LITHOTOMY (lithotomia) — operational opening of a bladder for removal of stones from it.
This operation is known from antiquity. A. Tsels in the first half of 1 century for the first time in detail described a perineal lithotomy, a cut began to call in the way Tsels. To the patient in situation on spin with the brought to a stomach and most divorced knees the operator entered index and average fingers of the left hand into a rectum, groped a stone in a bubble and pressed it to a crotch. After that by a semi-lunar section between a scrotum and an anus it was bared, and then on the centerline the neck of a bladder was cut. The stone was taken through an operational wound. Along with a median section of a proximal part of an urethra and neck of a bladder at perineal access the side, bilateral side section and rectovesical access was offered. The high suprapubic cystotomy for the purpose of removal of a stone (sectio alta) for the first time was manufactured in 1474 by J. Callot, and in Russia To. N. Grum-Grzhimaylo (1823).
N. P. Venediktov since 1767 produced St. 4 thousand perineal K. V 1887 so-called V. Sklifosovsky the idea about a possibility of a removing calculus by the section of intraperitoneal department of a bladder was stated. In a year L. Rydygier successfully made such operation.
Indications and contraindications
Indications: big stones of a bladder which cannot be shattered (see. Lithotripsy ); the stones which are followed by the expressed inflammation of a bladder, a prostate, urethra and external genitals; the stones complicating adenoma of a prostate of the III stage; the stones formed on foreign bodys of a bladder or located in its diverticulum. By means of To. any stones of a bladder can be removed. If stones of a bladder cause an acute ischuria, bleeding or are a source of an urosepsis, then is shown emergency To.
Operation K. it is contraindicated in cases when on the general state or owing to other serious illness of the patient is not able to transfer it.
Preoperative preparation includes washing of a bladder antiseptic solutions within 3 — 5 days if the urine infected, definition of sensitivity of flora of urine to antibiotics and usual a gigabyte. actions on the eve of operation.
Operation is performed under local anesthesia in combination with medicamentous preparation, under anesthetic, spinal or peridural anesthesia.
The most widespread way of an operative measure at stones of a bladder is suprapubic extra peritoneal K. Chrezbryushinnoye and subperitoneal To. apply extremely seldom, and perineal do not apply.
Suprapubic extra peritoneal lithotomy. On the operating table of the patient stack in the provision of Trendelenburga (see. Trendelenburga situation ). On a rubber catheter enter 200 — 300 ml of antiseptic solution then the catheter is blocked a clip into a bladder. Some surgeons fill a bubble with oxygen.
The skin section 6 — 8 cm long is carried out on the centerline of a stomach from a pubis to a navel. Layer-by-layer cut skin, hypodermic cellulose, an aponeurosis. Direct and pyramidal muscles move apart in the stupid way. Prevesical cellulose a gauze napkin or a ball on a clip after a cross nadsecheniye together with a fold of a peritoneum is otslaivat up and held in this situation (fig., a). It is impossible to separate a wall of a bladder from pubic bones. On a wall of a bubble at its top impose two silk handles at distance of 2 cm from each other. Remove a clip from a catheter and produce wash liquid or oxygen of willows of a bubble. Between handles longwise cut a wall of a bladder (fig., b); the section shall correspond to the sizes of a stone. If assume to make cross section of a wall of a bubble, then handles should be imposed at its top, but to longwise skin section. The choice of the direction of a section of a wall of a bubble (longitudinal, cross, slanting) depends on an arrangement of vessels, a cut on an internal wall define at a tsistoskopiya, and on outside — during operation. The stone from a bubble is deleted with nippers, spoons, fenestrated forceps, etc. After removal of a stone the bubble is taken in two-row catgut seams tightly (fig., c). At the expressed hypodermic fatty tissue or a big section of a bladder on the 1st days insert into a bottom corner of a wound the rubber graduate. If the wall of a bladder is thinned, at a moderate inflammation of a mucous membrane and a big section of a bubble it is reasonable to put on 1 — 2 days in it a constant catheter. At purulent cystitis, an atonichny bladder, and also after the emergency removing calculus and a serious general condition of the patient it is reasonable to finish operation with suprapubic drainage of a bladder (fig., d).
The most frequent mistakes suprapubic extra peritoneal To.: peeling of a bubble from pubic bones; a section of a wall of a bubble at a symphysis, but not at a top; insufficient audit of a cavity of a bladder; fixing of a vesical drainage at pubic bones, but not at a top of a bubble. A rare, but the most terrible mistake if it is not noticed, damage of a peritoneum is.
Subperitoneal lithotomy. Its feature is that the belly fold is otslaivat from a bubble so that it was possible to open a bubble in the place, otsloyenny from a peritoneum. After removal of a stone and sewing up of a bubble the place of a section becomes covered by a peritoneum again.
Transabdominal lithotomy. The abdominal wall is cut on the centerline over a pubis. The parietal peritoneum is cut without reaching on 2 — 3 cm a transitional fold. On a top of a bubble over a stone in lengthwise direction impose two handles. Between them in transverse direction cut a top of a bubble. The stone is deleted, and the top of a bubble handles is held over a wound. Then make audit of a cavity of a bladder. On a wound of a bubble impose the first row of the knotty catgut seams passing through a serous muscular layer. The second row of seams (gray and serous) is imposed continuous silk. The wound of an abdominal wall is layer-by-layer taken in. If the bubble was infected or after operation at the patient the urination is broken, then for 2 — 3 days leave a constant catheter.
The postoperative period
Irrespective of quick access later To. it is necessary to continue antiinflammatory treatment, to watch a regularity of an urination and a daily urine, function of intestines, a condition of a wound.
Outcomes later To. satisfactory. A recurrence of a lithogenesis is observed most often at to adenoma of a prostate (see) and a neurogenic bladder respectively to 25 and 40% of cases.
A lethality later To. less than 0,5%.
See also Lithotripsy .
Bibliography: Odenov B. S. Clinical justification of a transabdominal lithotomy, M., 1963, bibliogr.; The guide to clinical urology, under the editorship of A. Ya. Pytel, page 62, etc., M., 1970; Sklifosovsky N. V. Shov of a bladder at suprapubic section, Works of the 2nd congress the Russian doctor., t. 1, page 1, M., 1887; Tsulukidze A. P. Fundamentals of urological surgery, page 253, Tbilisi, 1962; M and at about of G. u. Z i n g g E. J. Urologische Operationen, S. 234, Stuttgart, 1973, Bibliogr.; Urolithiasis research, ed. by H. Pleisch a. o., N. Y., 1976, bibliogr.; Urologische Operationslehre, hrsg. v. G. W. Heise u. E. Hienzsch, S. 127, Lpz., 1970, Bibliogr.
I. P. Shevtsov.