A new laparoscopic technique for the placement of a permanent peritoneal dialysis catheter: the preperitoneal tunneling method

LAPAROSCOPIC PERITONEAL DIALYSIS CATHETER PLACEMENT WITH RECTUS SHEATH TUNNELING: A ONE-PORT SIMPLIFIED TECHNIQUE

BACKGROUND

The success of peritoneal dialysis depends on the proper placement and functional longevity of the dialysis catheter. Laparoscopic implantation of a catheter through a rectus sheath tunneling can minimize the risks of catheter failure.

AIMS

This study aims to describe one-port simplified technique for laparoscopic placement of a peritoneal dialysis catheter with rectus sheath tunneling.

METHODS

The simplified laparoscopic insertion of a Tenckhoff catheter with rectus sheath tunneling was performed in 16 patients with chronic renal failure.

RESULTS

During the follow-up period, no major complications occurred. Three patients were excluded. One was referred to the renal transplant some weeks after implantation, and one died for other reasons during the follow-up. Another patient needed adhesiolysis due to previous surgery, so an additional port was necessary. The other 13 catheters worked properly, and no postoperative hemorrhage, early leaks, hernia, or catheter migration occurred. One patient had a tunnel infection 11 months after the implant. No peritonitis was observed during the follow-up.

CONCLUSIONS

The technique is simple, reproducible, and safe, with good results in catheter function, few complications, and a high catheter survival rate. It does not require a special device or trocar and avoids excessive port sites.

Outcomes of Laparoscopic Peritoneal Dialysis Catheter Placement Using an Optimal Placement Technique

Background:

Peritoneal dialysis (PD) is a widely employed renal replacement modality. A prospective study was conducted to determine the short-term and midterm outcomes and complication rates associated with a standardized optimal laparoscopic peritoneal dialysis catheter placement technique.

Methods:

All patients undergoing laparoscopic PD catheter placement by one surgeon using our standardized method over a 5-year period were entered into a prospective database. Patients were evaluated preoperatively and postoperatively through office visits. Development of complications was assessed using follow up telephone or mail surveys.

Results:

A total of 100 patients with a mean age of 56 years underwent laparoscopic PD catheter placement over the 5-year study period. In total, 103 laparoscopic PD catheter placement attempts were made in 100 patients. Placement was successful in 98 (95.1%) attempts and no placement required conversion to an open operation. Omentopexy was performed in 82 (83.7%) patients. There was no mortality reported within 30 days of the index operation. For patients who successfully underwent laparoscopic PD placement, early complications developed in 9 (9.2%) patients, of which 6 (6.1%) complications were directly related to the PD catheter. Midterm complications developed in 25 (25.5%) patients. Complication-related catheter repositioning was required for 12 (12.2%) catheters and catheter-related complication removal was required for 18 (18.4%) catheters.

Conclusion:

Laparoscopic placement of PD catheters can be successfully performed using a combination of described standardized laparoscopic maneuvers for optimal placement resulting in acceptable perioperative and short and midterm complication rates with negligible mortality rates.

Laparoscopic preperitoneal tunneling technique using a novel device for peritoneal dialysis catheter placement

BACKGROUND

We aimed to introduce the puncture technique based on a novel device for preperitoneal tunneling in laparoscopic PD catheter placement and to evaluate the safety and efficacy of this technique.

METHODS

This novel device was used in our center from May 2016. We conducted a retrospective analysis of patients undergoing laparoscopic PD catheter placement. The traditional method was performed in 20 patients and the novel procedure in 18 patients. A straight Tenckhoff PD catheter was placed in all patients.

RESULTS

No intraoperative complications were encountered in both groups. Compared the traditional technique group, the procedure based on the novel device had a shorter operative time (49.2 ± 11.8 vs 53.9 ± 12.5). One patient in the traditional tunneling group underwent catheter obstruction. There were no pericatheter leakage, exit site and subcutaneous infection, hernia and peritonitis in the early postoperative days. No mortality was observed in these patients. The 6-month survival rate of the catheter was 100%.

CONCLUSIONS

Laparoscopic preperitoneal tunneling technique is an effective way to implant intra-abdominal catheter. Our method based on a novel puncture device for preperitoneal tunneling is safe and efficient.

