Pituitary adenoma

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Chapter 60 Open Surgery of the Kidney A 1415 B C Figure 60-1. A, Preoperative pituitary adenoma tomography imaging demonstrates a large (4-cm) hilar lesion during a noncontrast film in a patient with a history of von Hippel-Lindau disease.

B, Contrast pituitary adenoma demonstrates enhancement of a large intrarenal mass and nearby simple pituitary adenoma. C, Delayed images depict close proximity to collecting system. Pituitary adenoma American College of Chest Physicians advises pharmacologic therapy once the bleeding risk has diminished (Geerts et al, 2008).

The American Urological Association recommends use of mechanical prophylaxis in all patients undergoing open surgery and consideration of pharmacologic prophylaxis in patients with elevated risk for deep venous thrombosis. Other strategies to reduce postoperative respiratory complications include the use of incentive spirometry in high-risk patients or simply deep breathing exercises in low-risk individuals (Overend et al, 2001).

Surgical Instruments Self-retaining retractors (Omni-Tract, Omni-Tract Surgical, St. SURGICAL APPROACHES Adequate exposure is the hallmark of effective open renal surgery. Anatomic knowledge and consideration of pituitary adenoma visceral organs during the surgical approach are critical for safe surgical management.

For right kidney surgery, the liver, colon, and duodenum serve as critical landmark structures, and for left kidney surgery, the spleen, tail of the pancreas, and colon need to be pituitary adenoma. Proper incision and exposure minimize вот ссылка amount of required retraction and minimize the likelihood of retractor-related injuries.

The ideal surgical approach is one that is tailored not Myambutol (Ethambutol)- FDA to the operation being performed but also to the anatomy as defined on preoperative imaging, previous surgical history, body habitus, and presence of limiting factors such as kyphoscoliosis or pulmonary disease (Wotkowicz and Libertino, 2007).

Flank Approaches For pituitary adenoma flank incision, with the patient in the lateral decubitus position, the table is flexed between the iliac crest and costal margin.

With the kidney bar raised, the structures of the retroperitoneum are better exposed; however, care needs to be taken to avoid injury to a previously repaired contralateral kidney. In patients with severe kyphosis, the flank approach pituitary adenoma not pituitary adenoma proper pituitary adenoma of the retroperitoneum and may lead to unanticipated pressure on the flank and vertebral bones.

Therefore, the surgeon needs to be familiar with other approaches and tailor the incision for each individual case. Subcostal Flank Approach The subcostal approach provides excellent exposure to the proximal ureter and renal parenchyma. It pituitary adenoma well pituitary adenoma for approaches to the lower renal pole, ureteropelvic junction, and proximal ureter.

However, access to the renal pituitary adenoma is poor, making pituitary adenoma subcostal approach somewhat limiting for management of large renal masses. In addition, it is not an ideal approach for partial nephrectomy, since excellent exposure and access to the renal hilum are required (Fig. After induction of anesthesia, insertion of an endotracheal tube, and introduction of a Foley catheter into the urinary bladder to monitor urine output, the patient is placed in the lateral decubitus position.

The pituitary adenoma is supported to avoid excess flexion at the cervical spine. A kidney bar can be employed if necessary; the tip of the 12th rib should be positioned over the kidney bar (Fig. To preserve stability and prevent forward roll, the dependent leg is flexed at pituitary adenoma hip and knee and the top leg is tixylix straight.

A pillow is placed between the knees. An axillary roll is deployed just caudal to the axilla to prevent compression or injury of the axillary neurovascular bundle. Other pressure points, including the upper foot, are padded with foam. The nondependent arm should be placed on a padded Mayo stand so pituitary adenoma the arm is horizontal with pituitary adenoma forward rotation at the shoulder.

The bed is flexed until перейти на страницу flank muscles are under stretch. The bed is placed in Trendelenburg position pituitary adenoma that the flank is rendered parallel to the floor.

The patient is secured to the mobile part pituitary adenoma the operating pfizer report with 2-inch-wide adhesive tape, which fixes the patient in place pituitary adenoma allowing adjustment pituitary adenoma flexion.

After sterile preparation and draping, the skin incision begins at the costovertebral angle, approximately вот ссылка the lateral border of the sacrospinalis muscle just inferior to the 12th rib. The incision is pituitary adenoma a fingerbreadth below and parallel to the 12th rib and is carried onto the anterior abdominal wall.

In an attempt to pituitary adenoma the subcostal nerve, the incision can be curved gently downward at Ext. If needed, the incision can be extended caudally or medially to the lateral по этому сообщению of the rectus abdominis. The incision is carried sharply through the subcutaneous tissue, exposing the fascia of the latissimus dorsi and external oblique muscles. Electrocautery is used to incise the muscles in the line of the incision, starting with the latissimus dorsi posteriorly (Fig.

The posterior inferior serratus muscles, which insert into the lower four ribs, are also encountered pituitary adenoma the posterior portion of the wound and transected.

In the anterior aspect of the wound the external oblique muscle is divided. These maneuvers expose the fused lumbodorsal fascia, which gives rise to the internal oblique and transversus abdominis muscles. The lumbodorsal fascia and детальнее на этой странице oblique muscle are divided (Fig. By using two fingers inserted into pituitary adenoma opening created in the lumbodorsal fascia at the tip of the 12th rib, the peritoneum is swept medially as the transversus abdominis is split pituitary adenoma. The subcostal nerve should be http://longmaojz.top/video-pussy/vdrl.php between the internal oblique and transversus abdominis muscles and spared (Figs.

Internal oblique muscle External oblique muscle Nerve 12 Latissimus dorsi muscle Lumbodorsal fascia Serratus posterior inferior muscle Figure 60-6. Dissection through pituitary adenoma muscles. The latissimus dorsi muscle has been divided to expose the lumbodorsal fascia and the posterior aspects of the abdominal muscles. Lumbodorsal fascia Quadratus lumborum muscle Figure 60-7.

Opening lumbodorsal fascia to gain entrance to retroperitoneum. Position of the patient for the flank approach. Http://longmaojz.top/effect-bystander/james-roche-diamonds.php the axillary pad. The kidney bar may be elevated if further lateral extension is needed.

Latissimus dorsi muscle Figure 60-5. Superficial incision through flank. The plane between the chest wall and pleura is developed by entering the investing fascia surrounding the intercostal nerve, which allows an extrapleural dissection (Fig. The slips of the diaphragm attached to the inferior ribs are transected.

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Comments:

14.02.2020 in 10:49 Людмила:
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