Nephropexy
R. H. Gilpatrick
1916
Boston Medical and Surgical Journal
From a study of the anatomy and physiology of the kidney and of its relations and means of support, we must conclude that the organ is never a fixture. Mobility without symptoms may exist to marked degree, to be only accidentally discovered. The only primary supports for the kidney are intra-abdominal pressure, in-•clination of the spine so as to form a modified niche for the organ and maintained by correct posture and the attachments of the posterior kidney surface to the aponeurotic covering
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... f the quadratus lumborum muscle. In operating for pathologically mobile kidney it is, therefore, unnecessary and also unwise to attempt a fixation or a perfect replacement of the organ in its •exact anatomical position, an approach to within one inch being sufficient, safe and so much more -easily accomplished as to render the accurate approximation of the decapsulated posterior surface to the lumbar fascia much more certain in •each case. A kidney one inch lower than its supposedly normal level is still within its niche, and by not attempting to place it higher all -danger t)f injury to the diaphragm is avoided. Most commonly the ptosed kidney is a part of general enteroptosis and may be, as held by some authorities, the first step in development of that difficult and complicated condition. It is, however, a fact that many patients coming to operation for entirely dissociated conditions are found to have kidneys with great degrees of mobility without symptoms referable and lacking signs of general ptosis. From this fact it seems reasonable that an occasional uncomplicated pathologically floating kidney will be identified, and such has been our experience. Perfect end-results in a large number of nephropexies will bear a closer relation to the care and judgment of the surgeon than to any special operative technic, provided the functional activity of the kidney is not impaired. As a rule, the development of symptoms from mobile kidney is slow, accompanied by relaxation , of abdominal wall and perineum, faulty posture and lowered intra-abdominal pressure. Before surgical relief is undertaken there have frequently developed other abdominal disorders, either distinct from or secondary to the ptosis. Hence the need for discrimination before operation is advised, and for thoroughness once one enters upon that course. The wandering kidney must be considered innocent until proven guilty by a process of elimination. When proven guilty the correction of posture and increase of intra-abdominal pressure may give relief. A thin subject may also gain much help from a new deposit of fat, though in my experience this relief has been but transitory. If operation is undertaken it must result in readjustment of all faulty supports and elimination of all complicating conditions or it will not be completely satisfactory. If these conditions obtain the results will be satisfactory. So far as thé liephropexy alone and the relief of symptoms rightly laid to the wandering kidney are concerned, the operative mortality and resulting percentages of cures will rank with those for repair of inguinal hernia, the two conditions offering points of analogy. The surgical problem in each is one of mechanics, the restoration of normal anatomy without interference with the physiology of the organs or tissues involved. In hernial repair the normal relations may be and generally are to some degree changed without any resulting functional disturbance, the analogous step in nephropexy being the more or less complete decapsulation of the kidney. The final strength of the hernial repair is dependent upon scar tissue forming between edges of replaced, transplanted or reconstructed tissue, while the only permanently dependable kidney support, other than intraabdominal pressure and posture, which can be induced surgically is of the same nature, the scar formed between the posterior decapsulated surface of the kidney and the aponeurosis over the quadratus; and the strength of this agglutination of surfaces will depend upon the accuracy with which they are brought into contact, just as that of the hernial scar depends. A nephropexy which removes the wandering tendency of the kidney and results in its permanent residence at the site chosen for it, but at the expense of all or a generous portion of its functional activity, is not a success any more than the repair of an inguinal hernia which holds securely but results in atrophy of the testicle. Moore and Corbett demonstrated in 1910 that serious damage always follows puncture, incision or constriction of the kidney, and that the relative damage done is proportionate in the order named. Constriction by a suture not only destroys the portion of substance included in it, but a wide zone on either side. Three
doi:10.1056/nejm191606081742302
fatcat:32gzknwfdzf3flmupag6mhw7zy