Reprint from The Nashville Journal of Medicine and Surgery, 
June, 1895. 
SOME POINTS IN THE TECHNIQUE OF KIDNEY 
OPERATIONS * 
BY CHARLES S. BRIGGS, A.M., M.D., NASHVILLE, TENN. 
Professor of Surgery in the Medical Department of the University of 
Nashville. 
Among recent advances in surgery, operations upon the kid- 
neys occupy a prominent place. The success of these opera- 
tions is such that we are naturally encouraged to a more fre- 
quent employment of them in diseases of these important organs, 
the tendency of which, if unrelieved, is invariably to death. 
While some operations upon the kidney, as nephrotomy, are as 
old as surgery, and others, as both uephro-lithotomy and 
nephrectomy, done as accidental or casual operations, date back 
several centuries, most of them are of quite recent origin. 
The first deliberately planned nephro-lithotomy was perform- 
ed in 1880, by Henry Morris. The first nephrectomy was done 
in 1869, by Gustave Simon, of Heidelberg. The first nephror- 
rhaphy belongs to Hahn, of Berlin, who operated in 1881. 
Operations on the kidney may be classified as follows: 
Nephrotomy, or incisions of the kidney, including puncture. 
Nephrorrhaphy, or fixation by sutures of movable kidney. 
Nephrectomy, or removal of the kidney. 
Nephro-lithotomy, or incision of the kidney for stone. 
In this paper it is proposed to discuss briefly each of these 
operations, calling attention especially to valuable modifications 
*Read at the Sixty-Second Annual Meeting of the Stiti 
Medical Society, at Nashville, Tenn., Wednesday. April 10th. LSV5, 2 
applicable to nephro-lithotomy, by the employment of which 
some of the difficulties of that operation may be greatly lessened. 
In nephrotomy, an operation performed for various conditions, 
as suppression from impacted stone, cysts of various kinds, hydro- 
and pyonephrosis, the incision is made through the loin in the 
ilio-costal space, half an inch below and parallel with the 
twelfth rib, from the outer border of the erector spinse muscle 
forward four or six inches, through all the tissues to the peri- 
renal fatty capsule. 
This having been torn through and the kidney exposed, the 
future steps of the operation are based upon the conditions pres- 
ent. Additional space may be secured by a vertical incision ex- 
tending from near the posterior end of the first to the iliac crest. 
Nephrorrhaphy or nephropexy are terms applied to the op- 
eration of fixing a floating kidney by means of sutures connect- 
ing the renal capsule to the parietal wound. The incision is the 
same as in nephrotomy. 
This operation is notably free from danger, and is strongly to 
be urged in all cases of floating kidney which cause much pain 
and annoyance, and are not amenable to instrumental support. 
While the above mentioned operations, simple and remark- 
ably free from danger as they are, have added brilliant lustre to 
to the glory of modern surgery, they are slight when brought in 
comparison with the immense benefits conferred by the two 
more difficult, and on account of the conditions calling for them, 
the more dangerous procedures, nephro-lithotomy and nephrot- 
omy, operations which in point of importance and in certainty 
of results vie with any of the numerous operations in other 
fields, which adorn the history of modern aseptic surgery. 
The most brilliant results of recent surgery are those obtained 
by nephrectomy, or removal of the kidney, which operation is 
done for tumor, for urinary fistula and for disorganization of the 
organ from various causes. It is also required occasionally after 
nephrotomy and nephro-lithotomy, and for movable kidney. 
Much of the success of the operation depends upon the condi- 
tion of the opposite kidney. If sound, the chances are materi- 
ally enhanced; if diseased to any extent, a fatal result is almost 
sure to follow. For determining this question as well as decid- 
ing definitely in obscure cases the point as to which kidney is 3 
the diseased one, cystic endoscopy, is an available and practic- 
able measure. By its employment the interior of the bladder is 
rendered visible by electric light illumination so that the vesical 
orifices of the ureters can be exposed, and the amount and char- 
acter of the urine discharged by each into the bladder, definitely 
ascertained. There can be no doubt, however, but that the suc- 
cessful use of such apparatus demands the most skillful and ex- 
perienced management. 
Nephrectomy may be lumbar or extra-peritoneal, or ab- 
dominal or intra-peritoneal. The incision for the lumbar 
operation is the same as that described for nephrotomy and 
nephro-lithotomy, ample and sufficient room for ordinary sized 
kidneys being afforded in the ilio-costal space. Konig's 
incision is one made at first vertically along the outer border of 
the erector spinae muscle to the crest of the ilium, through which 
the kidney is exposed, and the peritoneum detached and pushed 
forward while the lower segment of the incision is curved 
along the iliac crest and over the abdominal walls towards the 
umbilicus as far as the linea semi-lunaris. This incision is cer- 
tainly free, but it not only possesses no advantages, but is more 
likely to be followed by hernia. There can be no doubt but 
that lumbar nephrotomy yields the best results when the condi- 
tions will admit of its performance, and that it should be the 
preferable method of operation. The kidney is easily accessible, 
the peritoneum is uninjured, if infection takes place the infected 
area is limited, a direct route for drainage is afforded, and if the 
organ is diseased in such a way as to preclude its removal, it is 
left under conditions less dangerous than it would be in other 
methods. 
