Pediatric Allogeneic Kidney Transplantation

Pediatric allogeneic kidney transplantation for the surgical treatment of kidney disease. The kidneys are located on both sides of the lumbar spine, behind the peritoneum of the posterior wall of the abdomen, and close to the posterior wall of the abdomen. The right kidney is about 1 to 2 cm lower than the left kidney due to the influence of the right lobe of the liver. The location of the kidney can vary depending on size, gender and age. The younger the age, the lower the position, and the lower pole of the neonatal kidney can reach the level of sputum. The posterior upper part of the kidney is adjacent to the diaphragm and is adjacent to the rib sinus and the 11th and 12th ribs of the diaphragm and pleural cavity. When performing kidney surgery, care should be taken to avoid damage to the pleura and cause pneumothorax. Both upper kidneys have adrenal coverage. The front of the kidney is different from left to right, the right upper part of the right kidney is attached to the right lobe of the liver, and the lower part is adjacent to the right curvature of the colon. The medial edge is adjacent to the descending part of the duodenum, and there is no peritoneal septum. The right renal vein is short, and the right kidney is adjacent to the inferior vena cava. Care should be taken to avoid damage to the inferior vena cava and duodenum during surgery on the right kidney. The upper part of the left kidney is adjacent to the fundus and spleen, the front of the middle part has a pancreatic tail crossing, and the lower part is adjacent to the jejunum and colon left curvature. The anatomical relationship between the lumbar fascia and its surroundings: the lower back fascia is divided into two layers, shallow and deep, with shallow layers covering the shallow surface of the iliac spine muscle, followed by the lower posterior serratus and latissimus dorsi; In the deep side, the lower part of the lumbar muscles is thickened, and the upper part is thickened to form the lumbar ligament ligament. After the cutting, the activity of the 12th rib can be increased to facilitate the exposure of the kidney. The deep part of the lumbar ligament has a pleural reflex. When the lumbar ligament is cut open on the inside, care should be taken not to injure the pleura. The deep and shallow layers of the lumbar fascia are fused on the lateral side of the iliac spine muscle to form the tendon of the transverse abdominis and the internal oblique muscle. Since the first implementation of human allogeneic kidney transplantation in Voronoy in 1936, the level of organ transplantation has continued to develop and improve. China's Lanzhou General Hospital has successfully transplanted newborn kidneys to adult recipients, and the transplantation of adult donor kidneys to 11-year-old children has also been successful. In foreign countries, Starzh and Tamer reported in 1964 that children aged 3, 6 and 8 years old were transplanted with kidneys for adults. After surgery, there was no effect on the cardiovascular status of children. The cardiac output did not increase. The transplanted kidneys functioned well after blood circulation. . Treating diseases: surgical steps Incision A right inferior (or left lower abdomen) oblique incision, starting from 3 cm above the inside of the iliac crest, obliquely downwards above the pubic symphysis. The aponeurosis of the external oblique muscle was incised, and the muscle fibers were separated. The upper part of the incision was cut open to join the aponeurosis and the peritoneum was pushed open. Cut off the inferior arteries and veins of the abdominal wall, free spermatic cord or round ligament, and cut off if necessary. 2. Exposing the iliac vessels When separating the connective tissue around the iliac vessels, the lymphatic vessels must be bundled and ligated to avoid lymphatic leakage after surgery. The common iliac artery and external iliac artery must be fully dissociated to prevent the renal artery and internal iliac artery anastomosis from being distorted, and the distal internal artery can be freed to a sufficient length to facilitate the opposite end with the renal artery. The external iliac vein must also be of sufficient length (6 cm) to allow the renal vein to conform to its end. 3. Vascular anastomosis Conventional anastomosis of the vein, followed by anastomosis of the artery. The purpose is to facilitate the deeper venous anastomosis operation technique, and it is not restricted by the kidney flipping, and the exposure is good. When the anastomosis is done, the kidneys must be placed in the ice crumbs to lower the surface temperature of the kidneys. (1) End-to-side anastomosis of the renal vein and the external iliac vein: for the end-to-side anastomosis of the renal vein and the external iliac crest (or iliac crest), and the semi-blocking of the vein with the heart-shaped tongs, refer to the size of the opening of the renal vein, and remove the equivalent For the size or slightly larger oval vein wall, use a 5-0 non-invasive nylon thread to suture one needle at each corner of the anastomosis as a two-point point. The inner wall or the outer wall can be anastomosed first. Heparin saline is injected into the lumen to drive out air bubbles. (2) for renal artery anastomosis: the proximal end of the internal iliac artery blocked the blood circulation with a pug clip, the distal end was cut, ligated, sutured, and heparin saline was used to flush the lumen. When the renal artery is in the shape of a disc of the abdominal aorta, the caliber is often inconsistent. To enlarge the anastomosis of the lumen, the internal iliac artery can be cut open. The use of two fixed points, continuous anastomosis, can also be used for intermittent sutures. The inner half of the vessel wall is sutured first, then the fixation line is exchanged and the outer vessel wall is sutured. When suturing, pay attention to suturing the whole layer of the artery, so that the anastomosis