The feasibility of removing a kidney in humans can be linked to many years of research on the best form of operation and the impact on physiological processes. The dog model was used in the initial tests. Tests done on dogs showed that compensative hypertrophy of the kidney remained and proved that an animal can survive with one kidney organ (Poletajew, Antoniewicz, & Borówka, 2010). A Canadian surgeon William Hingston was the first individual to carry out a nephrectomy on a human being in 1868. However, this was not recorded as an achievement because the patient died on the operating table after removal of his kidney. The pioneer of kidney removal surgeries was Gustav Christoph Jakob Freidrich Ludwig Simon who was a German surgeon. Simon successfully conducted the first surgery in 1869 (Poletajew, et al. 2010). Among his first patients was Margaretha Kleb who was a 46-year-old patient with a complication of the uterus as she had a left-sided ureterovaginal fistula. Three attempts were done to close the fistula but only kidney removal depicted to be the clinical solution for the problem. Simon conducted experiments using 30 dogs before he operated the patient in a surgery that lasted for 40 minutes. While complications were faced during the operation and postoperative period, Kleb was successfully discharged from hospital 2 months later (Poletajew, et al. 2010).
Initially, operations of the kidney were faced with high mortality rates approximated to even reach 50 percent mainly caused by the infection of the surgical wound. For partial nephrectomy, the surgery was done under conditions that were highly restricted, for patients who had bilateral kidney tumors, a tumor in a solitary kidney or patients with renal dysfunction (Russo, 2011). The first successful partial nephrectomy was done in 1887 when Czerny resected an angiosarcoma from a 30-year-old man’s kidney (Russo, 2011). Animal experiments done later showed bleeding control could be done using gentle pressure.
Through all the years that have passed since the first successful nephrectomy was documented, significant knowledge has been gained on renal diseases and functions and more importantly, the surgical workshop has faced considerable improvement. At the initial period, kidney removal operations were done because of renal lithiasis and ureterovaginal fistulas. As years passed, the operations were done to remove renal tumors. However, today, the current surgeries have drastically reduced the benefit of nephron sparing procedures as nephrectomy are mainly being done for organ donation. The initial surgeries were done using classical surgical methods but today because of extensive research in this field surgeries are now being conducted through the assistance of robots (Poletajew, et al. 2010).
The aim of this term paper is providing an analysis of a surgical technology-nursing program in this case open field partial nephrectomy. The paper has been subdivided in numerous sections such as the comparative description of partial and radical nephrectomy, a diagnosis for partial nephrectomy surgery, comparison of the types of partial nephrectomy and a description of patient preparation for open field partial nephrectomy. Moreover, the steps for surgical procedure have been explained, the post-operative care and the patient outlook.
Comparative description of partial vs. radical nephrectomy
Partial nephrectomy is an operation that is conducted to remove a part of a kidney that has been infected by a tumor or disease. Through partial nephrectomy, an individual is able to have the disease removed and at the same time preserve the kidney and its function in the body. During a partial nephrectomy, the surrounding fatty tissue, adrenal gland, lymph nodes and the upper end of the ureter (the tube that carries urine to the bladder from the kidney) are not removed. Often, partial nephrectomy is performed when the human tumor is less than 4cm wide (Rini, Campbell, & Escudier, 2009). Surgeons will prefer this type of nephrectomy when there is need to save a much healthy and normal kidney of the person undergoing the operation. By ensuring that the kidney is preserved, there are high chances that post-operative kidney function is maximized a phenomenon that helps in the reduction of risks related to renal failure. Partial nephrectomy is mainly preferred in the treatment of small kidney tumors and cancers that have not spread outside. The operation concentrates on removing the specific tumor leaving the rest of the Kidney intact (Rini, et al. 2009). This type of nephrectomy is also suitable for people who have tumors in either one or both kidneys including patients with one kidney. At times, partial nephrectomy is called nephron-sparing surgery. The nephron is the kidneys’ filtering unit so after the operation a patient has some working kidney left. However, not all patients are fit to undergo this operation. This is because it largely depends on the tumor position within the kidney. Initially, this was a rare type of surgery. Nonetheless, advancement of technology has allowed early identification of kidney cancer through intended or accidental scans. This is the most appropriate treatment for individuals with a stage one cancer.
