The principles and practice of modern surgery

Nephropexy.

—These methods all have in common the intent to produce adhesions between the kidney and its normal environment, by which it shall be held in or near its proper place and prevented from dropping. The kidney more than any other organ is held in a cushion of fat, and it becomes a question to what extent this mass of surrounding fat shall be removed. To take it all away considerably complicates the procedure; to leave it is to not furnish the firmest possible surroundings for the purpose. The patient should be placed either flat upon the abdomen or turned well over on the side opposite that to be operated, a cushion or bolster being usually placed beneath the abdomen and loin in such a way as to push upward and into prominence the side to be attacked. The incision employed may be parallel to the spine, about three inches away from it, and carried down to the tissues outside the quadratus lumborum and other spinal muscles. Most operators prefer an oblique incision, made between the lower rib and the upper margin of the pelvis, its centre about four inches from the spine, extending in either direction two inches or more, in order to afford sufficient access. It is carried down until the abdominal aponeurosis and muscles are exposed. These are then divided and the perirenal fat, which is sometimes excessive in amount, is exposed. The deep opening should now be stretched to a size to permit the introduction of a hand, and exploration made for the identification and retraction of the kidney. Much aid may be afforded in this effort by the use of the other hand upon the outside of the patient’s abdomen, which should all have been protected and sterilized to permit such free manipulation. Sometimes it is easy to find such a kidney, at other times and in persons of certain build it is a difficult matter. It lies behind the peritoneum, and this should never be opened during the effort. More or less of the perirenal fat may be cleared away. The more or less elusive kidney being identified, it should be seized with tenaculum forceps, which should secure only its capsule and not injure its substance. With these it is drawn up at least to the wound, or in some methods, it is withdrawn through it and delivered upon the surface of the body. If sutures alone are to be depended upon they may be placed after any one of a number of different methods. The older method was to place the kidney as nearly as possible in its normal relations and then unite the deep margins of the wound to the capsule, and perhaps the cortex of the kidney, by a series of two or three sutures on either side, either of chromic gut or of silk. The theoretical objections which prevail against passing sutures through the renal cortex are hardly well founded, and stitches may be so placed, if desired, but they should not be drawn too tightly (Fig. 636).

Senn and others have endeavored to induce the formation of dense adhesions by packing around the kidney with gauze, left in situ for several days, whose presence should provoke the formation of granulation tissue. In theory this works well, but in practise the presence of the gauze is painful, its removal especially so, and the wound must be left more or less open for the purpose. Since I have learned of the harmlessness and the advantages of decortication I have made a practise of decapsulating almost every kidney thus exposed, and of endeavoring to utilize a portion of the capsule for the purpose of support, as by cutting it into strips, which are threaded into a needle, and then passed through the tissues, thus utilizing the capsule for suture material, or by fastening it with sutures which are not passed through the kidney substance. All in all I have had best results from a combination of some such method as this with one of suspension, for which purpose tapes or gauze are used and passed beneath the kidney—one above the hilum and one below it—after it has been delivered well into the wound, by which it is, first of all, lowered into the position in which it is intended to hold it and then maintained there, the ends being left hanging out of the wound, where they are tied over a roll of gauze or something similar. This provides the smallest amount of gauze, whose presence may provoke granulation tissue, at the same time proving an efficient means of support, and leaving trifling strips to remove when the time for their removal has come. I have usually left them in place for nine or ten days, by which time they are comfortably loosened by the presence of granulations around them, and consequent moisture, so that they are easily withdrawn, with a minimum of discomfort to the patient. Da Costa has suggested an improvement on this by sewing the ends of strips of gauze with chromic gut and letting these sewed ends be placed beneath the kidney. In the course of time, as the catgut softens, the union is separated, and the strips are easily withdrawn. If there be a tendency in these tapes to slip from their desired position, they may be attached to the capsule by a single suture of catgut, which will have softened and disappeared before the time for their withdrawal has arrived. Again in many of these instances the capsule which has been stripped off, or more or less detached, may be utilized for the purpose of fixation by suture with its own tissue.

Nearly all of these operations are without mortality, although they are not yet as satisfactory as could be desired, the trouble inhering partly in the fact that the kidney is not fastened as high up as it should be, or else not in quite the same relative position, so that there is some strain upon its vessels or upon its ureter. Every effort should be made to imitate the original position as accurately as possible. Methods theoretically more perfect, yet more complicated and but little more advantageous, include fixation of the kidney to the twelfth rib, by suture passing through the capsule and then around the rib. No matter what method be adopted, it is necessary to keep the patient in bed for several weeks after these operations, in order that adhesions may not only form but may not be stretched by too early change of posture.

TUMORS OF THE KIDNEY.

