Lumbar (perinephric) blockade along the a.v. Vishnevsky

03.07.2020 -

Indications: acute intestinal obstruction, appendicular infiltrate, intestinal paresis of traumatic or postoperative origin, traumatic and burn shock, renal colic, acute cholecystitis, acute pancreatitis, reflex anuria, hepatic colic, shock with severe abdominal injuries and lower limbs

Technique. The patient is placed on his side with a cushion placed under the lumbar region. Into the angle formed by the XII rib and the long back muscles, 1 - 2 ml of a 0.25% novocaine solution is injected intradermally with a thin needle. Then, through the formed nodule, into the depths of the soft tissues, strictly perpendicular to the surface of the skin, a long (10 - 12 cm) needle is advanced, mounted on a syringe with a solution of novocaine. It is most convenient to use large-capacity syringes (10 - 20 ml). Advancement of the needle is preconditioned by continuous injection of the solution. Periodically, you should remove the syringe from the needle to ensure that there is no damage to the internal organ (kidney, intestine) and that the needle is located correctly.

Having passed through the muscle layer and the posterior layer of the renal fascia, the end of the needle enters the interfascial space, as evidenced by the free injection of novocaine without any effort on the part of the doctor and the absence of reverse flow of fluid from the needle when removing the syringe. If there is no reverse flow of the solution, begin to inject 60 - 100 ml of a 0.25% novocaine solution. If blood appears in the needle (kidney puncture), the needle is pulled out slightly until the bleeding stops and the administration of novocaine is continued. During perinephric blockade, the rule is strictly followed: from the needle - not a drop of liquid, not a drop of blood, since only with correct technique the novocaine solution spreads along the renal vessels and comes into contact with nerve formations. In the case of free distribution of the solution in the retroperitoneal space, the perinephric blockade is absolutely painless both during its implementation and after some time.

Complications: puncture of the kidney (appearance of blood in the needle), intestines (release of gases and intestinal contents through the needle). A puncture of the kidney, if it is noticed immediately and the needle is slightly extended outward, is practically safe. When puncturing the intestine, you should draw 10 - 15 ml of antibiotics dissolved in novocaine into a syringe (penicillin, streptomycin, monomycin, etc.), then, attaching this syringe to the needle, slowly remove it, simultaneously injecting the antibiotic solution. The patient should be closely monitored over the next 4 to 5 days, as retroperitoneal phlegmon or paranephritis may develop.

Shkolnikov block (intrapelvic). Indications. Technique. Possible complications.

INDICATIONS: traumatic shock for fractures of the pelvic bones and damage pelvic organs, isolated fractures of the ilium.

TECHNIQUE. The patient lies on his back. A thin needle is used to anesthetize the skin of the subcutaneous tissue 1 cm medially from the anterosuperior iliac spine.

A 14-15 cm long needle is inserted through the infiltrated area. The needle is advanced from top to bottom and front to back, applying a 0.25-0.5% anesthetic solution, constantly feeling the inner surface of the ilium with the needle. The needle should be oriented so that its bevel slides along the inner surface of the ilium. At a depth of 12-14 cm, the needle rests on the iliac fossa, where 250-300 ml of a 0.25% anesthetic solution is injected. When performing a bilateral blockade, 250 ml of a 0.25% anesthetic solution can be injected on each side.

POSSIBLE COMPLICATIONS. With strict adherence to the blockade technique, no complications were noted.

A - needle direction; 6 - stages of inserting a needle deep into the pelvis retroperitoneally.

1. Overdose local anesthetic and its toxic effect.

2. Injection of the solution into the blood vessel. Rapid entry of local anesthetic into the bloodstream causes a toxic effect. Prevention: performing an aspiration test.

3. Anaphylactic reactions.

4. Infection. Violation of the rules of asepsis leads to infection deep into the tissue. The result is the development of deep infiltrates, abscesses and phlegmons.

Indications for this blockade for diseases of the abdominal and pelvic cavities:

Infected long-term non-healing wounds and ulcers, acute aseptic and purulent inflammatory diseases(hemolymphatic extravasation, phlegmon, furunculosis, post-castration edema, rheumatic inflammation of the hooves), papillomatosis, verrucous dermatitis and purulent pododermatitis, colic in horses (flatulence, enteralgia, blockages of the thick section), initial stages toxemia, tympany and overfeeding in cattle, atony of the forestomach, enterocolitis, retained placenta in cows and goats, purulent endometritis, catarrhal form canine distemper, epizootic lymphangitis.