On the other hand, radical nephrectomy is where the surgeon removes the entire kidney including the tissues that surround it such as the adrenal gland which is attached to the kidney. Additionally, the surgeon removes some of the lymph nodes. Radical nephrectomy has been defined as resection of Gerota’s fascia and entire components composing of the kidney, lymphatic and perinephric and the ipsilateral adrenal gland (Novick, Jones, Gill, & Cleveland Clinic Foundation, 2006). Theoretically, a complete surgical excision of the entire cancer with negative surgical margins offers the best chance to cure patients who have renal cell carcinoma the most common malignancy of the kidney. This is the most frequent performed type of nephrectomy during the treatment of kidney cancer. A radical nephrectomy can be done in both laparoscopic and open manner. Open surgery is done by making a cut or incision in the patients lower back, abdomen or side to allow for the removal of the kidney. This incision allows a surgeon to have a close examination of the kidney and the surrounding tissues for any tumor spread. Laparoscopic radical nephrectomy is often used for localized renal tumors that are small, the procedure involves making small ‘key-hole’ incisions, and using a camera or laparoscope and specialized instruments, the tumor or kidney is removed. Diagnosis of radical nephrectomy is considered in all patients who have been suspected to have solid renal mass (Novick, et al. 2006).
Diagnosis for partial nephrectomy surgery
The evaluation of individuals with renal cell carcinoma in relation to partial nephrectomy includes preoperative testing. This testing is done to rule out the presence of locally metastatic or extensive disease. In many of the patients, performing preoperative renal arteriography in the delineation of the intrarenal vasculature helps in tumor excising with minimal damage and blood loss to the nearing normal parenchyma. Individuals who have small peripheral tumors can be exempted from this test (Urology Surgery, 2008). Patients with centrally or large located tumors undergo selective renal venography with an aim of evaluating intrarenal venous thrombosis. This diagnosis aids in determining the stage at which the tumor has advanced as well as making an evaluation of the technical complexity required for the tumor excision. As mentioned, partial nephrectomy is appropriate for candidates with kidney tumors less than four centimeters in size and is located on the kidney’s periphery. An aggressive approach to undertaking a partial nephrectomy may exist in cases of candidates with bilateral kidney tumors, a solitary functioning kidney, and candidates who face risk of non-functioning kidneys if radical nephrectomy is performed. However, with the advancement in technology, the scope of candidates who can be treated using the various types of partial nephrectomy such as robotic partial nephrectomy has expanded which now allows individuals with tumors less than 7 centimeters in size without the involvement of fat or veins to successfully undergo a surgery (Urology Surgery, 2008).
Comparison of types of partial nephrectomy
Three main types of partial nephrectomy include open, laparoscopic and robotic nephrectomy. Each type of partial nephrectomy has its own standard procedure and can only be used in specific situations.
Open partial nephrectomy
This is the traditional operation used for the removal of a specific part of the kidney. An open partial nephrectomy is required to be conducted by a surgeon if technically it is too difficult to remove the entire kidney. In this form of partial nephrectomy, the surgeon makes an incision that is six to eight inches long allowing enough space for the removal of the infected part of the kidney. Often this standard technique is used for renal tumor organ-sparing resection (Russo, 2011). After the removal of the infected tissue or part the kidney is reconstructed as the goal of this nephrectomy is saving as much kidney as possible having that kidneys are essential for life being the main body filters. Moreover, the open partial nephrectomy has the lowest rate of complications as the surgeon does the procedure in the safest manner possible. Open partial nephrectomy is used to manage tumors located at the kidney’s central portion. A number of reasons that can cause an open partial nephrectomy include infection, cancer, damage from kidney stones, high blood pressure, injury from trauma and congenital abnormalities (Russo, 2011).