The kidney is the site of an occasionally benign and frequently of a malignant tumor of some of the known varieties. The simplest forms, like the fatty and the fibrous, are uncommon and deserve no special consideration here. There is a so-called adenoma of the kidney, which does not deserve this expression any more than does the so-called adenoma of the thyroid, in that it is not built up of the normal type of secreting gland, but represents something more or less similar to it, perhaps only undergoing multicystic degeneration, its commonest expressions being of congenital origin. The consequence is the production of the so-called congenital adenoma or cystic or multicystic or polycystic kidney, in which may be seen a conversion of original renal tissue into a mass of cysts, surrounded by degenerated kidney tissue, all semblance to the original being lost, and the whole constituting a partial or complete invasion of the organ, by which sometimes its proportions are enormously increased. The condition is essentially of congenital origin, although its serious clinical expressions may not occur for years. The result is to destroy the renal function, to produce a growing mass, and to constitute an essentially surgical condition to be relieved only by nephrectomy. (See Fig. 637.) I recall one child of twenty-three months with a tumor of this character, of such size and extent that it could only stand erect when wearing from its neck a sort of suspensory in which the lower part of the abdomen was contained. I removed this kidney by abdominal section, the child recovering, and being at that time the youngest case that had ever survived a nephrectomy. A number of years later a similar condition developed in the other kidney, of which the child finally died, it having passed during the last thirteen days of its life not more than an ounce or two of urine.

Of the solid tumors of the kidney both carcinoma and sarcoma occur, the former usually as a secondary growth, the latter usually as primary, although any form may be met. The sarcomas are more frequent in early life and in general more common. On account of the kidney having a well-marked capsule metastasis is not so common, in the early stages, as from some other organs. These malignant tumors may attain great size; some grow regularly in shape, others constitute most irregular masses. The entire organ may be involved or only a part.

There are no indicative symptoms of renal cancer that may not be met in other conditions; the development of tumor, perhaps its displacement, pain, and hematuria, though late, and, in proportion to the rapidity of growth, enlargement of superficial veins and general cachexia. When the tumor is large enough to press upon the vena cava or upon one of the common iliacs there will be edema of one or both lower extremities. The veins of the external genitals are more likely to suffer early rather than late (Figs. 638, 639).

Hypernephroma.

—There is one peculiar variety of solid tumor of the kidney which deserves special mention, the so-called hypernephroma. These tumors consist essentially of adrenal tissue, although when they develop within the kidney their occurrence there is due to the presence of aberrant rests of the original suprarenal tissue. Gravitz, in 1883, was the first to recognize their real character. Supernumerary adrenal rests have been met with in many parts of the body, not alone in the kidney and perinephric tissue, but in the broad ligament, along the spermatic vessels, in the sexual glands of both sexes, in the liver, the mesentery, and even the solar and renal plexuses. Their occurrence in these localities may be explained by the close relationship between the mesonephros and the origins of these various organs. Hypernephroma has no pathognomonic signs or symptoms. It is usually a single tumor, although both kidneys have been affected. When the organ is not so involved as to mask all its original features the tumor will be found beneath the capsule, varying in size from that of a pea to that of a child’s head, its outer surface lobulated by depressed bands of capsule, its color lighter than that of the surrounding kidney texture, while projecting portions will be soft and almost cystic. When met with in other parts of the body its gross characteristics are essentially the same. Metastasis is very common, the tumor often extending along the walls of the veins, or even more often partially filling them than the lymphatics. A common method of extension also is by implantation within the peritoneal cavity; for the secondary implantation occurs most often along some portion of the urinary tract—e. g., the bladder.[66]

Hematuria and renal colic are the most conspicuous features connected with the growth of these tumors. The former often occurs during sleep, and blood is passed in almost pure form, perhaps for a considerable period of time, after which spontaneous recovery apparently takes place, the trouble recurring at intervals.

There is but one method of treating hypernephromas, like other solid tumors, namely, by complete extirpation, i. e., nephrectomy. Even this may be too late, but should be undertaken, except in the most unpromising instances. If the existence of metastatic involvement can be determined even nephrectomy may be considered useless. (See chapter on Cysts and Tumors.)

HYDRONEPHROSIS.

This term refers to a more or less permanent distention of the kidney cavity by retention of urine, due to partial or intermittent obstruction to its escape. An intermittent form is common, which, however, at almost any time may lead to some degree of enlargement, while when the obstruction is permanent the resulting tumor becomes practically a thin-walled cyst, which may contain an enormous amount of fluid, more or less altered urine, which will contain, in addition to the ordinary urinary elements, cholesterin crystals and other adventitious products. Hydronephrosis, then, may be congenital or acquired in origin, intermittent or permanent in character, and unilateral or bilateral in location. Among the acquired causes are strictures of any portion of the urinary tract below, either in the ureter, the prostate, or the urethra; tumors of any kind making pressure; movable kidney which permits of kinking; tuberculous diseases which lead to chemosis of the mucosa and consequent obstruction; renal calculi which plug the ureter; foreign bodies, blood clot, and the like (Figs. 640 and 641).