With this method, a solution of novocaine is injected into the fascial sheath of the kidney, where it penetrates the perinephric fatty tissue and affects the renal nerve plexus.

Lumbar (perinephric) blockade in horses according to I.Ya. Tikhonin.

Blockade technique.

When performing a blockade, the rules of asepsis and antiseptics are strictly observed.

For injection, use Beer, Bobrov needles or injection needles 10-12 cm long with mandrels, 1.5-2 mm thick with an end sharpened at an angle of 45 degrees.

The blockade is performed on a standing horse, fixed in a machine.
Novocaine solution can be injected from both the right and left sides.
For a right-sided blockade, the needle is inserted perpendicular to the skin in the space between the last rib and the transverse costal process of the first lumbar vertebra or between the 17th and 18th ribs, at a distance of 8-10 cm from the midline of the back (at the outer edge of the longissimus dorsi muscle) (drawing).
The depth of needle insertion is 8-10 cm.

1 – left kidney; 2 – right kidney; 3 – longissimus dorsi muscle; 4 – iliocostal muscle.

On the left side, the needle is inserted into the space between the last rib and the anterior edge of the transverse costal process of the 1st lumbar vertebra at a distance of 5-6 cm from the free end towards the midline of the body and to a depth of 5-6 cm, depending on the breed and fatness horses.

After preparing the surgical field, it is advisable to use a thin needle to make an intradermal injection and infiltrate the underlying tissues with a 0.25-0.5% solution of novocaine.
Then a puncture of the skin is made with a Beer or Bobrov needle. The needle insertion point should be in the middle of the intercostal space.
An injection needle with a mandrel is inserted into the resulting hole perpendicular to the skin and advanced to the required depth.
Then the mandrel is removed from it and a test infusion of the anesthetic solution is performed. When the needle is positioned correctly, the novocaine solution enters the perinephric tissue under light pressure on the syringe piston. Completely free entry of the solution indicates that it enters abdominal cavity. When introducing the solution intramuscularly or into the kidney parenchyma, the hand experiences significant resistance. The appearance of blood indicates penetration of the needle into the kidney parenchyma or into the lumen of a blood vessel.
After making sure that the needle is in the correct position, begin injecting the required amount of novocaine solution.

For injection, use a Janet syringe.

BLOCK OF THE ROUND LIGAMENT OF THE LIVER

Indications:spicy pancreatitis, acute cholecystitis.

The blockade is carried out when the first medical care and further treatment. Its purpose is to block afferent nociceptive impulses in the area of damage or inflammation of the pancreas and influence efferent impulses to reduce spasm of smooth muscles internal organs abdomen, ducts of the digestive glands, blood vessels.

Blockade eliminates paresis intestines, reduces exocrine pancreatic secretion glands, strengthens diuresis.

Information about the round liver ligament, see section “Umbilical vein”.

Patient position: on back.

Technique: strictly along the midline 3-4 cm above the navel, the skin is anesthetized through a thin needle. Change the needle to a thicker and longer one, which is used to pierce the linea alba of the abdomen. Preceding the advancement of the needle with a solution of novocaine, 250-300 ml of a 0.25% solution of novocaine or trimecaine is slowly injected into the tissue of the round ligament of the liver. The location of the needle tip corresponds to the attachment of the ligament to the anterior abdominal wall. Novocaine diffusely permeates not only the preperitoneal tissue and round ligament of the liver, but also bed gallbladder,

hepatoduodenal and hepatogastric ligaments, head of the pancreas (D.F. Bagovidov and T.I. Chorbinskaya, 1966;

I.N. Siparova and Yu.B. Martova, 1970).

Contraindications: the presence of scars in the epigastric region and right hypochondrium, hernia of the white line of the abdomen, intolerance to novocaine.

Indications: injuries of the abdominal organs and retroperitoneal space, reflex anuria, dynamic intestinal obstruction, paresis of the gastrointestinal tract, hepatic-renal failure, renal colic, spasm and atony of the ureters, burns of the torso and lower extremities, blood transfusion shock, obliterating endarteritis, prolonged compartment syndrome, trophic ulcers lower extremities.