Laparoscopic partial nephrectomy
Laparoscopic partial nephrectomy is a keyhole surgery that is performed without the need of the surgeon making a large cut. In this case, surgery is done using small keyhole instruments where they are inserted by a surgeon to the abdomen through small incisions. To ensure that the internal organs are seen the abdomen is filled with carbon dioxide gas (Aron, Koenig, Kaouk, Nguyen, Desai, & Gill, 2008). It is an effective and safe way of removing small tumors while ensuring the kidney is preserved. Patients are exposed to less discomfort when compared to the open partial nephrectomy. When Laparoscopic partial nephrectomy is compared to the open partial nephrectomy, the latter has less post-operative pain, patients have a shorter stay in the hospital, and they have a high likelihood of returning to their normal duties and activities in a short period (Aron, et al. 2008).
Robotic partial nephrectomy
Finally, the robotic partial nephrectomy is a laparoscopic surgery that uses robotic assistance via small keyhole incisions. It uses a combination of 3D magnification, miniature instruments, robotic technology to enhance the skills of a surgeon when removing the infected kidney portion and reconstructing the kidney that remains. This type of partial nephrectomy requires a small incision compared to the open partial nephrectomy (Ficarra, Bhayani, Porter, Buffi, Cestari, & Mottrie, 2012). This partial nephrectomy uses four robotic arms one that is equipped with the high definition camera. The second arm acts as the arm of the surgeon and the fourth arm is used for holding back the tissue. Through the camera, the surgeon can be able to have an enhanced detail, panoramic view, true depth of field and the broad range of movement provides a greater dexterity by the robotic arms. The surgeon remotely operates the robotic arms when in a console located near the patient. This type of partial nephrectomy is beneficial in terms of patient losing less blood, less medication required after operation, quick recovery and resumption of normal activities and it is less scary (Ficarra, et al. 2012).
Description of patient preparation for open field partial nephrectomy
Before the open field partial nephrectomy is carried out, the patient is prepared adequately in a number of ways. First, the patient undergoes through anesthetic assessment days before the surgery is scheduled. This pre-assessment clinic is critical for the surgeon to assess the fitness and suitability for anesthetic and surgery. A number of tests are done to ensure that the heart, kidneys and lungs are in good working condition. Some of the tests may include blood tests, chest x-ray, and ECG that records the heart’s electrical activity (NHS, 2016). Secondly, if a patient is a smoker, the doctor can ask them to stop. This is because smoking increases an individual’s risk of developing a blood clot in the lung or leg, or chest infection. Smoking can also delay the healing of the wound because the amount of oxygen that reaches the body tissues is reduced significantly. Finally, a patient is given advice about any medicines which they may be consuming and may be required to temporary change the dose or stop before the surgery is done (NHS, 2016). If admitted for the surgery procedure, a patient should not eat or drink six hours before conducting the operation. Consent for the procedure should always be obtained. The operation is done under a general anesthetic to ensure the patient is asleep during the entire surgery period and feels no pain (NHS, 2016).
List of instruments
Some of the instruments that are required to conduct a successful open field partial nephrectomy include a bulldog clamp, ultrasonic knife or electric scalpel, clips, a catheter, dressings, and oxygen mask among other instruments that the surgeon deems critical for a successful surgical operation (NHS, 2016).
Surgical Procedure for the open field partial nephrectomy
The open field partial nephrectomy involves a surgical procedure that the surgeon has to follow strictly to achieve a successful operation. The first step involves positioning the patient in the right angle ready for treatment. Moreover, there is identification and control of the renal and ureter vessels with loops. At this point, the instruments are positioned and the kidney is exposed ready for the operation on the part that is infected. Additionally, the Kidney is mobilized without the removal of perinephric fat which overlays on the tumor (Novick, 2002).
When this is done, the surgeon does a vascular control which allows for the incision of the kidney capsule with a margin of 5 MM. The clamping of the renal artery using a bulldog clamp follows this and upon completion, the tumor is resected and the clipping of the visible vessels is done. Following this, the collecting system and vessels are closed using a running suture (Novick, 2002). This is followed by the removal of the bulldog clamp from the renal artery. The renal defect should be controlled for the vessels that are bleeding. The next step is renorrhaphy where the surgeon approximates the cortical edges using the help of interrupted clips and sutures. Finally, the interrupted sutures are tied to a bolster. To simplify the operation the surgeon can chose to use hemostypic agents that support hemostasis (Dirk, 2016).