Operative Technique for Laparoscopic Placement of Continuous Ambulatory Peritoneal Dialysis Catheter

Background: Peritoneal dialysis (PD) is an increasingly utilized treatment modality for renal replacement therapy that affords medical and lifestyle benefits to the patient and financial savings to the health care system. Successful long-term use of PD is reliant upon an optimally functioning catheter. Many potential catheter-related complications can be avoided through utilizing optimal placement technique. As widespread use of PD as a renal replacement modality continues to increase, the need for a safe, standardized, catheter placement technique has become more evident. Objectives: To present a succinct synopsis of the rationale and elements of our current surgical management strategy for patients undergoing evaluation for PD and to provide a detailed stepwise description of our operative technique for PD catheter placement. This review describes potential pitfalls that may prevent optimal catheter function and describes each step taken to prevent potential complications. This description is combined with intraoperative photographs to highlight key steps. Conclusion: Following a defined reproducible stepwise approach, laparoscopic placement of continuous ambulatory peritoneal dialysis catheters can be performed safely and known potential complications hindering optimal catheter function can be addressed prophylactically.

Advanced Laparoscopic Peritoneal Dialysis Catheter Insertion: Systematic Review and Meta-Analysis

BACKGROUND

The optimal methodology of establishing access for peritoneal dialysis (PD) remains controversial. Previously published randomized controlled trials and cohort studies do not demonstrate an advantage for 1 technique over another. Four published meta-analyses comparing outcomes of laparoscopic versus open PD catheter (PDC) insertion have given inconsistent conclusions and are flawed since they group basic and advanced laparoscopy together. The aim of this systematic review and meta-analysis is to examine whether advanced laparoscopic interventions consisting of rectus sheath tunneling and adjunctive procedures produce a better outcome than open insertion or basic laparoscopy used only to verify the catheter position.

METHODS

A literature search using Medline, Embase, and Cochrane Database was performed, and meta-analysis was performed using RevMan 5.3.5 software (Nordic Cochrane Centre, The Cochrane Collaboration, London, UK). Outcomes evaluated incidence of catheter obstruction, migration, pericannular leak, hernia, infectious complications (peritonitis and exit-site infection) and catheter survival.

RESULTS

Of the 467 records identified, 7 cohort studies, including 1,045 patients, were included in the meta-analysis. When advanced laparoscopy was compared with open insertion, a significant reduction was observed in the incidence of catheter obstruction (odds ratio [OR] 0.14, 95% confidence interval [CI] 0.03 - 0.63; p = 0.01), catheter migration (OR 0.12, 95% CI 0.06 - 0.26; p = 0.00001), pericannular leak (OR 0.27, 95% CI 0.11 - 0.64; p = 0.003), and pericannular and incisional hernias (OR 0.29, 95% CI 0.09 - 0.94; p = 0.04), as well as better 1- and 2-year catheter survival (OR 0.52, 95% CI 0.28 - 0.97; p = 0.04 and OR 0.50, 95% CI 0.28 - 0.92; p = 0.03, respectively). Compared with basic laparoscopy, catheter obstruction and migration were significantly lower in the advanced laparoscopic group, whereas catheter survival was similar in both groups. All outcomes, except catheter obstruction, were similar between the basic laparoscopy and open insertion. The infectious complications such as peritonitis and exit-site infections were similar between the 3 groups.

CONCLUSIONS

Advanced laparoscopy was associated with a significant superior outcome in comparison with open insertion and basic laparoscopy.

Wang's Forceps-Assisted Percutaneous Insertion and Fixation of Peritoneal Dialysis Catheter

