Operations

The abdominal portion of the ureter can be reached for operative purposes by prolonging the oblique incision used in kidney procedures downward. It should pass about 2.5 cm. (1 in. ) in front of the anterior spine and the same distance above Poupart's ligament. Access to the ureter through the abdominal cavity is not satisfactory because of the presence of the duodenum and, when distended, the ascending colon on the right side and the sigmoid and distended descending colon on the left. The surest way of recognizing the ureter in operations is to follow it downward from the hilum of the kidney or to have it contain an ureteral catheter introduced upward into it from the bladder.

The ureter (with the kidney) is most often excised for tuberculous disease; therefore, instead of its having its normal size of 5 mm. (A in.) when distended, its diameter may be increased to 12 mm. or 18 mm. (1/2 to 3/4 in.). Excision has been most often done in women, as in them the pelvic portion is much more accessible. It can be reached through an incision in the anterior vaginal wall at its upper portion instead of using an oblique incision through the abdominal muscles. Konig advised a transverse incision between the lower edge of the ribs and the crest of the ilium. Bovee (Journal of Am. Med. Assoc., Oct. 23, 1909) gives the following technic: The cervix uteri is to be drawn downward with a volsellurn. On the anterior vaginal wall, at the uterovesical juncture, a small dimple will be seen. From the outer side of this dimple an incision from one to one and a half inches in length is made downward and outward. By careful blunt dissection the ureter can be exposed, brought down with a hook, and traction made to liberate it as it passes through the broad ligament. Its lower end may then be ligated and divided. At this stage of the operation the pelvic portion of the ureter may be resected or not as desired. Then a transverse incision, four inches or longer, is made through the extraperitoneal portion of the abdominal wall, opposite the lower pole of the kidney (Konig); its inner end need not go beyond the semilunar line. Through this wound the kidney is liberated and brought out and the ureter separated by gentle traction and freeing with the fingers.