Fig. 644
Nephrectomy. Complete delivery of kidney and ligation of its vessels and ureter. (Hartmann.)
Under some circumstances the surgeon may so complete the nephrectomy that the external wound may be closed without drainage; but when there has been contamination, as by escape of contents, either purulent or urinary, or when a considerable mass of tissue has to be left enclosed within an elastic ligature surrounding the stump, then an opening should be left in order that slough may easily escape and ample drainage be afforded. A reliable ligation of the renal vessels should be made, which is best done with at least two ligatures, taking the pedicle in parts, or else carefully isolating the vessels when sufficiently exposed, and tying each one of them separately, after which the whole group may also be enclosed in a single ligature. A few operators have reported such accidents as tearing the renal vein from the vena cava, and such a wound has been successfully sutured, the patient recovering; this requires, however, both coolness and resourcefulness in the presence of serious difficulty and danger. Certain dense tumors can be removed by process of morcellation, i. e., removal of a portion at a time, the separate pieces being cut away with scissors or knife, as may be the more convenient, and hemorrhage being controlled by clamps.
The anterior or Trendelenburg route is rarely selected for nephrectomy, but may be adopted when this procedure is made a part of other abdominal work, or may be necessitated by the presence of a large tumor in a small abdomen, as, for instance, in children. The abdomen will be opened as for any abdominal tumor, either in the middle or to one side, as may seem best. The tumor itself will so far displace the viscera as to perhaps present at once beneath the knife. It may be necessary to go through the peritoneum twice. After being thus exposed, and the abdominal cavity protected, the balance of the operation is again a process of enucleation, with securing access to the pedicle of the tumor, where its vessels and the ureters may be found. These again are ligated and the mass removed as though it were from the peritoneal cavity. Posterior drainage may be added, although rarely necessary.
Other operations have been suggested to meet the needs of individual cases. Thus pyelectomy, or removal of a portion of the dilated pelvis of the kidney, has been performed by Murphy and others, the process being essentially an excision of a portion of the sac wall and its retrenchment by sutures. Plastic attachment of the dilated upper end of a ureter to the floor of the renal pelvis has also been effected in much the same way, as in a case reported by Murphy, where, after opening the sac of the pelvis, the ureter was slit for a considerable distance, while at the lower angle a V-shaped piece of the sac was fastened into the ureteral opening, thus making a funnel-like communication.
Again, as illustrative of some of the radical suggestions of recent years, Watson has proposed that in instances of hopeless bladder conditions, where the patient is made miserable, there should be a turning out of both ureters on the loin, and the formation of two ureteral fistulas, after which the patient may wear a drainage receptacle, and in this way enjoy a comfort otherwise unattainable. He has reported the case of such a patient, who has thus passed all the urine for four years, and urine from one side for eleven years, who was otherwise in comfortable health.
Fig. 645
Fig. 646
Fig. 647