Web release: 2011-06-23 20:11Publisher: Wang Jianming (visit: 1882).

Percutaneous nephrolithotomy is a minimally invasive operation, but it also has risks. Both the operator and the patient should have enough knowledge. One: Intraoperative bleeding is the most common and dangerous complication. The kidney is an organ with rich blood circulation and fragile texture. Segmenting the blood vessels of the kidney, and dividing the renal artery into two groups: the anterior group and the posterior group, with an avascular zone in the middle called Brodel line, and the anterior group is pointed, up, middle and down, as shown in the figure; Therefore, it is necessary to avoid damaging these great vessels during the operation, and the puncture position should be selected near the Broad line as far as possible, and the puncture should not be too deep, and it is best to penetrate the renal calyceal vault. If the blood vessels are slightly larger or the operation time is too long, it will cause excessive bleeding. The choice of puncture site should be considered comprehensively. Choosing the least puncture channel can achieve the best effect, clean the stones, remove the stones as quickly as possible, minimize the damage to the kidneys and reduce the main bleeding. At the same time, the puncture position should not damage the surrounding organs to the maximum extent. Methods to prevent bleeding: First, make full preparations before operation, prepare blood, and do hematological examination before operation, which is a taboo for patients with anemia and abnormal coagulation function. Second, try to reduce the number of puncture during the operation, and try to choose the puncture site on the back of the kidney or the young part of the blood vessel. The third is to minimize the operation time, and if necessary, the stones can be removed by several operations. Fourth, the renal drainage tube can be temporarily clamped after operation to achieve the purpose of hemostasis. Fifth, try not to move or swing the scope greatly during the operation, because it will tear the renal parenchyma and cause bleeding. Sixth, pay attention to the patient's state and bleeding volume at any time during the operation, terminate the operation in time, and take the stone in the second stage if necessary. If great vessels are found punctured during operation, corresponding measures should be taken, or open surgery or interventional surgery should be adopted to stop bleeding, so as not to delay the operation opportunity. During surgical puncture, if the kidney essence is thick, or the range moves too much after puncture, it will be found that the color of the irrigation solution is heavy, or bright red blood flows out of the puncture channel. At this time, the operation should be terminated or the endoscope should be pressed to stop bleeding according to the patient's condition. If it is a vein or renal parenchyma tear, the bleeding will not be very severe. Stop local compression and clamp the drainage tube after operation, which can generally stop bleeding. If it is arterial or vascular bleeding, interventional therapy and highly selective renal vascular embolization are needed. Laceration of the second renal pelvis; Renal pelvis laceration is caused by puncture, or it may be caused by ballistic laser or ultrasonic lithotripsy. If the patient's local tissue is fragile due to local inflammation or previous surgical history, it is also easy to cause injury. In most cases, as long as the drainage is smooth, these injuries can be recovered. Three: water poisoning, in the process of percutaneous nephrolithotomy, a large amount of normal saline should be used to keep the surgical field unblocked. If the operation time is too long or the irrigation fluid pressure is too high, the patient will absorb too much water, thus causing water poisoning. Because patients generally use general anesthesia, the clinical manifestations are not obvious, mainly manifested as fast heart rate, late arrhythmia, blood pressure fluctuation, hypothermia and so on. For some patients with long operation time, doctors should have a clear understanding. At the same time, the excessive absorption of physiological saline increases the burden on the heart. For patients with a history of cardiovascular diseases, special attention should be paid to cardiovascular manifestations to prevent the occurrence of heart failure. For patients with long operation time, renal parenchyma injury and renal pelvis laceration, attention should be paid to the pressure of irrigation solution. Four: There are organs around during the operation. During percutaneous nephrolithotomy, it is possible to damage surrounding organs, such as pleura, intestine, peritoneum, important blood vessels and ureter. Therefore, in the process of establishing renal puncture operation channel, we should not only pay attention to the puncture direction, but also pay attention to the control of puncture depth at any time-shallow rather than deep, light and precise operation, and make accurate judgment on any situation at any time during operation. As you can see, the organs around the kidney: the spleen is above the left kidney, the descending colon is below the left kidney, the stomach is in front, and the pancreatic tail is in front of the renal pedicle. The right liver is outside the kidney, the descending part of the duodenum is in the inner front, the ascending colon is in the outer front, and there are fewer organs behind the bilateral kidneys, and the upper pole of the kidney is closely connected with it. All these organs are in danger of being damaged. Pleural injury of 1: For patients who have already punctured the 1 1 intercostal space, this puncture point has the advantages of good puncture angle and short distance. In the process of puncture under the guidance of B-ultrasound, the ultrasonic image of the1/intercostal space is clear, which is easy to approach the stone, but it is easier to damage the pleura. Therefore, we should pay attention to the performance in the operation field and whether there is abnormal performance of gas overflow in the operation channel, and do closed thoracic drainage if necessary. Intestinal injury: In the process of puncture, the direct channel should be selected to avoid the puncture channel passing through the abdominal cavity or chest cavity and damaging the organs. Pay attention to the change of operation area at any time during the operation, exclude the damage of other organs at any time, and change to open surgery when necessary. Ureteral injury: In percutaneous nephrolithotomy, both ureteral intubation and nephrolithotomy may damage the ureter. In the process of ureteral intubation, when the ureteral orifice is unclear and the orifice is ectopic, the operation should not be rough. First of all, before entering the ureteroscope, try to find the ureteral orifice and insert the guide wire. After entering the guide wire, it is necessary to adjust the direction of ureteroscope in many directions and gently enter the ureteroscope to prevent the ureteral orifice from being damaged. Light will cause laceration and contusion of ureteral orifice, and severe will not be able to enter ureteroscope. It is often difficult to identify the ureteral orifice and it is impossible to insert it. You should be patient. You can empty or fill the bladder, or find the opposite hole first. Ureteral orifice is mostly located in the area rich in blood vessels in the triangle of bladder. Adjust the distance between ureteroscope and ureteral orifice. The orifice is often located on the lateral upper side of ureteral fissure and can be found along the muscle fiber of the orifice. If necessary, the cystoscope can be changed for observation, or methylene blue can be injected intravenously to find the orifice. In the process of catheter entering the ureter, always keep the endoscope moving under direct vision, always keep the guide wire as the guide, avoid being rude, pay attention to the resistance in the process of advancing, keep rotating the endoscope and keep the field of vision clear. In the process of ureterolithotomy, the ureteral wall is easily damaged due to its thinness, inflammation, edema and congestion, ranging from contusion and bleeding to perforation, tearing or avulsion of the ureter. Small perforation or conservative treatment with double J tube, large laceration or avulsion should be treated by open surgery.