively.
structures of the kidney has been considered to be at least as good by other approaches in all cases, and superior to more conventional exposure techniques in most instances. Significant urinary drainage from the drain sites was noted in only 2 instances (10, 12) in both of which there was considerable edema at the site (ureteropelvic junction) of impacted stones. In both of these cases, drainage ceased by three days postoperatively. In all other cases there was no significant postoperative urinary drainage. Postoperative nephrostomy tube drainage of the kidney in those instances (1, 2, 3) in which it was used was discontinued by ten days postoperatively. Comment Although the anterior transperitoneal approach has been used by others2 review of the present series of patients was considered ap-
332
propriate since most renal stones are still removed by the flexed lateral or prone position approach.3-5 The natural posterior angulation of the lateral part of the kidney in the renal fossa is a natural advantage for the anterior approach allowing excellent vision into the internal structure of the kidney without need for extensive mobilization of the kidney or ureter (Fig. 1B). The transperitoneal incision is considered important to allow adequate mobilization of the colon (and duodenum on the right side) away from the medial portion of the kidney. The extended pyelotomy through the anterior wall of kidney pelvis has been easy to accomplish even in those patients previously operated on through flank incisions. The generally stated advantage of posterior pyelotomy is that there are fewer vessels overlying the pelvis in this area. We have, however, found no real difficulty in exposing the anterior
UROLOGY
/ OCTOBER1976 / VOLUMEVIII, NUMBER4
portion of the kidney pelvis by the simple traction and rotation maneuvers described. The plane between the anterior wall of kidney pelvis and the hilar vessels is developed easily. Developing the plane on the pelvis itself leaves a thin layer of fatty areolar tissue around the vessels. At times a dusky appearance of the kidney in that portion which is being retracted occurs, but this is easily relieved by removal of the traction for a few moments. Stone fragments were retained in 3 patients (Fig, 2). We do not believe that this is a limitation of the approach itself, but rather points to the need for further refinements in technique such as the use of a nephroscope or other instruments to gain better visualization within the infundibula. 6,7 Intraperitoneal drainage of urine postoperatively has not been a complication in any of the aforementioned patients. Several features are probably responsible for the minimal drainage noted, including the tendency for the pyelotomy to reapproximate itself, the natural covering of the pyelotomy by the anterior portion of the kidney and by the colon, and the additional protection offered by the omentum near the drain sites. Since the exposure of the pelvis is very direct, the ureter remains in its usual location without need for traction or distortion of this structure. This probably is important in early recovery of efficient peristaltic activity in the ureter which likewise may minimize postoperative urinary extravasation. The supine position is well tolerated by the anesthetized patient whereas the flexed lateral and prone positions are the most poorly tolerated.8,g Venous return in the flexed lateral and prone position is significantly decreased by the dependent posture of the lower half of the body, favoring development of systemic hypotension. The myocardial depression of halothane, the curarized muscle paralysis of the legs, and vena cava compression are all factors which further decrease venous return. If hypotension occurs in the flexed lateral or prone position, the most physiologic approach to restore cardiac output is to elevate the legs by decreasing the flexion. This, however, may be incompatible with maintaining adequate surgical exposure. Despite mechanical ventilation, intrapulmonary shunting occurs in the lateral positions. The upper lung receives most of the ventilation but
UROLOGY /
OCTOBER 1976 /
VOLUME VIII, NUMBER 4
the least circulation, while the dependent lung receives the greatest circulation and the least ventilation. The ventilation-perfusion relationship is thereby disturbed and arterial oxygen tension is decreased. This can cause significant hypoxia, seen most commonly in the aged and in emphysematous patients. The supine position also permits better management of other specifically difficult patients such as the quadriplegic patient in the present group. The anterior approach is particularly advantageous in those patients having “malrotation” of the kidney and in those requiring other procedures such as removal of ureteral stones. The ability to check the intraperitoneal structures for evidence of other pathology is of potential importance. In 2 patients in this group, appendectomy and cholecystectomy were considered indicated and were accomplished through the same operative exposure. Bilateral kidney stone removal is likewise more easily accomplished with this approach (Fig. 3). X-ray control during the procedure is possible by exposure of the films placed beneath the patient or placed under the kidney itself. University of Rochester School of Medicine and Dentistry Department of Surgery (Urology) Rochester, New York 14642 (DR. C. A. LINKE) References 1. LINKE, C. A., ROGOFF, S. M., LIND, B., and FRIDD, C. W. : Intraoperative roentgenograms of kidney, Urology 3: 28 (1974). 2. POUTASSE, E. F.: Anterior approach to upper urinary tract surgery, J. Urol. 85: 199 (1961). 3. GIL-VERNET, J.: New surgical concepts in removing renal calculi, Urol. Int. 20: 255 (1965). 4. BOYCE, W. H.: Surgery of renal calculi, in Glenn, J. F., and Boyce, W. H., Eds.: Urologic Surgery, New York, Harper and Row, 1969, chap. 3, p. 88. ANDALORO,V. A., and LILIEN, 0. M. : Posterior approach to the kidney, Urology 5: 600 (1975). HERTEL, E.: Intraoperative nephroscopy, ibid. 4: 13 (1974). CLARK, P.: Nephroscopy, Br. J. Urol. 47: 599 (1975). DON, H. F., CRAIG, D. B., WAHBA, W. M., and CouTURE, J. G.: The measurement of gas trapped in the lungs at functional residual capacity and the effects of posture, Anesthesiology 35: 582 (1971). 9. MARSH, H. M., REHDER, K., SESSLER, A. D., and FOWLER, W. S.: Effects of mechanical ventilation, muscle paralysis, and posture on ventilation-perfusion relationships in anesthetized man, ibid. 38: 59 (1973).
333
