By: Yessenbekkyzy N., Schneider A., Rais L. 335 GM

Gross Anatomy of the Kidney Has: anterior side dorsal side upper pole lower pole lateral surface medial surface weighs 120–200 g 10–12 cm vertically 5–7 cm transversely

Capsula fibrosa follows medially the renal parenchyma does not surround the renal hilum Capsula adiposa perinephric fat is surrounded by a connective tissue sheath Gerota's fascia (Fascia renalis) surrounds the kidney, fat, the adrenal gland fascia is closed by fusion of the anterior and posterior sheat

Renal and retroperitoneal fascias: Renal and retroperitoneal fascias: 1. fascia transversalis 2. anterior sheat of the Gerota's fascia 3. parietal peritoneum 4. perinephric fat (Capsula adiposa) 5. paranephric fat 6. M. quadratus lumborum 7. M. erector spinae

Topographic Anatomy of the kidneys The kidneys are located in the retroperitoneum, right and left of the spine and below the diaphragm. Left kidney: from the 11th rib to third lumbar vertebra. Right kidney: slightly lower position, 12th rib to the lower part of the third lumbar vertebra.

Topographic Anatomy of the Right Kidney Dorsally: 12th rib, subcostal nerve, iliohypogastric nerve, ilioinguinal nerve, quadratus lumborum muscle, diaphragm with pleura at the upper pole Cranially: adrenal gland. Medially: psoas major muscle, inferior vena cava, ovarian/testicular vein, ureter. Ventrally: liver, duodenum, ascending colon. Dorsally: 12th rib, subcostal nerve, iliohypogastric nerve, ilioinguinal nerve, quadratus lumborum muscle, diaphragm with pleura at the upper pole Cranially: adrenal gland. Medially: psoas major muscle, inferior vena cava, ovarian/testicular vein, ureter. Ventrally: liver, duodenum, ascending colon.

A, Axial diagram at level of kidneys. B, Sagittal diagram in plane of right kidney. Three major retroperitoneal compartments shown: anterior pararenal space (hatched), perirenal space (cross-hatched), posterior pararenal space (stippled). L, liver; P, pancreas; LS, lesser sac; S, spleen; V, vena cava; A, aorta; RK, right kidney; LK, left kidney; C, colon; D, duodenum.

Topographic Anatomy of the Left Kidney Dorsally: 11th and 12th rib, subcostal nerve, iliohypogastric nerve, ilioinguinal nerve, quadratus lumborum muscle, diaphragm with pleura at the upper pole Cranially: adrenal gland, spleen. Medially: psoas major muscle, aorta, ovarian/testicular vein, ureter. Ventrally: spleen, pancreas, stomach, descending colon. Dorsally: 11th and 12th rib, subcostal nerve, iliohypogastric nerve, ilioinguinal nerve, quadratus lumborum muscle, diaphragm with pleura at the upper pole Cranially: adrenal gland, spleen. Medially: psoas major muscle, aorta, ovarian/testicular vein, ureter. Ventrally: spleen, pancreas, stomach, descending colon.

A, CT scan at level of left kidney. Anterior renal fascia (long straight arrow). Posterior renal fascia (curved arrow). Lateroconal fascia (short arrows) B, Diagram of same layers of renal fascia. C, colon; ARF, anterior renal fascia; LCF, lateroconal fascia; PRF, posterior renal fascia.

Approaches to the Kidney.

Simons Incision Simon incision is carried along the edge of the long muscles of the back from XII rib to the iliac bone, Péan's cut - laterally from the outer edge of Musculus rectus abdominis toward the spine

a a : 1 Simons incision; 2 Péan's cut; 3 Bergman-Yisraels incision, 4 incision of S.P. Fedorov b: b: 1 posterior-lateral approach; 2 posterior-medial; posterior-obliquely-transverse; 4 anterior intermuscular approach, в: в: 1 pararectal cut; 2 medisectional cut

