KIDNEY EXPOSURE THROUGH THE TWELFTH RIB

303 It seems justifiable, however, to attempt direct laryngoscopy in all such cases where the respiratory embarrassment cannot otherwise be relieved, and tracheotomy should be done only when this manoeuvre fails. The sedation of these patients, who are extremely restless and of necessity using their accessory muscles of respiration, requires care. Respiratory depressants, such as morphine, must not be used, at least until an adequate airway has been established. Hewerpoints out the very real dangers of intravenous barbiturates in respiratory obstruction, and emphasises the necessity of an adequate local application of cocaine or other surface analgesic before instrumentation is attempted.

Fig. I-Relation

SUMMARY

A haemophilic man with severe respiratory obstruction resulting from a pharyngeal hsematoma recovered after direct laryngoscopy and intubation. An attempt is made to justify intubation in preference to tracheotomy for such cases. I am indebted to Dr. A. E. Clark-Kennedy, F.R.c.r., and Mr. A. Bowen-Davies, F.R.C.S., for permission to publish this

case.

KIDNEY EXPOSURE THROUGH THE TWELFTH RIB C. PATRICK SAMES M.S. Lond., F.R.C.S. ASSISTANT

DIRECTOR, SURGICAL UNIT, ST. MARY’S HOSPITAL, LONDON

THE indications for

exposing the kidney by the retroperitoneal approach through the loin are well established, but the details of the operation are by no means standardised-the incisions used vary from the nearly vertical of Mayo to the more oblique of Morris. All these loin incisions have in

common

certain short-

comings, which are eliminated by exposure of the kidney through the bed of the last rib. This approach has so many advantages that it is surprising it has not received wider recognition. Though practised by a few British urological surgeons it is not described in any standard British work on operative surgery or urology. The first account of it in English was by Hess (1939), and it was later described by Digby (1941). Robinson (1947), in a presidential address at the Royal Society of Medicine, spoke of fourteen years’ experience with this kidney approach, and he cited Von Lichtenberg as having practised it. A comparable approach was described by Hertz (1927) for exposing the suprarenal gland and has been used latterly by many surgeons for operations on the splanchnic sympathetic. Egon Wildbolz (personal communication) states that he and his father, the late Prof. Hans Wildbolz, have used this approach to the kidney for more than thirty years, but neither they nor Von Lichtenberg have ever written about it. THE

OPERATION

The patient is placed in the customary kidney position, with a rigid support beneath the lower ribs, which facilitates the exposure. The length of the patient’s last rib is checked radiographically, for when this is unduly short care is needed to avoid mistaking the llth rib for the 12th. The incision is made over the last rib, starting an inch medial to the lateral border of the erector spinae and continuing in the same line beyond the tip of the rib to a point depending on the length of the last rib ; an extension of 21/2-3in. beyond this usually suffices with a rib of average and a kidney of normal size. The wound is deepened through the latissimus dorsi and serratus posterior inferior muscles down to the rib ; it is advisable to nick a few of the outermost fibres of the erector spinae. The exposed portion of the rib is resected subperiosteally ; freeing of the extreme tip from the attached

length

3. Hewer, C. L. Recent Advances in Anæsthesia and Analgesia. London, 1948.

of

pleura to 12th rib bed after incision of posterior periosteum of rib.

periosteum requires a little patience. The of the rib bed is then incised, with special care at its medial part where the horizontal fold of the pleura is sought and found. The pleura, occupying the inner and upper angle of the rib bed (fig. 1), is deliberately but easily dissected free and displaced from the line of further incision. The lowest fibres of the diaphragm are then incised in the same line and the extrarenal fat and fascia immediately become visible. The incision through the external oblique, internal oblique, and transversalis muscles is extended outwards from the outermost part of the rib bed for a variable distance-usually 21/2-3 in. This extension must be in strict line with the continuation of the rib ; if it tails downwards at all, the subcostal nerve or some of its branches may be endangered. Once the perinephric plane is found, this outward extension through the muscles is facilitated by cutting down on to two fingers of the left hand placed inside the wound. In the outer angle care must be taken not to damage the reflected fold of the peritoneum, which must be stripped away as required. The perinephric fascia (Zuckerkandl) is incised, and the kidney freed from its perinephric fat. muscles and

