OPERATING ON AN INJURED KIDNEY

INDICATIONS FOR EXPLORING THE KIDNEY Avoid exploring a patient’s injured kidney if you can. Try to refer those patients who need an operation. if you cannot refer a patient you may have to operate on the indications given above.

EXPOSING THE KIDNEY FROM THE LOIN

POSITION This is critical. Lie the patient on his normal side, with his back near the edge of the table. Flex his hip and his knee on the side next to the table. Extend his upper leg and place a soft pillow between his legs. if your table does not have a kidney bridge to extend his loin, place a large sandbag under his normal loin. If possible, support his upper arm. This will relieve the pressure on his chest, and help to hold him in place.

Find your landmarks by feeling his vertebral column, his iliac crest, and his twelfth rib.

CAUTION ! Don’t mistake his twelfth rib for his eleventh or you will incise too high and open his pleura. Sometimes the twelfth rib is very short, so examine his ribs on the films from his pyelogram.

Start the incision just medial to the angle between his erector spinae muscle and his twelfth rib. Deepen it to show the muscles. The tissue planes will be more easy to identify if you infiltrate them with adrenaline and saline.

In the upper half of the incision, cut latissimus dorsi in the line of the incision. In the lower half of the incision cut the patient’s external oblique almost in the line of its fibres.

The next layer is the internal oblique. Cut this almost across the line of its fibres.

If you see his twelfth thoracic nerve, try not to cut it. Avoid clamping it with forceps when you clamp the artery that runs with it.

Place retractors under the edges of the incision, and you will see his transversals muscle anteriorly, attached to the dorsolumbar fascia posteriorly.

Incise the dorsolumbar fascia first, and use a gauze swab to push the peritoneum lying under transversalis forwards and laterally.

Complete the division of the dorsolumbar fascia and transversalis muscle in the line of the incision.

Underneath you will find the patient’s perirenal fascia and the fat round his kidney.

DECIDING WHAT TO DO NEXT Base your decisions on the following indications.

Drainage There is a mass of blood clot which may be infected over the kidney.

Packing (1) You are not sure if the patient has a normal kidney on the other side, or not. (2) He is in such poor condition that he will not stand a further operation. (3) You are inexperienced, and have little help and few facilities.

Suturing tears Linear tears which can be sutured. DRAINING A PERIRENAL HAEMATOMA Avoid the patient’s peritoneal cavity by approaching the mass well to the side. Incise its most fluctuant part. Scoop out the blood clot, then either pack the area or close it with a wide corrugated rubber drain.

PACKING A RUPTURED KIDNEY Clear the blood clot from the patient’s perinephric space. Put one roll of gauze on the medial side of his kidney, and another on the lateral side. Fill the wound with a third roll of gauze. Tie them together so you can later pull them all out together.

Bring the skin edges together loosely, watch him carefully, and transfuse him as necessary.

If he has severe haematuria, or excessive oozing, reopen the wound immediately.

48 hours later, remove the packing in the theatre. His kidney will probably be dry and not bleeding. Insert a drain.

SUTURING A RUPTURED KIDNEY Pass catgut mattress sutures about 5 cm through the kidney tissue. Don’t tie them too tightly or they will cut out, or strangulate the renal tissue. Tighten the knot steadily, and avoid a sudden jerk.

Put three further stitches through the kidney, one at the middle of the tear and one at either end. if you cannot control bleeding insert a pack. Alternatively, use haemostatic gauze.

Take a small corrugated drain down to the patient’s renal pelvis, and leave it protruding from the wound.