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It is always recommended that the surgeon should conduct a wound drainage. If there was deep entry to the collecting system an insertion of the DJ urethral stent can be done through the opened system or via a pyelotomy or after the renal defect is sutured. Additionally, a catheter should be inserted in a period between five to ten days depending on the volume of drainage each day (Dirk, 2016).
Post-operative care
After a successful surgery, it is required that the patient adhere to the post-operative care to avoid any form of complications. Post-operative care involves pain-controlled analgesic, a device that controls the patient’s pain. The device administers medication related to pain at the dosage prescribed by the doctor and at the interval recommended. The device has a button that the patient can self-administer under close monitoring. It is often discontinued after day 2 of post-operative and oral pain medication is given. Secondly, the patient is put under an incentive spirometer which promotes full lung expansion and prevents the patient from suffering any respiratory complications. Thirdly, the patient is put under sequential compression devices which aid blood circulation by provision of compression on the legs to prevent any formation of blood clots (Dirk, 2016).
Post-operative care also involves the patient doing flexion exercises. It is recommended that the patient should start by pointing their toes towards the side of the bed where the feet are. Then the patient should point their toes towards their face. This should be done repeatedly when awake for at least 100 times. In addition ambulation is recommended as walking as soon as possible promotes effective breathing, improves circulation, mobilizes secretions and it relieves the pressure. Postoperative care will also involve dressing and suture that will be done on the part the kidney was removed. This will be a daily routine until moving out of the hospital. The patient will be required to be on a recommended diet.
Patient outlook
The recovery of the patient will largely depend on their attitude towards recovery. Importantly, after discharge, the patient should adhere to the instructions provided to ensure that they avoid any sought of complications. A patient should honor appointments with their doctors to ensure that they their road to recovery is as planned. Appointments helps in making an assessment of the progress of the incision and monitor closely on any complications that might be emerging. Patients should know that they had a surgery and require adequate time to fully recover before resumption of their normal work duties. A patient ought to be active with light duties, rest and sleep more after the operation.
References
Aron, M., Koenig, P., Kaouk, J. H., Nguyen, M. M., Desai, M. M., & Gill, I. S. (2008). Robotic and laparoscopic partial nephrectomy: a matched‐pair comparison from a high‐volume centre. BJU international, 102(1), 86-92.
Dirk, M. (2016, November 29). Open Partial Nephrectomy. Retrieved March 17, 2017, from Urology Textbook: http://www.urology-textbook.com/open-partial-nephrectomy.html
Ficarra, V., Bhayani, S., Porter, J., Buffi, N., Lee, R., Cestari, A., ... & Mottrie, A. (2012). Robot-assisted partial nephrectomy for renal tumors larger than 4 cm: results of a multicenter, international series. World journal of urology, 30(5), 665-670.
NHS. (2016). Open Partial Nephrectomy . Retrieved March 17, 2017, from Amazonnaws.com: http://s3-eu-west-1.amazonaws.com/files.royalfree.nhs.uk/Patient_resources/Renal/Open_partial_nephrectomy.pdf
Novick, A. C. (2002). Nephron-sparing surgery for renal cell carcinoma. Annual review of medicine, 53(1), 393-407.
Novick, A. C., Jones, J. S., Gill, I. S., & Cleveland Clinic Foundation. (2006). Operative urology at the Cleveland Clinic. (Springer e-books.) Totowa, N.J: Humana Press.
Poletajew, S., Antoniewicz, A. A., & Borówka, A. (2010). Kidney removal: the past, presence, and perspectives: a historical review. Urology journal, 7(4), 215.
Rini, B. I., Campbell, S. C., & Escudier, B. (2009). Renal cell carcinoma. The Lancet, 373(9669), 1119-1132.
Russo, P. (2011). Open partial nephrectomy. Personal technique and current outcomes. Arch. Esp. Urol., 64, 571-593.
Urology Surgery. (2008, September 1). Partial Nephrectomy. Retrieved March 17, 2017, from Urology Surgery: https://urologysurgery.wordpress.com/2008/09/21/partial-nephrectomy/
