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A selfretaining retractor (Finochietto, Bookwalter, or Omni-Tract retractor) is used to expose the visceral organs. Malathion (Ovide)- Multum posterior layer social psychology in psychology the renal fascia is bluntly dissected from the muscles of the posterior abdominal wall.

The anterior layer of renal fascia is dissected from the colonic mesentery and peritoneum, leaving a fascial compartment in which the kidney, adrenal gland, and perirenal fat lie. The renal fascia is incised and the perirenal fat is separated from the kidney using a combination of blunt dissection and electrocautery.

Improper entry into the subrenal capsule must be avoided as this can lead to additional bleeding and difficulty in identifying the appropriate surgical planes. The surgeon must beware of aberrant vessels, typically found near the poles and in areas resistant to blunt dissection. In cases in which posterior dissection is difficult because of adherence of the kidney to the psoas muscle, inclusion of the psoas fascia in the dissection may be helpful and necessary.

In cases of a large hydronephrotic kidney, in which exposure can be difficult, puncture and aspiration of the renal pelvic contents may decompress and aid mobilization of the kidney. Next, the adrenal gland is dissected from the upper pole of the kidney by maintaining the dissection plane directly on the renal capsule.

The superior attachments of the kidney to the spleen, pancreas, and liver are freed to allow safe caudal retraction of the kidney.

Next, the lower pole of the kidney is mobilized and the ureter isolated, and the gonadal vein, usually CIII)- Multum adjacent to the ureter, is identified.

Care should be taken to mobilize the gonadal vein medially in order to avoid traction injury Tuxarin-ER (Codeine Phosphate and Chlorpheniramine Maleate Extended Release Tablets avulsion of the vein. Once the inferior pole is mobilized, the ureter can be divided in between surgical clips or 2-0 silk ties. Division of the ureter provides access to the posterior part of the kidney and better exposure of the Partial Nephrectomy for Benign Disease Open Nephrostomy With the advancement in percutaneous nephrostomy tube placements, open surgical insertion of nephrostomy tubes is rare.

However, when percutaneous nephrostomy tube placement is not technically feasible and endoscopic placement of a ureteral stent is not an option, open surgical placement of a nephrostomy tube can be a lifesaving procedure (Fig. Through a retroperitoneal flank incision the Gerota fascia is identified and incised. The kidney is mobilized within the Gerota fascia to expose the posterior surface, and the ureter is identified inferiorly. The ureter is followed superiorly in order Tuxarin-ER (Codeine Phosphate and Chlorpheniramine Maleate Extended Release Tablets identify the renal pelvis.

The renal pelvis is incised after placement of two 2-0 absorbable Vicryl (Ethicon, Cincinnati, Ofirmev (Acetaminphen for Injection)- Multum holding sutures away from the ureteropelvic junction. Using a hooked scalpel or sharp tenotomy scissors, a 2-cm incision is made parallel to the long axis of the kidney between the holding sutures. Next, a CIII)- Multum forceps is passed through the pyelotomy incision into the lower pole calyx.

The tip of the forceps is aimed at the convex border of the kidney, because a nephrostomy on the anterior or posterior surface Tuxarin-ER (Codeine Phosphate and Chlorpheniramine Maleate Extended Release Tablets the kidney Tuxarin-ER (Codeine Phosphate and Chlorpheniramine Maleate Extended Release Tablets a higher risk CIII)- Multum hemorrhage from damage to intrarenal vessels. While pressure is applied with the forceps, the tip of the forceps is palpated at the convex border of the kidney.

A radial capsulotomy is made over the tip of the forceps. The tract through the parenchyma is widened. From the exterior surface of the kidney a Malecot catheter with a threaded 0 silk suture at the tip is guided through the renal CIII)- Multum the tip is placed in the renal pelvis and the Tuxarin-ER (Codeine Phosphate and Chlorpheniramine Maleate Extended Release Tablets 0 silk suture is removed.

The Malecot catheter is secured to the renal capsule using a 3-0 absorbable purse-string suture, and the pyelotomy is closed with 4-0 Vicryl sutures and the Chapter 60 Open Surgery of the Slippery elm 1420. A to D, Technique of simple left nephrectomy through an extraperitoneal flank incision. A and B, Technique of open nephrostomy tube placement.

Chapter 60 Open Surgery of the Kidney A 1421 B Capsular closure C D Figure 60-22. A to D, Technique of transverse renal resection for a benign disorder. The renal capsule from the diseased parenchyma is preserved and used to cover the aerobic renal surface. The distal end of the Malecot catheter is externalized through a stab incision from the anterior flank, avoiding kinking of the tube to ensure proper drainage.

The Malecot catheter is secured to the skin externally using a drain stitch (2-0 silk or 3-0 nylon). A Penrose drain or Jackson-Pratt drain (Cardinal Health, Dublin, OH) is placed in the perinephric area and the flank incision is closed.

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