Patient position: on the side, under the lower back, a cushion with a diameter of 15 cm is placed. The leg on which the patient lies is bent at an angle of 90° at the knee and hip joints, pulled towards the stomach; the top one is extended. Defining the end of the left index finger the most pliable place in the corner formed by the XII rib and the outer edge of the muscle that straightens the trunk, a nodule is formed through a thin needle with a 0.25% solution of novocaine. Through it, a long needle (up to 12 cm) with a syringe attached is directed strictly perpendicular to the skin into the tissue depth by 5-7 cm, sending an anesthetic solution in front of the needle. By passing the needle through the muscles and the posterior layer of the paramuscular fascia, the surgeon experiences tissue resistance. When the needle penetrates the perinephric cellular space, the solution begins to spread freely between the sheets of fascia. They catch the moment when drops of solution stop appearing from it: “dry needle” when removing the syringe. After making sure that no blood enters the syringe, 60-100 ml of a warm 0.25% novocaine solution is injected. When a perirenal blockade is carried out correctly, the novocaine solution reaches the renal, solar, mesenteric plexuses, and splanchnic nerves, providing anesthesia. The patient must remain in bed for 1-2 hours (Fig. 59).

Fig- 59. Paransfr;1lnaya novocain blockade. I - point insertion of an injection needle; 2 - XII rib; 3 - kidney; 4 - long back muscle.

Errors and dangers: 1) if the needle is not advanced perpendicular to the surface of the skin, the needle may enter the abdominal cavity or intestinal lumen: when suctioning, gas with a fecal odor and intestinal contents will enter the syringe. The needle must be removed, and large doses of antibiotics must be injected through another into the perinephric tissue. wide range actions;

2) if the needle pierces the kidney parenchyma, the administration of novocaine becomes difficult, pain occurs, and novocaine mixed with blood comes out of the needle. The needle must be pulled back 1 cm. After repeated monitoring, you can continue administering the novocaine solution.

Perirenal block is the injection of an anesthetic into the perinephric space.

Indications for perirenal blockade: renal or hepatic colic, peritonitis, pancreatitis, (dynamic), obliterative diseases of the vessels of the lower extremities.

Position of the patient during perinephric block: lying on the healthy side. The leg on the side of the manipulation is extended, on the opposite side it is bent at the knee and hip joints. A cushion is placed under the healthy side.

Perinephric block technique

A long (10-12 cm) puncture needle is rolled into the angle between the erector spinae muscle and the 12th rib strictly perpendicular to the surface of the body. The skin at the injection site is first numbed. The puncture needle is advanced with continuous injection of novocaine until the needle feels like it is falling through and novocaine flows out freely when the piston is lightly pressed. To check the correct placement of the needle, remove the syringe from it. If the needle has passed through a piece of renal fascia located behind the kidney, its cannula oscillates in time breathing movements diaphragm. Inject 60 ml of 0.25% novocaine, heated to 36-37 °C. Since the perinephric space is different people varies, if bursting pain appears in the lumbar region, the administration of the solution should be stopped.

Complications of perirenal block

the penetration of the needle into the kidney parenchyma is determined by the tight movement of the needle, the difficult flow of novocaine from the syringe and the return flow of a blood-stained solution into it;
the needle enters the intestine, as evidenced by the free flow of novocaine and the entry of gas with an intestinal odor after removing the syringe from the needle;
the needle enters the kidney vessels, which is determined by the significant flow of blood into the syringe.

The mechanism of action of the blockade is that when the perirenal tissue is filled with novocaine, the anesthetic substance along the vascular pedicle of the kidney reaches the aorta and blocks the numerous sympathetic nerve plexuses located on its anterior surface.

The article was prepared and edited by: surgeon

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Indications for performing a perinephric block are: renal or hepatic colic, peritonitis, pancreatitis, dynamic intestinal obstruction, obliterating diseases vessels of the lower extremities, that is, the need to influence solar plexus. Solar plexus located on the anterior wall of the abdominal aorta around its branches: the celiac trunk and the superior mesenteric artery (it consists of the celiac plexus and the superior mesenteric plexus). The solar plexus is involved in the innervation of the contents of the retroperitoneal space and abdominal cavity.