Percutaneous insertion of peritoneal dialysis catheters is theoretically most preferred by nephrologists because of the advantages of bedside performing, surgery independence, and minimal injury over other procedures of catheter placement such as open surgical dissection or laparoscopic operation. However, blindly placing catheters in the percutaneous procedure brings the risk of catheter malposition or bowel perforation; this largely retarded it's implementation. We had previously developed a novel technique termed "Wang's forceps-assisted catheter insertion and fixation," which had been successfully applied in the open surgical catheter insertion and displaced catheter reposition in our center. In this study, we further explored the possibility of applying the Wang's forceps in the procedure of percutaneous catheter insertion both in porcine model and patients with end stage renal disease (ESRD). A total of three miniature pigs successfully received percutaneous catheter insertion using Seldinger's technique with Wang's forceps assistance. The catheters were all placed in the right position and functioning well in dialysate drainage. This novel method of percutaneous catheter insertion was then performed on 20 ESRD patients. The procedure showed effective time-saving with the average operating time of 29.2 ± 3.53 min and was well tolerated by patients with minimal pain and injury. During a follow-up time of 6 months, no complications of catheter displacement, leakage, or blockade occurred. Our preliminary observation demonstrates that utilization of Wang's forceps in a percutaneous procedure conferred benefits of accurately placing and fixing catheters while preserving the merits of minimal invasion and simple performance.

Identification of the appropriate fixation site to avoid peritoneal catheter migration based on a mechanical analysis

Aim: To conduct mechanical analysis on the relationship between abdominal wall fixation point and the displacement of catheter top, and establish the finite element model for the complex forces and conditions that the catheter wears in human abdominal cavity, in order to provide the scientific basis for optimizing the catheter position in abdominal wall fixation method.

Methods: Using the PIPE59 finite elements to divide units, and taking the lower part of catheter, that is, below interior polyester cuff to simulate and compute the displacement formula.

Results: The whole model includes a total of 1701 units. Periodic load was used to simulate the dynamic pressure that peritoneal dialysis catheter gets in abdominal cavity. The load direction was perpendicular to the catheter axis. We used pressure amplitude, duration and frequency as the boundary conditions, and adjusted the fixation point of the catheter lower part at the same time, thus calculating the extreme displacement value of the catheter top end with changing parameter conditions. We also did fitted regression on the results and obtained the displacement formula: y = 0.2 × 0.87^x (y: the end displacement of peritoneal dialysis catheter, x: the distance between fixation point and the interior polyester cuff), R²: .982. Simulation the catheter maximal displacement on flat surface demonstrated that additional catheter fixation at the site of 9 cm or more below the internal cuff significantly restricted the catheter migration.

Conclusions: The optimal position of fixation point in peritoneal dialysis is about 9 cm away from the interior polyester cuff.

Modified Simple Peritoneal Wall Anchor Technique (PWAT) in Peritoneal Dialysis

♦ BACKGROUND: Outflow obstruction, a common complication in patients with peritoneal dialysis (PD), usually results in unnecessary catheter removal or replacement. This study describes a modified simple method of anchoring a PD catheter on the anterior peritoneal wall without using a laparoscopic system (peritoneal wall anchor technique, PWAT). ♦ METHODS: We performed a retrospective cohort study of consecutive PD catheter insertions, and compared the catheter survival rate between the traditional method and the modified simple PWAT. The traditional method was used in 54 cases and the modified simple PWAT was used in 17 cases. The primary endpoint was the occurrence of surgical catheter repair because of outflow obstruction by day 365. The secondary endpoint was the occurrence of catheter migration with obstruction requiring any interventions, including the alpha-replacement method by day 365. Catheter survival was analyzed by Kaplan-Meier survival curves. ♦ RESULTS: Migration-free catheter survival was significantly (p = 0.02) higher in the PWAT group (100%, 17/17) than in the traditional group (72.2%, 39/54). Catheter survival without surgical repair or cessation of PD was also significantly (p = 0.04) higher in the PWAT group (100%, 17/17) than in the traditional group (77.8%, 42/54). Similarly, migration-free and surgery-free catheter survival rates in cases with a straight-type catheter in the PWAT group were significantly higher than those in cases with a straight-type catheter in the traditional group. ♦ CONCLUSIONS: Our results suggest that the modified simple PWAT provides a better catheter survival rate than the traditional method by preventing catheter migration with obstruction in PD.

Long-Term Outcomes of Single-Port Laparoscopic Placement of Peritoneal Dialysis Catheter

INTRODUCTION

Laparoscopic insertion of peritoneal dialysis (PD) catheter has become a preferred method compared to the traditional open technique for PD catheter insertion. We retrospectively report the outcome of 1-port laparoscopic placement PD catheters in our institution.