of the whole wall and the intima of the blood vessel is directly aligned to prevent the anastomosis from narrowing. If the internal iliac artery is not suitable for anastomosis, the renal artery and the external iliac artery can be anastomosed. (3) Anastomotic blood leakage test: After completion of vascular anastomosis, the arteriovenous anastomosis should be examined for blood leakage. The arteriovenous vein near the renal portal can be temporarily blocked by non-invasive vascular clamp, and renal arteriovenous blood flow is opened. Carefully check the anastomosis for blood leakage or oozing. If there is a large blood leak, the needle should be sutured. Small oozing can be partially suppressed to stop bleeding. (4) Restoration of renal blood flow: first open the renal vein tongs, and then open the renal artery to block the forceps. Open renal arteriovenous blood flow, after the recovery of renal blood circulation, the kidney color is ruddy, the kidneys become hard, the renal blood vessels beat well, and after a few seconds, the ureteral orifice can be seen to urinate or see urinary urination. Place the transplanted kidney in the armpit and check if the renal vein is twisted or angled. If necessary, make adjustments. 4. Uretary reconstruction of transplanted kidney After the transplantation of renal vascular anastomosis, the urinary tract reconstruction of the transplanted kidney must be done. How to prevent complications such as ureteral anastomotic stenosis, reflux, urine leakage and infection are also the key to the success of kidney transplantation. The three most commonly used methods are the following. (1) The extravesical ureter (donor) is directly matched with the bladder (recipient): the ureteral stump is trimmed into a horseshoe shape, and its caliber is enlarged, and a "double pig tail" catheter is placed in the ureter for stenting and drainage. Under the filling of the bladder, the bladder muscle layer was cut longitudinally on the top right side of the bladder, and separated by a hemostatic forceps to separate the bladder mucosa. The mucosa was opened at the corner of the incision and the bladder was evacuated. With a 5-0 absorbable suture, two fixed points, continuous suture of the ureter and the bladder mucosa. Then 2-0 absorbable line interrupted suture of the bladder muscle layer, embedding the ureter, forming a bladder submucosal tunnel to resist anti-reflux. (2) ureter (supply) and ureter (acceptance): if the ureter is too short, this method is used. The recipient's ureter was cut at the level of the iliac vessels, the proximal end was ligated, and the distal end was slightly detached to protect the blood supply. The donor and recipient ureteral stumps were cut into a "horse hoof" shape, the ureter was built into the "double pig tail" tube, the 5-0 absorbable line, two fixed points, and intermittent full-layer suture. (3) Renal pelvis (supply) and ureter (acceptance) anastomosis: the method is consistent with the ureter and ureter, must be placed. (4) Replacement of the ileum with the ileum: According to the length of the ureteral defect, the free ileum segment with vascular pedicle is used, the proximal end of the heart is anastomosed to the ureter, and the distal end is anastomosed to the bladder. 5. Close the incision and place the drainage Before closing the incision, check the position of the transplanted kidney, the renal artery and vein anastomosis, and whether the ureter is twisted or not. Check the bleeding point carefully and stop bleeding properly. The latex drainage tube is placed on the upper and lower sides of the wound, and the percutaneous skin is additionally punctiated. 6. Apply adult kidney to children recipients Because the pelvic cavity is small, the recipient can't accommodate the adult kidney. At the same time, the child's iliac crest is too small, so it should not be transplanted in the ankle, but transplanted in the retroperitoneum, right lower back. The entire operation must be performed through the abdominal cavity, and the abdominal incision is from the xiphoid to the upper edge of the pubic symphysis. After entering the abdominal cavity, the cecum and ascending colon are moved to the midline. The peritoneum was cut longitudinally to expose the beginning of the inferior and inferior vena cava of the abdominal aorta and the common iliac artery and common iliac vein. The renal arteries and veins were respectively anastomosed to the lower abdominal aorta and inferior vena cava. The method of vascular anastomosis is basically the same as that of adults. The General Hospital of the People's Liberation Army transplanted adult donor kidneys to children aged 11-12 years, and also used adult transplantation methods. Surgery was successful in the extraperitoneal. At present, the longest kidney has survived for more than 6 years. 7. Fetus, baby cadaver kidney transplantation 1 fetal kidney transplantation, generally using a double kidney transplant. The abdominal aorta and vena cava were sutured and sutured at the proximal end of the renal pedicle. The distal end of the vena cava is anastomosed to the distal end of the recipient's iliac crest (or iliac crest); the distal end of the abdominal aorta is anastomosed to the end of the iliac (or iliac) artery; the ureteral opening with the triangular area of the bladder and the recipient Bladder anastomosis. 2 infants and children with cadaveric kidney transplantation, depending on the situation, you can use a double kidney transplant or a single kidney transplant. Single kidney transplantation is the same as adult kidney transplantation. complication 1. After receiving adult kidney transplantation, children may have low blood pressure due to large kidney volume, insufficient blood perfusion in the kidney, and similar changes in hypovolemic shock, and renal function recovery is slower. 2. The pediatric blood vessels are fine, the diameter of the renal blood vessels is thick, and the vascular anastomosis is prone to stenosis.