The patient should lie on the operating table in the same way as when performing kidney operations: on the opposite side, under which a cushion is placed. The leg on which the patient lies should be bent at the knee and hip joints. Perinephric block should be performed at the posterior renal point located at the intersection of the lower edge of the 12th rib with the outer edge of the erector spinae muscle . After treating the manipulation site with an antiseptic and creating a “lemon” crust.” the needle is inserted perpendicular to the surface of the skin.

Rice. Place of perinephric blockade: 1. – lower edge of the 12th rib; 2. – outer edge of the erector spinae muscle; 3. – place of perinephric blockade.

Advancement of the needle must be preceded by the administration of an anesthetic. This not only provides pain relief, but also prevents the needle from clogging soft tissues. The depth of the injection depends on the individual tissue thickness. The doctor should focus on feeling of failure(overcoming resistance) that arises when puncturing the retrorenal fascia. After this, the advancement of the needle must be stopped and the syringe must be disconnected from the needle. If the injection with a needle was carried out correctly, then the tip of the needle should be in the perinephric tissue. At the same time oscillatory movements of the outer part of the needle should be observed(up and down) in time with the patient's breathing. This movement of the needle is due to the fact that the retrorenal fascia is fused with the diaphragm. When you exhale, the diaphragm rises up, pulling with it the retrorenal fascia and the tip of the needle - outer part the needle will move down thanks to the lever, the role of which is played by the 12th rib. When inhaling, the needle returns to its original position. After the doctor is convinced of the presence of oscillatory movements of the needle, a syringe is attached to it and the anesthetic is injected. The second sign confirming the location of the needle tip in the perinephric tissue is the relatively free (without significant resistance) administration of the anesthetic, which fills the perinephric tissue.

Possible complications when performing a perinephric block:

1) Inserting a needle into the kidney parenchyma. In this case, there is usually resistance to the administration of the anesthetic; if the intrarenal vessels are damaged, blood will flow back into the syringe.

2) Damage to the renal vessels by the needle. In this case, the anesthetic is injected freely, and arterial or venous blood flows back into the syringe.

3) Puncture of the renal pelvis. In this case, the anesthetic is injected freely, and urine flows back into the syringe.

4) Puncture of the ascending colon(right) or descending colon (left). In this case, the anesthetic is administered freely, and when the syringe is disconnected, an intestinal odor is felt.

If no symptoms of complications are observed, the doctor administers it through a needle. about 80 ml of anesthetic, which should completely fill the perirenal tissue. In this case, the patient usually feels the appearance of bursting pain in the lower back, which confirms the correctness of the manipulation and indicates the filling of the perirenal tissue. Considering that the size of the fascial capsule of the kidney is individual, the volume of injected anesthetic can also vary significantly. After filling the perirenal tissue, the anesthetic will begin to spread along the path of least resistance towards the solar plexus - to the final site of its action.

15. Carry out projection of extraperitoneal access to the kidney according to Fedorov.

The most popular approaches to the kidneys are the Fedorov access and the Bergmann-Israel access. Both approaches are extraperitoneal, that is, they are not accompanied by dissection of the peritoneum. This is their advantage, since extraperitoneal approaches minimize the risk of damage to the abdominal organs and infection in the abdominal cavity. In both cases, the patient should lie on the opposite side, under which a cushion is placed. The patient's leg, on which he lies, is bent at the knee and hip joint(for greater stability of the torso). Fedorov access lead from the point of intersection of the lower edge of the 12th rib with the outer edge of the erector spinae muscle ( posterior renal point), to the navel, however, they do not reach the navel, but end along the outer edge of the rectus abdominis muscle. Thus, Fedorov’s approach is performed in the outer parts of the lumbar region and the anterolateral abdominal wall. During lumbotomy according to Fedorov, elements of the superficial, middle and deep layers are dissected layer by layer. The surface layer includes: skin, subcutaneous tissue and superficial fascia . Three layers of muscles are dissected as elements of the middle layer: superficial, middle and deep muscle layers. TO superficial the muscles dissected during lumbotomy according to Fedorov include latissimus dorsi and external oblique. Then they are dissected inferior posterior serratus muscle and internal oblique abdominal muscle ( middle layer muscles). After this they dissect transverse abdominis muscle and its aponeurosis (deep layer of muscle). When separating the edges of the dissected transverse muscle and its aponeurosis, the integrity is usually compromised intra-abdominal (transverse) fascia– element of the deep layer. In this case, the surgeon enters the abdominal cavity, namely the retroperitoneal space. Own retroperitoneal tissue (the superficial layer of tissue in the retroperitoneal space) is shifted to the sides and a fairly dense tissue is dissected retrorenal fascia(one of the two layers of the retroperitoneal fascia). After this it shifts perirenal fiber(part of the middle layer of fiber of the retroperitoneal space) and the kidney dislocates into the wound. The kidneys should be dislocated carefully so as not to tear accessory renal artery , which in 30% of cases can extend from the abdominal aorta to the lower pole of the kidney. When this artery ruptures, it contracts and goes deep into the tissue with the development of very profuse and difficult to stop bleeding, which is life-threatening for the patient. Therefore, before dislocating a kidney, you should palpate it from the lower pole for the presence of an accessory renal artery there. If the kidney is going to be removed, then this artery is crossed between the clamps. Surgical access to it is completed by dislocating the kidney.