METHODS

A total of 263 patients with end-stage renal disease who underwent single-trocar laparoscopic PD catheter insertion during a recent 6-year period were reviewed. Laparoscopic technique involves introducing a PD catheter over a stiff guidewire into the abdominal cavity through a 10-mm laparoscopic port. Pertinent clinical variables, procedural complications, and follow-up outcome were analyzed.

RESULTS

There were 182 men and 81 women. The mean age was 56 years. Technical success was 95.8%. Catheter occlusion was the most common early complications (<6 months) that occurred in 4 (1.5%) patients. Late complications (> 6 months) including catheter occlusion, cuff extrusion, catheter leakage, catheter migration, infection, and hernia occurred in 5 patients (1.9%), 2 patients (0.8%), 3 patients (1.1%), 3 patients (1.1%), 6 patients (2.3%), and 4 patients (1.5), respectively. Mean follow-up time was 39 ± 18 months. Catheter survival rate at 1, 2, 3, 4, and 5 years was 96%, 94%, 90%, 85%, and 82%, respectively.

CONCLUSION

Laparoscopic PD catheter implantation via a single-trocar utilizing a stiff guidewire technique is feasible and safe. This method can result in low complication and high catheter survival rate.

Flexible endoscopic single-incision extraperitoneal implant and fixation of peritoneal dialysis catheter: proof of concept in the porcine model

BACKGROUND

Peritoneal dialysis (PD) catheters placed in the pelvic space without anchoring present a high rate of migration. We aimed to assess the feasibility of a single-incision approach, using a flexible endoscopic preperitoneal tunneling for catheter implantation and fixation.

MATERIALS AND METHODS

Eight pigs were involved in this experimental study. A 2/0 Vicryl loop was sutured at the tip of a PD catheter. In 4 pigs, a 1.5 cm incision was made on the left paramedian line and the parietal peritoneal layer was identified by splitting rectal muscles. A gastroscope was inserted in the incision and advanced in the extraperitoneal space. An exit hole was made in the peritoneum over the low pelvic cavity. A guidewire was left in the abdominal cavity, and the PD catheter was inserted over the guidewire. The endoscope was inserted in the tunnel again, and endoscopic clips were deployed over the Vicryl loop to fix the catheter. In 4 pigs, the PD catheter was inserted laparoscopically using a two-port approach. The catheter's tip was fixed with laparoscopic clips on the Vicryl loop. A strain test to assess the force required to detach clips was performed using a digital dynamometer.

RESULTS

Operative time for flexible endoscopic tunneling was longer when compared to the laparoscopic implant (29.5 ± 4.43 vs. 22.7 ± 2.51 min). Mean force to displace the catheter was similar after flexible endoscopic fixation when compared to laparoscopic clip fixation (5.57 N ± 2.76 vs. 4.15 N ± 1.76).

CONCLUSIONS

Flexible endoscopic extraperitoneal tunneling allows for minimally invasive single-incision PD catheter placement and fixation.

Preperitoneal tunneling-a novel technique in peritoneal dialysis catheter insertion

INTRODUCTION

This study describes a new preperitoneal tunneling (PPT) method for inserting a peritoneal dialysis catheter (PDC), thereby lessening surgical complications and increasing the catheter's survival.

METHODS

This new technique was used in 23 cases from December 2005 to January 2007 and followed up until March 2011 (63 months). The procedure was performed laparoscopically under local (16 cases) or general (7 cases) anesthesia by one surgeon. Catheter survival is reported by Kaplan-Meyer analysis.

RESULTS

The catheters were mechanically obstructed in 2/23 cases (8.7%); and were withdrawn due to a peritonitis in 2 cases and inadequacy of peritoneal dialysis in 1 case. Ten patients received kidney transplantation and six died before completing this follow-up period. The patients still reaped the benefits of the PDC until receiving a kidney transplant or death. The 5-year survival rate of the catheter was 89%. No incidence of catheter migration, omental wrapping, herniation or leakage was noticed.

CONCLUSION

Preperitoneal tunneling is a simple and safe method for insertion of PDC, and can effectively prevent catheter migration, dislocation and omental wrapping.