In large tumors of the kidney, the lumbar method is im- 
practicable for the reason that sufficient space is not afforded for 
delivery. 
After exposure and enucleation of the kidney, the pedicle, 
consisting of the vessels and ureter, are ligated in separate loops. 
Occasionally the operation has to be abandoned on account of 
adhesions. 
The removal of the kidney by anterior abdominal section 
may be accomplished through Langenbeck's incision, made in the 
linea semi-lunaris, or through the linea alba. In the former, after 4 
the incision through the parietes is made, the small intestines with 
the colon are pushed to the opposite side and protected with 
sponges and the posterior layer of the meso-colon incised verti- 
cally over the kidney. 
Enucleation is done as in the posterior operation and the 
pedicle ligated as already described. It is only in exceptional 
cases that the abdominal method should be given the preference, 
as, for example, where uncertainty exists as to the condition of 
the opposite kidney, or when the operation is for large tumor. 
Not only is the success of the operation endangered by the nec- 
essary wounding of the peritoneum, but drainage, so frequently 
necessary after such operations, can be secured, not through the 
anterior wound but through an additional one made in the loin. 
Since by cystic endoscopy the condition of both kidneys can be 
ascertained, the usefulness of the anterior operation is limited to 
cases of large tumors or cysts of the kidney. 
Nephrectomy may be rated as a very successful operation, as 
shown by statistics provided by Dr. Newman, and quoted in 
Treve's Manual of Operative Surgery. Out of 268 nephrec- 
tomies performed for various conditions, there were 94 deaths, 
thus giving a mortality of forty per cent. The mortality as 
given by the same authority is placed at thirty and five-tenths 
per cent, after the lumbar method, and forty-seven and one-tenth 
per cent, after abdominal nephrectomy. 
Henry Morris, M.A., F.R.C.S., of London, performed the 
first deliberate operation for the extraction of stone from the 
kidney in 1880, and by his numerous operations since has done 
more to develop this special operation than any other surgeon. 
His statistics show a remarkably low rate of mortality. New- 
man has collected forty-two examples of the operation where the 
kidney was not extensively diseased, without a death. Tait re- 
cords fourteen operations for stone with one death. Statistics 
show the operation to be unusually successful, when the magni- 
tude of the undertaking is considered. 
In discussing the points of the operation, as a matter of 
course, the question of diagnosis first presents itself. By at- 
tention to the rational symptoms and by careful study of the 
physical signs, the presence of renal calculus can be predicated 
with a reasonable degree of certainty. When in doubt and cir- 5 
cumstances demand it, an exploratory lumbar incision can be 
made with as much reason, and with far less danger than the 
laparotomy incision, so generally approved of by the profession 
for exploratory purposes. Two methods of operation are em- 
ployed, lumbar and abdominal. The posterior operation through 
the ilio-costal space is the safest, the surest, and the least diffi- 
cult. The route through the anterior abdominal parietes was 
strongly advocated a few years back, and still has numerous ad- 
herents, on the ground that the condition of both kidneys can 
be ascertained and the danger of removing one kidney, a step 
frequently rendered necessary by the disorganized state of the 
kidney sometimes found, while the other is also diseased, may be 
thus avoided. The recent employment of cystic endoscopy ren- 
ders the resort to this, the more dangerous method, on this ac- 
count unnecessary. 
As for the argument that the anterior incision affords more 
room for the necessary manipulation, it is only necessary to say 
that the lumbar incision affords the most direct route.to the dis- 
eased organ and with the management to which I propose now to 
call attention, ample room is afforded. 
Formerly the kidney was exposed through one of the sev- 
eral incisions mentioned above, in connection with nephrectomy 
and the search for the calculus prosecuted with the greatest 
difficulty and uncertainty through the depths of the wound with 
the kidney in situ. Naturally the search thus carried out, re- 
sulted many times in disappointment. Cases are recorded in 
which stones as large as a marble have been overlooked when 
the investigation was conducted in this manner. 
In the case which I beg leave to insert here, I experienced 
this difficulty in a marked degree, and overcame it in a manner 
which I shall now proceed to describe. 
In October 1891, I was called by the late Dr. C. W. Winn 
to see a German woman, aet. 53, a resident of this city, who for 
some time had been harassed with a train of renal symptoms, 
which pointed strongly to the presence of renal calculus of the 
right side. Briefly, the symptoms were occasional paroxysms of 
severe renal colic, attended with hcematuria and pus in the urine, 
with, at times, scanty flow of urine, constant pain and ten- 
derness on the right side over the kidney, the pains ra- 6 
diating. to points supplied by branches of the lumbar plex- 
us of nerves and by the passage of small calculi after such 
attacks. The frequent paroxysms and constant suffering brought 
about such a condition of health, that relief became impera- 
tively demanded. When seen in consultation, the patient was 
greatly emaciated, the quantity of urine reduced and invariably 
loaded with pus, the right renal region tender and, as shown by 
palpation, the kidney was somewhat enlarged, and a condition 
of hydronephrosis from probable impaction of calculus present, 
it was decided to perform nephro-lithotomy without delay. 