16. Carry out projection of extraperitoneal access to the kidney according to Bergman-

Bergmann-Israel access rational use in cases where it is necessary to expose not only the kidney, but also the ureter. The patient's position on the operating table is the same as with Fedorov's approach. The incision is made from the middle of the 12th rib obliquely down and forward, parallel to the iliac crest and inguinal ligament, 3-4 cm above them. If necessary, the incision is adjusted to the lower third of the inguinal ligament, which allows for extraperitoneal access not only to the kidney, but also to most of the ureter. The layers that are dissected during this lumbotomy are the same as with Fedorov’s approach.

Rice. 67. Projection of access to the kidney ( A.– rear view; B.– front view):

1. - according to Fedorov; 2. – according to Bergmann-Israel.

Of the surgical techniques (and stages of surgery) on the kidney and ureter, the following are most often performed:

Nephrectomy (kidney removal);

Kidney resection (removal of part of it);

Neftostomia (fistula on the kidney);

Nephrotomy (kidney dissection);

Nephropexy (kidney fixation);

Pyelotomy (dissection of the renal pelvis);

Pyelorrhaphy (suturing of the renal pelvis);

Ureterotomy (dissection of the ureter);

Ureterorrhaphy (suturing of the ureter).

When removing a kidney, the components of the renal pedicle are usually treated in the order in which they are located from back to front (i.e., from more superficial formations to deeper ones): first, the ureter is ligated and crossed, then the renal artery, then the renal vein. However, the sequence in which these components are processed depends significantly on the reason for the operation. Yes, when malignant tumor kidneys, you should first ligate the renal vein along with the lymphatic vessels located next to it; in case of hydrocele of the kidney, first ligate the renal artery (to stop the flow of fluid to the kidney), etc. Right renal artery is usually longer than the left one (since both are formed from the abdominal aorta, which is displaced in left side). The right renal artery crosses the inferior vena cava, being behind it (which corresponds to the principle of expediency, since otherwise it would press the inferior vena cava to back wall abdomen). The testicular (ovarian) arteries may arise from the renal artery. This occurs more often on the right than on the left (since the right renal artery is longer). The left renal vein, as a rule, is longer than the left (so both flow into the inferior vena cava, which is displaced in right side). The left renal vein crosses the abdominal aorta, located in front of it. The testicular (ovarian) veins flow into the left renal vein more often than the right. If there is a choice, they try to take a kidney from a donor on the left side, so that the graft has a larger segment of vein - to restore the kidney during transplantation venous drainage It is quite difficult and sometimes the failed vascular suture has to be cut off.

It is advisable to remove coral stones that fill most of the renal pelvis by dissecting not the pelvis, but the kidney. In this case, the kidney is dissected into two halves along the Tsondeka line, passing 1 cm posterior to the convex edge of the kidney. This line approximately separates the posterior segment of the kidney from other segments occupying a more anterior position (thus, less intrarenal formations are damaged). Features of kidney suturing are described in the chapter devoted to suturing parenchymal organs. When applying a suture to the pelvis and ureter, the principles of intestinal sutures are observed. However, through sutures are not used to avoid contact of the suture material with urine, as this promotes stone formation.

17. Justify the technique and simulate a high section of the bladder.