Dual-incision laparoscopic surgery for peritoneal dialysis catheter implantation and fixation: a novel, simple, and safe procedure

BACKGROUND

Peritoneal dialysis (PD) is an alternative modality to hemodialysis and is usually used to treat patients with end-stage renal disease. Dual-incision laparoscopic surgery (DILS) had been reported in several surgical fields; however, no report was proposed about DILS in PD catheter implantation (DILS-PD). In this study, we present DILS with a novel, simple, and safe procedure for PD catheter implantation with fixation and describe the long-term outcome.

SUBJECTS AND METHODS

We conducted a prospective data collection and retrospective review of all PD patients from April 2010 until June 2012. During this study period, we performed open surgery for PD catheter implantation (OS-PD) and DILS-PD concurrently. Demographic data, medical, operative, and postoperative findings, and information regarding complications were compared between these two groups.

RESULTS

Forty-eight patients had DILS-PD, and 70 patients had OS-PD. There was no difference between the two groups in age, gender, American Society of Anesthesiologists grade, creatinine level, body mass index, and previous abdominal surgery. There was no surgical mortality in either group. The follow-up period ranged from 6 to 24 months, with a mean of 22.4±16.5 months. There was no tube migration in the DILS-PD group, but 25.7% of the patients in the OS-PD group had tube migration (P<.001). A significantly decreased exit-site/tunnel infection rate was found in the DILS-PD group (4.2%) compared with the OS-PD group (17.1%) (P=.032). However, there was no obvious difference in peritonitis occurrence between groups. A significantly decreased catheter failure rate was found in the DILS-PD group (4.2%) compared with the OS-PD group (22.9%) (P=.006). DILS-PD group patients had a favorable survival rate for catheter implantation compared with OS-PD group patients.

CONCLUSIONS

Our DILS-PD with fixation technique is a simple and safe procedure. This procedure minimized or even eliminated the possibility of migration without additional cost. Our DILS-PD fixatation technique should be recommended for use routinely.

A modified method in laparoscopic peritoneal catheter implantation: the combination of preperitoneal tunneling and pelvic fixation

Introduction. Continuous ambulatory peritoneal dialysis (CAPD) is widely accepted for the management of end-stage renal disease (ESRD). Although not as widely used as hemodialysis, CAPD has clear advantages, especially those related to patient satisfaction and simplicity. Peritoneal dialysis (PD) catheter insertion can be accomplished by several different techniques. In this study, we aimed to evaluate our results obtained with peritoneal dialysis catheter placement by combination of pelvic fixation plus preperitoneal tunneling. Material and Methods. Laparoscopic peritoneal catheter implantation by combining preperitoneal tunneling and pelvic fixation methods was performed in 82 consecutive patients with end-stage renal disease. Sex, age, primary disease etiology, complications, mean duration of surgery, mean duration of hospital stay, morbidity, mortality, and catheter survival rates and surgical technique used were assessed. Analysis of catheter survival was performed using the Kaplan-Meier method. Results. Mean follow-up period was 28.35 ± 14.5 months (range of 13–44 months). Mean operative time was 28 ± 6 minutes, and mean duration of hospital stay was 3 ± 1 days. There were no conversions from laparoscopy to other insertion methods. None of the patients developed serious complications during surgery or the postoperative period. No infections of the exit site or subcutaneous tunnel, hemorrhagic complications, abdominal wall hernias, or extrusion of the superficial catheter cuff was detected. No mortality occurred in this series of patients. Catheter survival was found to be 92% at 3 years followup. Conclusions. During one-year followup, we had seven patients of migrated catheters due to separation of pelvic fixation suture from peritoneal surface, but they were reimplanted and fixated again laparoscopically with success. Over a three-year followup period, catheter survival was found to be 92%. In the literature, similar catheter survival rates without combination of the two techniques are reported. As a conclusion, although laparoscopic placement of PD catheters avoids many perioperative and early complications, as well as increasing catheter free survival period and quality of life, our results comparing to other studies in the literature indicate that different laparoscopic placement methods are still in debate, and further studies are necessary to make a more accurate decision.

Laparoscopic-assisted placement of a peritoneal dialysis catheter with partial omentectomy and omentopexy in dogs: an experimental study

OBJECTIVE

To describe a technique of laparoscopic-assisted placement of a peritoneal dialysis (PD) catheter with simultaneously performed partial omentectomy and omentopexy.

