Gibbon has suggested intra-abdominal exploration and palpation of the ureter for the discovery and location of impacted calculi, and recommends that when discovered they may be removed by extraperitoneal incision, which may be lumbar, iliac, inguinal, vaginal, or even sacral or rectal; while with the advantage of combined manipulation, the operator having one hand in the abdominal cavity, the actual work is more rapid and certain.
This procedure is not to be advised in every case by any means, but may prove of advantage in doubtful cases, and especially in those where, when the abdomen has been already opened, a stone is accidentally found in the ureter, since when the latter is opened extraperitoneally it is rarely necessary to suture it.
The non-operative treatment of ureteral calculi has been considered when speaking of renal calculi. The operative treatment, inversion of the patient having failed, may consist of exposure of the upper two inches of the tube, by an incision parallel to the twelfth rib, and carried well forward and downward toward the middle of Poupart’s ligament. Through such an incision the whole length of the ureter may be reached. The opening is made down to the peritoneum, which is then pushed toward the median line. On its posterior surface, adherent to it, will be found the ureter. At the point where the stone is impacted the ureter is to be divided and the stone removed. In theory sutures should be inserted; in practice, they are rarely needed, as these incisions usually heal kindly without them.
A stone impacted at the vesical orifice of the ureter may, in the female, be removed after such dilatation of the urethra as shall permit access, or it may be removed through the vault of the vagina. In the male only the most expert manipulators within the bladder will attempt its removal in this way without at least a perineal section.
OPERATIONS UPON THE KIDNEYS AND URETERS.
In addition to the operative procedures already described the principal operation upon the kidney is nephrectomy. While this may be partial, under rare circumstances, the procedure is so essentially similar to the complete operation that it is only necessary to say that if a portion of the kidney be removed, bleeding from spurting vessels should be arrested by ligature, while the oozing, at first pronounced, will soon subside under the application of hot water, after which absorbable sutures may be used in sufficient number to approximate the parts.
Fig. 643
Position of patient and various lines of incision for nephrectomy and other operations upon the kidneys. A, the favorite method of approach for most purposes. (Hartmann.)
Total nephrectomy is usually done by the lumbar route, the kidney being exposed by an oblique incision extending obliquely downward from near the spine, parallel to the lower rib, between it and the crest of the pelvis, and as far forward as may be required for the purpose. For removal of a large solid tumor a large opening should be made, and the above incision may be extended in any required direction, or an additional cut may be made wherever required. In fact, in attacking some of the very largest growths it becomes necessary to apparently almost bisect the patient in order to furnish sufficient space. As the mass to be attacked lies behind the peritoneum it is rarely necessary to open the peritoneal cavity. This is usually done only by inadvertence or because of density of adhesions, and the effort should then be made to at once close it temporarily or permanently. Especially should every attempt be made to prevent contamination when dealing with tuberculous or suppurative renal disease. Ordinarily the abdominal opening does not extend nearer to the spine than the border of the spinal muscles. These may, however, be divided if necessary. So also may the deep fascia be divided in any direction, and, in fact, the last rib may be removed in toto if required. The kidney or the tumor, having now been reached, should be isolated. If the condition be cancerous as much of the surrounding tissue should be removed as the case will permit; if otherwise, an enucleation of the kidney from its more or less infiltrated bed will be sufficient. It is usually removed with its capsule, but sometimes the latter is so adherent that it is easier to enucleate the kidney itself from within it. Adventitious vessels may enter the kidney, more especially from below. The surgeon must be prepared, then, at any time to clamp and secure them if found. Sometimes enucleation of the kidney is exceedingly easy; at other times old adhesions or surrounding infiltration make it a matter of great mechanical difficulty. The intent is to not only isolate it, but to make such exposure of its pedicle that one may be securely protected against hemorrhage. Incidentally the ureter should be examined from above, by passage of a probe, or by injecting a colored solution, in order to know later if it passes freely into the bladder. It is the accurate securement of the renal vessels which is perhaps the most necessary feature of the operation and upon which most depends. When this is made impossible by extraordinary circumstances expedients must be adopted, as, for instance, the use of an elastic ligature—i. e., a piece of small rubber tubing, drawn tightly around the base of the mass and secured by clamp, ligature, or suture, the intent being to leave it for at least two or three days until it shall have accomplished its work, and then either to remove it or to allow it to loosen itself in time and come away.