Accordingly she was conveyed to the Hospital of the Good 
Shepherd, and a few days after her admission the operation was 
performed as follows. The transverse incision in the ilio-costal 
space, half an inch below and parallel with the twelfth rib was 
employed. The kidney was exposed without difficulty but al- 
though the patient was thin and the wound was ample, a satisfac- 
tory examination of the kidney was found impossible. Observ- 
ing that thcorgan was very movable, it occurred to me that it 
might be brought entirely out of the wound upon the loin and 
then examined with both eye and hand. This was easily accom- 
plished and the kidney having been drawn out, was twisted 
slightly on its pedicle so as to make it straddle the wound. The 
organ was carefully palpated and a suspicious point of indura- 
tion having been detected, a long Hagedorn needle was passed 
through the cortex to this point and a grating sensation elicited 
which declared calculus present. 
This fact was demonstrated satisfactorily to all present. An 
incision was made along the convex border through the kidney 
substance to the pelvis, the finger passed through the wound 
and the stone touched. In the effort to grasp it with a slender 
pair of forceps, it was dislodged and escaped into the ureter. 
I still attempted to reach it by passing long slender forceps 
into the ureter to the depth of six inches, but only succeeded 
in pushing it so far that it was deemed unwise and inexpedient 
to prosecute the attempt any further. Three days after 
the operation it was passed per urethram while at stool, 
with a good deal of pain. Hemorrhage from the renal wound 
was copious, but it was easily controlled by an iodoform gauze 
packing. The kidney was carefully replaced, drainage tubes 7 
inserted and the wound closed by silk-worm gut sutures, 
except at the lower angle which was left open for the gauze 
packing. The subsequent progress of the case was in every 
way satisfactory. The oozing of blood and urine quite pro- 
fuse at first, gradually lessened. The packing was removed 
on the fourth day. After three weeks the wound closed 
and the patient was discharged from the hospital. She has con- 
tinued in excellent health since, with no reappearance of the old 
symptoms. 
The point which I wish to emphasize in this case is the turn- 
ing the kidney out of the wound upon the surface of the loin in 
order to permit of a thorough examination. On reflecting upon 
the ease with which this was done, it occurred to me that 
it might have been due to unusual mobility of the kidney. 
In order to satisfy myself on this point, I made a series 
of examinations upon twelve bodies at different times, and 
to my satisfaction found that it could be done upon either 
side with the greatest ease, and as proved by dissection 
without injury to either blood-vessels or ureter. The im- 
mense advantage secured by this method of drawing the kid- 
ney entirely out of its bed to the outside, can only be fully ap- 
preciated by one who has made the attempt to search for stone 
in the orthodox manner and as usually taught. 
If in dead bodies the kidney can be treated in this manner 
without laceration of the vessels and ureter, how much less the 
danger of such an accident in the living body where these struc- 
tures are so much more elastic and so much less friable. 
Of course cases will be met with in practice, in which, from 
long standing disease, this treatment of the organ cannot be 
carried out, on account of close adhesionsand the matting together 
of the tissues, but in the majority of cases operated upon forexplo- 
ratory purposes, such obstacles do not exist and this important 
manoeuvre can be accomplished. 
The plan was original, in this my only case of nephro-lithot- 
omy, with me for it was not until some time afterward that my 
attention was called to one of a course of lectures on the sur- 
gery of the kidney, by Henry Morris, of London, in the Brit- 
ish Medical Journal, April 27th, 1892, in which he advocated 
the same plan and stated that he had been practicing it for a 8 
number of years. Another point made by him, and referred to 
in the same paper, was the closure of the kidney wound by cat- 
gut sutures passed through its substance from back to front. He 
showed that not only was this the best plan of controlling a 
hemorrhage, which is occasionally alarming, but that the wound 
in the kidney thus treated, invariably healed rapidly. 
Another point still demonstrated by this same authority is 
that the incision through the kidney to reach the calculus should 
be made through the cortex, rather than through the pelvis, as 
being less likely to be followed by urinary fistula. 
By way of summary I would conclude with the following 
propositions. 
1. Kidney operations as performed in the past few years 
have yielded remarkably successful results when the important 
character of the organs so attacked are considered. 
2. In nephrectomy the posterior method is preferable, because 
it is more easily performed, it is safer and better adapted to all 
cases requiring removal of the kidney, except when the organ is 
too large to admit of delivering it through the limited ilio-costal 
space. 
3. Cystic endoscopy is a most valuable means of determin- 
ing the condition of the two kidneys and should be resorted to 
when the rational symptoms usually depended upon fail. 
4. A most important point recently developed in the tech- 
nique of the operation of nephro-lithotomy is the method estab- 
lished by Henry Morris of lifting the kidney out of the cavity 
upon the loin so as to allow of thorough examination for stone. 
5. The other points established by the same surgeon are the 
readiness with which wounds of the kidney heal when sutured 
and the fact that incision to reach the calculus in nephro-lithot- 
omy should be made through the substance and not through 
the pelvis, as being less liable to be followed by urinary fistula.