periosteum

ADVANTAGES

A ccess This approach is anatomically sound. The last rib is one of the normal posterior relations of the kidney, and on the left side closely approximates to the hilum (fig. 2) ; not uncommonly the kidney occupies an even higher position. It is more rational to come down directly on to the organ than to approach it from below. With the more classical incisions great difficulty is often experienced in freeing the kidney from the perinephric fat, owing to the dense strands of fibro-fatty tissue which anchor the upper pole. Because of poor exposure, attempts are made to mobilise the last rib by dividing the lumbocostal 1 i g a ment (not the external arcuate ligament as is suggested in some textbooks of --

operative surgery). Forceful

retraction is then employed, and often resection of the rib is finally resorted-to. It has also been recommended that the outermost fibres of the quadratus lumborum be nicked in the upper angle of the wound. Itt is 2-Relation of pleura and edges of during these addi- Fig.erector spinae muscle to kidney and 12th tional manoeuvres rib. that the

pleura

and subcostal nerve may be damaged, and troublesome haemorrhage may ensue. With exposure through the rib bed the kidney can be handled with ease, and nephrolithotomy or other procedures can be performed without delivering the kidney

304 from the wound. However, if delivery is required it is facilitated by the adequate exposure and it will be still easier if an assistant presses on the abdomen ; this manoeuvre tends to squeeze the kidney upwards and outwards through the wound, whereas with the other loin incisions it usually forces the kidney still further under the overhanging last rib. Kidney exposure is usually difficult in patients with a reduced iliocostal gap, whether this is a result of scoliosis, an unduly long 12th rib, or a general squat stature. Exposure through the last rib bed overcomes all such difficulties, for even in the very fat or muscular patient the final wound seems to be less deep than it would be with the more classical approach. The Pleura In surgery it is axiomatic that when damage to an important structure is feared, that structure should be clearly visualised and then avoided. The relation of the fold of the pleura to the 12th rib bed is illustrated in fig. 1 ; minor variations are found (Melnikoff 1923), but these are of no practical importance provided that the pleura is sought for and carefully pushed away by delicate dissection. With other loin incisions, damage to the pleura usually results from efforts to improve an inadequate exposure. Hess (1939) makes no attempt to excise the rib subperiosteally and advised " tearing the transversalis fascia with the fingers " so as not to endanger the pleura-surely a most unsound procedure. The Subcostal Nerve The course of the subcostal nerve varies in obliquity, and consequently it is endangered in the classical loin operations. By many surgeons it is boldly severed and the consequent muscle weakness and anesthesia are disregarded. Some accept an area of anaesthesia " the size of the palm of the hand " as a regular accompaniment of kidney operations. When the kidney is approached through the rib bed, the line of incision is essentially segmental between the llth and 12th myotomes ; the subcostal nerve always lies at a more distal level and is out of danger whatever its variations. The approach thus protects the nerves from damage, and it also appreciably reduces the amount of bleeding. WOUND CLOSURE AND HEALING

Hernia is

by no means rare as a complication of kidney operations. This is not surprising in view of the extensive muscle cutting involved, and an additional factor is probably the difficulty of suturing in the lower angle of the wound because of the excessive retraction of the transversalis muscle beneath the internal oblique. In the operation here recommended the muscle cutting is reduced, and much of the wound in the rib bed is

repaired by fibrous tissue. The diaphragm and the posterior and anterior periostea are sutured as one layer ; healing is .sound and no postoperative herniae have occurred. INDICATIONS S

This incision should be used always, except when the middle or lower parts of the ureter are to be exposed. Latterly the incision has been used in the removal of tuberculous kidneys. After the vascular pedicle has been divided, the ureter is stripped as far down as possible. The kidney is delivered and allowed to hang outside the wound, attached only by its ureter, while the wound is closed around it. The lower end of the ureter is then divided extraperitoneally through a midline infra-umbilical incision, and the kidney and ureter are withdrawn from the upper wound. A large kidney mass is no contra-indication since the incision can be prolonged in the same line, even to the lateral border of the rectus sheath. This operative approach has been in constant use on the surgical unit of St. Mary’s Hospital for the past three years ;and the improved exposure, ease of

performance, established its

and

freedom from complications have over the other approaches.

