Category: Stones: PCNL
Introduction & Objective :
We show 7 tips collected over the years and from different centers for those who already have experience in percutaneous surgery and seek to make the transition to supine position
1. ACCOMMODATION OF THE ROOM. We show the modality where the C arm is placed on the same side, to have a better ergonomics for the visualization of both monitors having an additional space for a second assistant for the realization of ECIRS.
2. Patient position, Reference Points and adipose panniculus fixation. In the position of Valdivia Galdakao, a bag of saline solution of 3000 ml is placed below the patient; our reference points are the eleventh and twelfth ribs, the iliac crest and the posterior axillary line. We believe that the best option is to do the marking once the patient is in position. The adipose panniculus can hinder any surgery in obese patients; in these cases we suggest using a pair of adhesive strips to pull the adipose panniculus forward. It is important to mark the patient after having done this maneuver
3. Digital Dilation. With the introduction of a finger, making a digital dilation towards the retroperitoneal space, opening a hole of the muscular aponeurosis with a clamp. We can use a straight clamp to observe the displacement of the kidney.
4. The position modifies the puncture. As we place a solution bag under the patient, often the puncture has to be from the bottom up. We start almost always with an angle of 15 to 20 °. So the direction of the puncture should be from the bottom up or horizontally. We started the puncture with the C-Arm with a rotation of approximate 20 ° which compensates for the angulation generated by the pouch. The depth of the puncture is verified by placing the C-arm at 0 °
5. The kidney is extremely mobile, a Valsalva maneuver can displace the kidney from 2 to 4 cm, so the ideal is perform the puncture of the kidney during a short apnea.
6.Straight clamp for help the puncture and sign of the fovea. By guiding us with the straight clamp we can place the chiba needle in parallel to ensure the puncture. When the crushing of the cavities with the Chiba needle, we are sure that the puncture is in the right place and that there is a tactile feedback when drilling cavities that is clearly identifiable
7. Tubeless. When we finished the surgery we used a plug of sterile sponge of natural absorbable gelatin, we marked on the tip with contrast and is inserted inside the Amplats, and pushit to the rigth place
Results : These tips help us in the most difficult part of the percutaneous surgery that is the puncture for the access the formation of the tract and one more at the end for the finalization tubeless safer
Conclusions : We believe that these tips can help us start the learning curve in supine position
Edgar Beltran-Suarez– Mexico City, Distrito Federal, Mexico