Bergman-Yisraels incision Cutting line starts from the middle of the XII rib passes obliquely downward and anteriorly toward the iliac bone, retreating inwards from it on the 3-4 cm edges of the wound are widely bred in sides and cut a wide back muscles and external oblique muscle of the abdomen, and then musculus serratus posterior inferior and internal oblique muscle, deep leaf of lumbodorsal fascia and transverse abdominal muscles. Then reveal adipose capsule. Iliohypogastric nerve pulled posteriorly, and peritoneum pulled anteriorly to hooks which strongly stretches wound. For reveal of kidney of adipose, in one of the portions of the rear surface of the kidney is dissected and the posterior surface sequentially isolated

a - malacotomy of muscles b - baring of muscles c - cut of renal fascia d - outcrop of fat capsule of the kidney e – release of kidney from adipose capsule.

Incision of S.P. Fedorov Cut commencing at the XII rib at the bottom edge of m. iliocostalis lumborum and carried out in the transverse direction toward the navel. Cut through the skin, subcutaneous tissue, superficial fascia. Muscles dissected along the layers of the skin incision.

After dissection of fascia transversalis, the muscles fiber of the musculus transversus curved by scissors are disconnect along the section line, thus exposing a piece of fascia propria abdominis.

Peritoneum is separated from the of renal fascia and pulled down and anteriorly. Posterior piece of renal fascia is dissected and fat is pushed, then make reveal kidney and output it to the wound.

Skin incision begin from the end of XII rib and lead down towards the Petit triangle, on the border adjoining the external oblique abdominal muscles and musculus latissimus dorsi Posterior-lateral approach

Musculus latissimus dorsi and musculus obliquus externus abdominis widen to the sides, exposing the internal oblique muscle. along the muscle fibers widen the internal oblique muscle, Musculus transversus abdominis, exposing the fascia and the first fatty layer of retroperitoneal space.

Clamp capture perirenal adipose tissue together with back piece of fascia and tighten the wound. By opening postrenal fascia, kidney is revealed.

Posterior-medial approach The incision is carried out from the middle of XII rib obliquely downward and medially towards the recess between the iliac crest and spine. After skin incision, Musculus latissimus dorsi is exposed.

Posterior-obliquely-transverse approach o The skin incision is carried from Costa vertebral angle 2 cm below the rib XII and parallel to it from back to front with the patient on his stomach. o dissect the posterior abdominal wall muscle, musculus latissimus dorsi and partly m. serratus posterior inferior o partially dissected external and internal oblique abdominal muscles, exposing transversus abdominis muscles.

o expose Musculus quadratus, on the lateral margin of which lies the first fatty layer of retroperitoneal space. o Reveal paranephritis and expose the rear surface of kidney and upper ureteral segmen

Anterior intermuscular approach The skin incision is carried from the XII rib anteriorly obliquely downward. By opening the skin and fascia of the external oblique abdominal muscles fibers it delaminated, exposing the internal oblique muscle. Downstream muscle fibers, defoliate the internal oblique, and then the transversus abdominis. After this piece of renal fascia is opened, exposing the front of the pelvis.

Operations on kidneys

Renipuncture Surgical technique. Lumbar incision exposing the kidney and released it from the fat capsule without dislocation of the wound. Thereafter, on the convex edge dissect own kidney capsule and bluntly separated it from both sides of the gate kidney parenchyma. Approaching the gate, the capsule is completely cut. Retroperitoneal drainage tube is introduced and the wound was sutured in layers.

a - dissection own renal capsule, b - office capsule from the parenchyma, c - clipping capsule.

Operation of nephroptosis NephropexyAvtoplastic By using the capsule of the kidney By the facial and muscular flap By strengthening the vaginal facial kidney By skin graftAlloplasticCombined

Operation S.P. Fedorov. Kidney exposed and freed from fat capsule. On the convex edge longitudinally short 3-4 cm to the lower pole, dissect capsule and blunt delaminated from the parenchyma. Delaminated region, except for the top, the entire length of stitch ketgu - tum seam. At the bottom of the seam is carried through the capsule. Both ends of the thread is carried out for the XII rib tightened and knotted over it. The lower pole of the kidney to cause strong scar adhesions, fed for 5-6 days gauze and the wound sutured by conventional.