superiority

REFERENCES

Digby, K. H. (1941) Surg. Gynec. Obstet. 73, 84. Hertz, J. (1927) Pr. méd. 35, 323. Hess, E. (1939) J. Urol. 42, 943. Melnikoff, A. (1923) Arch. klin, Chir. 123, 133. Robinson, R. H. O. B. (1947) Proc. R. Soc. Med. 40,

201.

Preliminary Communications ANTIDIURETIC FACTOR IN THE URINES OF PATIENTS WITH NUTRITIONAL ŒDEMA* THE pathogenesis of nutritional oedema, still awaits elucidation. It is, however, becoming increasingly clear that this condition cannot be satisfactorily explained on the basis of Starling’s classical concept of aedellla formation. The hypothesis that the cedema is the result of decreased colloidal osmotic-pressure, consequent on a fall in the serum-albumin level, has been contradicted by several observations." Youmans, Wells, et al.2 emphasised the factor of tissue-pressure, but their calculations as to the magnitude of this pressure have been rejected. 9 10 It seems probable, therefore, that in the development of nutritional cedema factors other than those covered bv Starling’s hypothesis may be concerned. In the present investigation it has been shown that the urine of patients with nutritional cedema contains an antidiuretic substance which promotes water-retention. ’

CLINICAL MATERIAL

Twelve patients with nutritional cedema were investigated. Nine of these were destitutes, and the other three belonged to the poorest section of the community. All were men between the ages of 25 and 50 years. In these cases a detailed dietetic history was naturally not obtainable, but it was obvious that all thepatients had subsisted on grossly inadequate diets for several months before they developed symptoms. All the subjects suffered from obvious cedema, which pitted on pressure. The cedema was maximal in the dependent parts ; and in all cases the feet, ankles, and legs, and the hands and forearms were swollen. In the severe cases the cedema was more extensive, involving All non-nutritional causes of oedema, even the face. and renal conditions, were cardiovascular including carefully excluded. The urine was free from albumin and granular casts. Clinical signs of wet beriberi were sought and were absent. In three typical cases large doses of thiamine given parenterally did not relieve the cedema ; and in three other cases screening revealed that the heart-shadow was either normal or smaller than normal. Contrary to the observation of some workers, who reported polyuria in cases of nutritional aedema, 5 9 all cases here showed pronounced oliguria, the 24-hour urinary output in several cases being less than 750 ml. even though fluid-intake was not restricted. EXPERIMENTAL PROCEDURE

Collection, concentration, and dialysis of urine.-The procedure adopted here was generally similar to that employed by Ralli et al." The urine from each patient was collected under toluene for exactly 24 hours ; care was taken to see that all the urine passed during this period was collected. *

1.

2. 3. 4. 5.

Wet beriberi is not included.

Youmans, J. B., Bell, A., Donley, D., Frank, H. Arch. intern. Med. 1932, 50, 843. Youmans, J. B., Wells, H. S., Donley, D., Miller, D. G. J. clin. Invest. 1934, 13, 447. Youmans, J. B. Int. Clin. 1936, 4, 120. Keys, A., Taylor, H. L., Mickelsen, O., Henschel, A. Science, 1946, 103, 669. Davidson, C. S., Wilcke, H. L., Reioner, P. Cited in Ann. Rev.

Biochem. 1949. 6. Dicker, S. E. Proc. R. Soc. Med. 1948, 41, 548. 7. Nutrit. Rev. 1948, 6, 210. 8. Sinclair, H. M. Proc. R. Soc. Med. 1948, 41, 541. 9. Smirk, F. A. Clin. Sci. 1935, 2, 317. 10. Burch, G. E., Sodemann, W. A. J. clin. Invest. 1937, 16. 845. 11. Ralli, E. P., Robson, J. S., Clarke, D., Hoagland, C. L. Ibid, 1945, 24, 316.