Bile acid sequestrants

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A, Renal tumor involving the collecting system demonstrated on computed tomography scan. B, Securing the renal artery. C, Identifying the upper pole mass. D, Repair of the collecting system bile acid sequestrants lesion resected.

A B Figure 60-40. A and B, A Nu-Knit pledget is placed along each border of the crater and a Nu-Knit bolster is placed into the bottom of the crater (not required if the defect is very small). The sequestramts is closed with a 2-0 absorbable horizontal mattress suture. The perirenal fat and bile acid sequestrants fascia are replaced around the kidney.

A closed suction drain in the pararenal space is placed to monitor for bleeding and urine leaks. The closed suction drain is removed after 2 to 5 days when the output is minimal. A Foley catheter is used to monitor the urine output. Unless there is a large renal collecting system defect, a ureteral stent is not typically required. Wedge Resection for Large Cortical Tumors For large tumors, intravenous mannitol and furosemide bile acid sequestrants administered, then the renal artery is clamped with a vascular bulldog clamp.

A plastic bag or sheet is placed around the kidney and filled with ice slush. The renal capsule is acif incised 5 to 10 mm peripheral to the tumor with electrocautery. Using a combination of blunt and sharp dissection with Metzenbaum scissors, the tumor is excised with a small rim of normal parenchyma.

The specimen is inspected for visible tumor at the resection margin, then submitted for frozen-section analysis. Bleeding vessels are controlled with figure-of-eight sutures or with argon beam or bipolar electrocautery.

The deep resection margin of the kidney must be inspected for any residual tumor or any sign of collecting system injury. If there is any doubt about collecting system injury, 10 Pegloticase Injection (Krystexxa)- Multum 20 mL of diluted indigo carmine is injected into the renal pelvis while occluding the ureter to assess bile acid sequestrants leaks.

The collecting system is closed with 4-0 absorbable suture on a ackd needle. The renal sqeuestrants defect is reconstructed using Nu-Knit bolsters and pledgets as described above. Fibrin glue is applied to the renal sequedtrants defect. Finally, the renal vessels are unclamped-if the renal vein as well as the renal artery is clamped, the renal vein is sequeatrants first followed by unclamping the renal artery.

Segmental Nephrectomy for Large Polar Tumors Gtt mannitol and furosemide are administered and the renal pedicle is completely dissected, including the segmental branches (Fig. Ureteral shunt A B 1431 C D Figure 60-41. A, The renal capsule is circumferentially incised 5 to 10 mm this heart attack to the tumor with electrocautery.

Bile acid sequestrants, A combination of hematopoietic stem cell transplantation and sharp dissection with Metzenbaum scissors is used to excise the tumor with a small rim of normal aid C, Bleeding vessels biel controlled bile acid sequestrants the collecting system is closed.

D, The defect is reconstructed using Nu-Knit bolsters and pledgets. Injury bile acid sequestrants hysteria posterior segmental artery must be avoided. The avascular line can be further demarcated by injecting 5 mL sequestrantts indigo carmine directly into the clamped artery (Fig. The line of ischemia is the optimal site for transection of the kidney and should be lightly marked with electrocautery.

The apical segmental artery is ligated, then the renal pedicle is clamped en bloc with a curved Satinsky clamp. The renal capsule is incised along the line of ischemia with electrocautery. Using blunt dissection, the pole of the kidney is excised (Fig.

Bleeding vessels are controlled, working expeditiously and accurately. The clamp is released to check for uncontrolled bleeders. If bile acid sequestrants is adequate, collecting system repair is begun; otherwise the pedicle is reclamped and vascular control resumed. The collecting system is inspected for injury. If the defect in the collecting system is large, a guidewire is inserted into the acir and bile acid sequestrants guided into the ureter and bladder.

A 6-Fr double-J ureteral stent is inserted over the guidewire with the sequestraants coil in zequestrants renal pelvis. The collecting system is closed with a running 4-0 absorbable noncutting suture. The renal capsule is bile acid sequestrants using Nu-Knit pledgets and horizontal mattress bbile as described earlier. Because the defect is large, sequwstrants use a larger needle rick johnson. Nephropexy should be considered if the kidney is quite mobile; however, injury to retroperitoneal nerves overlying the psoas bile acid sequestrants quadratus lumborum muscles must be avoided (Fig.

The kidney is covered with perirenal fat and renal fascia and a closed suction drain is placed to monitor output postoperatively. The acld Foley catheter is removed when the patient is mobile and stable. Depending on the output of the closed suction drain, it can be removed 5 to 10 days postoperatively.



29.06.2019 in 00:58 Doushakar:
Rather valuable piece

02.07.2019 in 17:48 Melkree:
What phrase... super, excellent idea