bimbingan lumbotomy

1. Lumbotomy
Proximal Ureterolithotomy
Djodie Depati Singalaga

2. Definition
• Manual of urologic surgery, Jackson E. Fowler. 2012
Flank Incision : Surgical approach to
provide direct extraperitoneal access to
the kidney, proximal ureter
• Hinmann Atlas of Urologic Surgery. 2012
Proximal ureterolithotomy : Open surgery
procedure performed for the removal of
proximal ureteral stones

3. Anatomy
Skandalakis Surgical Anatomy, 2014

4. Indication
• Ureterolithotomy proximal
• Nephrolithotomy
• Pyelolithotomy- extended
pyelolithotomy
• Bivalve nephrolithotomy
• Pyeloplasty
• Nephrectomy-partial nephrectomy
Lumbotomy :
all procedure to
access kidney
and proximal
ureter by
extraperitoneal
approach by
open surgery
such as
(Manual of Urologic Surgery, Jackson E. Fowler. 2012)

5. Indication for open surgery in ureteral stone
Large impacted stones
Multiple ureteral stones
When other non-invasive or low-invasive procedures have
failed
For proximal ureteral calculi, ureterolithotomy has the
highest stone free rate compared to URS and SWL
EL-HUSSEINY, Tamer; BUCHHOLZ, Noor. The role of open stone surgery. Arab journal of urology, 2012, 10.3: 284-288.
Moufid K, Abbaka N, Touiti D, Adermouch L, Amine M, Lezrek M. Large impacted upper ureteral calculi: A comparative study between retrograde ureterolithotripsy and percutaneous antegrade ureterolithotripsy in the modified lateralposition. Urol Ann. 2013;5(3):140-
146. doi:10.4103/0974-7796.115729

6. Contraindications
Malrotation and malposition of kidney
Bleeding disorder
Patients who are medically unfit for an open
surgery
Manual of Urologic Surgery, Jackson E. Fowler. 2012
Muslumanoglu, Ahmet Yaser, et al. When is open ureterolithotomy indicated for the treatment of ureteral stones?. International journal of urology, 2006, 13.11: 1385-1388.

7. Preparation
Surgical cap, mask, sterile gawn,
sterile hand gloves
Sterile
gauze
Disinfection
clamp
Doek Clamp
Povidone Iodine 10%

8. Preparation
Surgical blade no 23, 11, scalpel
handle
Electronic cauter
Sharp spreader
Langenback
Suction
Tiemann Spreader
Spreader

9. Preparation
Pean/mosquito
clamp Scissors
DJ stent
Pinset Needle holder
Stone forceps
Nelathon Catheter
Right angle
Babcock
clamp
Ring clamp
Kocher

10. Preparation
Redon Drain NGT
Foley Catheter +
urobag

11. Procedure
Insert
antibiotic
prophylaxis
Placement
the Imaging
Patient in
general
anastesia
Insert
urethral
catheter
Lumbotomy
position
(Hinmann Atlas of Urologic Surgery, 2012)

12. Procedure
• Disinfect operation fields using Povidone Iodine 10%
• Narrowing the operation field

13. • Incise skin starting from
Subcostae towards the
umbilicus approximately 15
cm.
• Structures are incised: skin,
subcutaneous fat, External
oblique m., Internal oblique
m., Transverse abdominis m.
until internal abdomen fascia
• Open the lumbodorsal muscle
fascia slightly to the posterior
in the posterior axillary line.
(Hinmann Atlas of Urologic Surgery, 2012)

14. • Separate the
peritoneum with steel
deppers toward the
medial
• After the peritoneum
clearly separated, the
incision widened.
• Attach spreader
(Hinmann Atlas of Urologic Surgery, 2012)

15.  Insert a self-retaining
retractor.
 Enter Gerota's fascia
bluntly to displace part of
the perirenal fat
posteriorly, and expose
the ureter.
(Hinmann Atlas of Urologic Surgery, 2012)

16. Procedure
• Find the ureter by opening
the fascia gerota , infront
of M. ileopsoas
• Use nelathon catheter
(no.8 fr) to teugel the
ureter
• Identify the ureteral stone
• Incise the ureter with
blade no.11, upon the
ureteral stone.
• Remove the ureteral stone
(Hinmann Atlas of Urologic Surgery, 2012)

17. Procedure
• Evaluate fluid/urine that
coming out from the ureter
• Sondage to the distal and
proximal of ureter
• If sondage can be done well,
do spoeling, and also DJ
stent insertion if needed
• Stitch the ureter with
polyglactin 4-0
• Wash operation field with PZ
• Lower the kidney rest, and
partially flatten the table
top
(Hinmann Atlas of Urologic Surgery, 2012)

18. Procedure
• Evaluate bleeding
• Put redon drain in
retroperitoneal
• Closure the wound
▫ Muscle and fascia with polyglactin
1-0 continous or interrupted
▫ Sub cutan fat with plain cat-gut
3-0 interrupted
▫ Skin with polypropylen 3-0
interrupted
• Close the wound by tulle and
gauze
(Hinmann Atlas of Urologic Surgery, 2012)

19. • Bleeding (2-6%) ; injured peritoneal
cavity and intra abdominal organ (2%)
; axillary nerve palsy (1%)
During
operation
• Wound infection (10-15%) ; urosepsis
(10%) ; hematuria (9-15%) ; leakage of
urine-urinoma (1-5%)
Early
postoperative
• Ureteral stricture (15-20%) ; Fistule
(5%)
Late post
operative
Complication
Borofsky, Michael S.; Lingeman, James E. The role of open and laparoscopic stone surgery in the modern era of endourology. Nature Reviews Urology, 2015, 12.7: 392.
Chen, Ding-Yuan; Chen, Wen-Chi. Complications due to surgical treatment of ureteral calculi. Urological Science, 2010, 21.2: 81-87.
El-husseiny, Tamer; BUCHHOLZ, Noor. The role of open stone surgery. Arab journal of urology, 2012, 10.3: 284-288.

20. Post operative care
KUB post
operatively
Remove urethral
catheter 1 or 2 day
post operatively
Remove drain if
production is <20 cc
2x24 hours
Release the stitches
10-14 days
postoperatively
Borofsky, Michael S.; Lingeman, James E. The role of open and laparoscopic stone surgery in the modern era of endourology. Nature Reviews Urology, 2015, 12.7: 392.
HU, Qingfeng, et al. Retroperitoneal laparoscopic ureterolithotomy for proximal ureteral calculi in selected patients. The Scientific World Journal, 2014, 2014.
Muslumanoglu, Ahmet Yaser, et al. When is open ureterolithotomy indicated for the treatment of ureteral stones?. International journal of urology, 2006, 13.11: 1385-1388.

21. Thank you