Until the infectious or suppurative element be added the urine is in these cases but little changed. When infection is added the case becomes one of pyohydronephrosis, and perhaps finally one of distinct pyonephrosis. The symptoms produced at first are not very pronounced and will vary with the exciting cause. If the result of acute obstruction, renal colic is perhaps the most significant. When this is accompanied by tumor in the region of the kidney the interpretation of the phenomenon is easy. Sudden decrease in size of such tumor, with unusually great escape of urine, is also pathognomonic of intermittent hydronephrosis. The discovery and the history of a gradually increasing tumor in which, when large, fluctuation can be determined, and in which fluid is easily found with the aspirating needle, will permit a differentiation of these pseudocysts from solid tumors of the kidney. They are to be distinguished from ovarian cysts, from general ascitic accumulations within the abdomen, and from perinephritic and spinal abscesses. Their location, which corresponds so closely with that of the kidney, especially while they are small, their gradual growth, the displacement of the abdominal viscera forward and to their inner side, their enlargement downward and their fluctuating character will usually provide features by which they may be accurately recognized.

Treatment.

—The treatment of intermittent hydronephrosis in its earlier stage may be accomplished by some measure less radical than nephrectomy or nephrotomy, particularly when due simply to abnormal movability or to pressure of some extrinsic growth. Hydronephrosis due to obstruction by renal calculus may be relieved by removal of the obstructing stone, but a hydronephritic cyst, which has attained large size, in which practically all semblance to secreting kidney structure has disappeared, should be extirpated, unless this should entail too formidable an operation, in which case it should be freely opened and drained until such time as it has contracted to a size justifying enucleation (Fig. 642).

THE URETERS.

There are a few morbid surgical conditions of the ureters, so distinct from those of the bladder below or the kidneys above as to require separate consideration here. They are frequently involved in the pyogenic and tuberculous infections, which spread along them in either direction, but the chief surgical diseases deserving mention here are stricture and calculus.

STRICTURE OF THE URETER.

Stricture of the ureter may result from intrinsic or extrinsic lesions. Thus it has been injured in operations upon the pelvic viscera, as in parturition, and it is not infrequently pressed upon by neoplasms; but the majority of its contractions are cicatricial, and are consequences of ulceration or injuries done by calculi. Stricture of the ureter is to be recognized rather by its consequences—i. e., hydronephrosis—than by more direct symptoms. Its accurate location is now possible by the use of the cystoscope and the ureteral bougie or catheter. When by the cystoscope no urine is seen escaping from the ureter one naturally infers its complete obstruction—in fact, the degree of the latter is fairly estimable with this instrument. However, with the passage of a bougie the trouble may be found. This is particularly of value when the lesion is an impacted calculus, for it indicates to the surgeon the level at which he should direct his operative relief, a matter which may also be decided by a skiagram.

While in the hands of experts dilatation of the ureters may be accomplished from below, it is usually beyond the ability of the average surgeon. He has to decide, then, as to whether the ureter should be exposed along its course, from the loin, extraperitoneally along the groin, or by abdominal section. A ureter hopelessly entangled in a mass of cancer may be turned into the other ureter or into the bowel. A ureter fixed in a narrow, cicatricial band may be divided and its upper end turned into the tube below the stricture by a process of transplantation or anastomosis, which is one of the feats of modern surgery; but a ureter hopelessly involved for a considerable portion, or hopelessly diseased, will require nephrectomy, as the kidney above it may be compromised and can probably be well spared.

Calculi impacted in the ureter are most commonly arrested at those points where its caliber is normally smallest, just below its origin, at the pelvic brim, and just above its orifice. The symptoms of impaction are those of renal colic, already considered. It should be sufficient that extreme pain and the escape of pus and blood in the urine, accompanied by more or less distention of the kidney above, are noted. If there be a history of previous attacks of this kind, with the passage of small calculi, the diagnosis may be regarded as positive. This may or may not be confirmed by the x-rays, or by the catheterization of the ureter from below.

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.

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.

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.

Operations upon the Ureters.

—The surgery of the ureters is also quite modern, and has been worked out in the experimental laboratory. That ureteral tissue will heal has been proved by Murphy, who has remarked that “The peritoneum is the only tissue that unites as kindly as does the ureter.” After accidental injuries during other operations the ureter may be sutured almost as though nothing had happened. These sutures should be made with fine round needles, and be placed closely together. They should be made of fine silk or thread.

Not only end-to-end union but lateral anastomosis and even more ingenious methods of transplantation and implantation are now in vogue. Figs. 645, 646 and 647 illustrate some work in this direction, and show what may be done by work quite similar to that done upon the small intestines or the bloodvessels. More complete instances of transplantation have been effected in connection with exstrophy and carcinoma of the bladder, where, for instance, the ureters individually, or the base of the bladder containing the ureteral orifice, have been dissected out and implanted in the colon or the rectum.[67]