NEPHRECTOMY - REMOVAL OF A KIDNEY.
Nephrectomy, or the complete removal of a kidney, is an operation which may be required for various conditions already incidentally re ferred to. Though, as a rule, we are provided with two kidneys, it should not be forgotten that examples occasionally occur where this is not the case and where the necessary amount of gland tissue requi site for the excretion of the urine is consolidated in one mass, some what variously disposed so far as shape is concerned. Instances are recorded, but very rarely, where the operator has discovered, when too late, that the kidney removed, though hopelessly diseased, was the only one. It is, therefore, of the first importance before proceed ing to remove a kidney for the surgeon to satisfy himself by all avail able means that the opposite organ not only is in existence, but is in sufficient health to be able to provide for the entire urinary excre tion; that, in fact, it is capable of undergoing those hypertrophic changes requisite for the attainment of this end.
Assuming in a given case that there is evidence that one kidney is seriously crippled by one or other of the various conditions already referred to, the surgeon will not neglect by frequent examinations of the urine to ascertain that in regard to both its quantity and quality a fair standard is maintained. The amount of urea voided should be carefully estimated. The result of such an examination of the urine might lead, if the symptoms were not pressing, to some temporary postponement of the operation of nephrectomy, with the view of giving the sound organ a little more time for adaptation. With the same object the practitioner will not neglect, in prospect of extirpating a kidney, to ascertain by an inspection of the interior of the bladder with the electric light, or perhaps even by more direct means in a very doubtful case, whether both Ureters are in action. The cy_sto scope is often a most valuable and practical means of diagnosis under these circumstances, which I consider should never be neglected in cases of this kind. Not only in this way can the pumping action of, and flow from, the ureters be, as a rule, seen, but the different char acter of the two urines discharging from these ducts, as for instance when one is purulent or tinged with blood, as compared with the normal flow from the opposite one, may be recognized.
The operation of catheterizing the ureters in the female is thus referred to in a case published by Mr. H. E. Clark "To settle our doubts as to the soundness of the right kidney we again catheterized the ureters. This was done by Dr. Macintyre and myself by means of Pawlik's catheter.' The operation is in the female a very simple one, two ridges felt on the anterior wall of the vagina serving as use ful and reliable guides, which lead the catheter directly to the ure teral orifices. The small quantity of urine removed from the right
ureter was in every respect normal; that from the left contained pus, epithelial debris, and a trace of albumin." It has been urged iu favor of abdominal nephrectomy that the operator is not likely to be exposed to the risk of removing a solitary kidney by reason of his being able to ascertain beyond all doubt that this is not the case. • The lumbar operation consists in exposing the kidney by incision through the loin as already described. Sufficient room should be provided for manipulating the part to be removed by the extension of the transverse portion of the opening to about four inches in length. The surface of the organ having been recognized the operator should proceed to free it, mainly with the index finger, from surrounding connections. Care will be required in detaching it in front not to exercise too great force for fear of opening the peritoneal cavity. When the kidney has thus been isolated with the exception of its pelvic attachments, it should be gradually drawn through the wound, when the parts constituting the pedicle may sometimes be more clearly defined by the use of a blunt dissector. The pedicle is best secured by passing an aneurism needle armed with a long, stout silk ligature between the ureter and vessels. If, as the needle is with drawn, the ligature is divided in the middle, a noose will be provided for each of the two portions now forming the pedicle. As they are tightened the ligatures should be pressed well backward so as to give sufficient room for the removal of the kidney by division of the pedicle with the scissors. Morris mentions that the process of drawing out the kidney may be much facilitated by pulling the lower ribs up ward with the fingers of the left hand passed into the incision. The ligatures should be cut off short and the pedicle dropped into the wound; when there is difficulty in restraining hemorrhage by ligatures, the bleeding points may be secured by pressure-forceps, which can be left in the wound where they will temporarily serve the purpose of drainage-tubes. In case this is not necessary a good-sized rubber tube should be passed to the bottom of the wound, when the superficial incision may be adjusted with sutures. If in the course of the oper ation the peritoneum is opened, the rent should be carefully closed with catgut sutures. The position of the patient in the after-treat ment is entremely favorable for repair, and it is remarkable with what rapidity these wounds frequently heal.