Nephropexy by S.P. Fedorov

V.A. Gorash method. Conventional oblique lumbar incision expose the retroperitoneal space. Reveal the total renal fascia. Blunt kidney was freed from adhesions, adhesions and adipose capsule, after which it was raised in the upper quadrant and held in this position. Then, over the ureter to the front and rear fascias sheets impose top- down pleated seams at a distance of 3-4 cm from each other. After that tighten joints and tie. Bottom-up is applied to the second floor pleated seams. Further, all available in capsule form fat swab placed under the lower pole of the kidney and put 3-4 suture tightening facial bag. Two seams stitched facial bag fixed to the periosteum of the rib XII. The wound was sutured in layers tightly. The patient should stay in bed days.

a - the imposition of the first row of stitches on the facial pleated sheets, b - the imposition of the second row of stitches on the facial pleated sheets, c - facial bag fixed to the periosteum of the rib XII.

Rivoira method. After exposure of retroperitoneal mobilization produce buds on all sides, except for the upper pole. Then, from the lateral margin of the m. psoas muscle flap is isolated. Dissect its distal end at an unmarked line. Several lower hilum of renal transversely cut through fibrous capsule and stupidly separate it from the parenchyma to the side of the lower pole. By convex edge kidney flush with or slightly higher than the previous cutting capsule laterally sectioned. In the resulting subcapsular tunnel flap. End of muscle flap is performed over the edge XII or XI ribs wrapped around it and fixed to the same beam m. psoas. The wound was sutured in layers tightly.

a - education subcapsular tunnel, b - nephropexy.

Nephrotomy Expose the kidney, carefully selecting it from the surrounding tissue, and dislocating the wound in order to mobilize the renal pedicle. Impose on the vascular pedicle soft clip Stewart, clip K.T. Ovnatanyana or other firm grip on the jaws which put rubber tube. The next stage of the operation is a dissection of the fibrous capsule and the renal parenchyma. Proposed several cuts.

a - leg buds seized soft clamp b - line cut kidney sectioned at nephrotomy c - Kidney cracked on the convex edge d - mattress sutures which were on the renal parenchyma at nephrotomy, d - the imposition of nodal joints on the renal parenchyma, e - Renal wound swabbed with a piece of "broken" muscle.

1. Sectional cut, going from a convex edge kidney 2. Longitudinal section cm posterior to the convex edge of the kidney - cut Tsondeka. 3. Transverse ( radiarny ) incision through the kidney by Rubashov - Marvedelyu, Gasselbaheru. After appropriate manipulation of the kidney ( stone removal, foreign body ) begin to wound closure. Since the renal pedicle clamp is removed, and if significant bleeding, bleeding vessels are ligated or cut away. Wound edges are pressed firmly against one another and through the entire thickness of the parenchyma, pelvis cut above impose a series of mattress sutures. If the wound is small size, it is sewn knotted sutures. In addition to ligation sutures to stop the bleeding, you can use a piece of tamponade renal injury or muscle perirenal fat. Muscle injury in the same reinforce seams, which is sutured wound. Tightly wound sutured only when there are no obvious signs of infection ( A.P. Tsulukidze ). In the presence of the latter in the pelvis must enter a drainage tube.

a - the line Tsondeka, b, c - on Gasselbaheru.

Special mention should be partial and subcapsular nephrotomy. Above the stone kidney parenchyma often thinned, atrophied and softened, so naked kidney stone can easily probe. If it is not defined, it is installed localization puncture needle, guided by voiding. Stumbling over dissected fibrous capsule and along the needle to him stupidly spend clip you grab it and remove. Wound was sutured nodal catgut sutures.

If necessary, a secondary operation surgery can be very difficult due to the large number of dense adhesions. In such cases shows subcapsular nephrotomy (I.P. Pogorelko). Bluntly dissected and peeled fibrous capsule. Dissect the parenchyma, it is passed through the clamp and the stone removed. Thereafter, the wound was sutured and parenchyma separate sutures sutured fibrous capsule. Leave rubber drainage, wound sutured. In the presence of infection process ends nephrostomy..