STUDY DESIGN

Pilot experimental study.

ANIMALS

Beagle dogs (n = 6).

METHODS

After placement of 1 sub-umbilical laparoscope portal and 1 instrument portal in the left cranial abdominal quadrant, laparoscopic-assisted partial omentectomy, and omentopexy were performed, and a modified Tenckhoff PD catheter was placed under laparoscopic guidance. A modified dialysis protocol was used twice daily for 4 days. The feasibility of the procedure, surgical duration, operative complications, and dialysis efficacy were evaluated. Postoperative pain and inflammation were graded (0-3).

RESULTS

The procedure was successfully performed in all dogs with a median operating time of 25 minutes. No operative complications occurred. Procedure-related postoperative pain and inflammation were minimal. Eight consecutive PD procedures were successfully performed, and no leakage or obstruction was observed.

CONCLUSIONS

Laparoscopic-assisted partial omentectomy and omentopexy can be performed at the same time as PD catheter placement with minimal morbidity.

Videolaparoscopic catheter placement reduces contraindications to peritoneal dialysis

BACKGROUND

Videolaparoscopy is considered the reference method for peritoneal catheter placement in patients with previous abdominal surgery. The placement procedure is usually performed with at least two access sites: one for the catheter and the second for the laparoscope. Here, we describe a new one-port laparoscopic procedure that uses only one abdominal access site in patients not eligible for laparotomic catheter placement.

METHOD

We carried out one-port laparoscopic placement in 21 patients presenting contraindications to blind surgical procedures because of prior abdominal surgery. This technique consists in the creation of a single mini-laparotomy access through which laparoscopic procedures and placement are performed. The catheter, rectified by an introducer, is inserted inside the port. Subsequently, the port is removed, leaving the catheter in pelvic position. The port is reintroduced laterally to the catheter, confirming or correcting its position. Laparotomic placement was performed in a contemporary group of 32 patients without contraindications to blind placement. Complications and long-term catheter outcome in the two groups were evaluated.

RESULTS

Additional interventions during placement were necessary in 12 patients of the laparoscopy group compared with 5 patients of the laparotomy group (p = 0.002). Laparoscopy documented adhesions in 13 patients, with need for adhesiolysis in 6 patients. Each group had 1 intraoperative complication: leakage in the laparoscopy group, and intestinal perforation in the laparotomy group. During the 2-year follow-up period, laparoscopic revisions had to be performed in 6 patients of the laparoscopy group and in 5 patients of the laparotomy group (p = 0.26). The 1-year catheter survival was similar in both groups. Laparoscopy increased by 40% the number of patients eligible to receive peritoneal dialysis.

CONCLUSIONS

Videolaparoscopy placement in patients not eligible for blind surgical procedures seems to be equivalent to laparotomic placement with regard to complications and long-term catheter outcome. The number of patients able to receive peritoneal dialysis is substantially increased.

Laparoscopic internal fixation is a viable alternative option for continuous ambulatory peritoneal dialysis catheter insertion

Purpose

One of the major drawbacks of peritoneal dialysis (PD) is catheter migration and dysfunction. Preventing catheter migration is one of the main concerns. We compared laparoscopic internal fixation method with open surgical method for catheter migration rates.

Methods

From January 2008 to August 2009, PD catheters were inserted by laparoscopic fixation (LF) method in 22 patients and by open surgery (OS) in 32 patients. Clinical data were reviewed retrospectively. The frequency of migration, peritonitis, and other complications were compared. Catheter and patient survival rates were also compared.

Results

The mean age and sex ratio were not different between groups. Mean follow-up duration was 29.1 months in LF group and 26.1 months in OS group. More patients in LF group (27.3%) had history of laparotomy than in OS group (3.1%) (P = 0.01). The mean operation time was significantly longer in LF group (101.6 ± 30.4 minutes) than in OS group (72.4 ± 26.03 minutes) (P = 0.00). The cumulative incidence of catheter migration was 65.6% in OS group and 13.6% in LF group (P = 0.00). Migration-free catheter survival was higher in LF group (P = 0.001). There were no differences in complication rates between groups. Overall catheter survival was similar (P = 0.93). Patient survival rate at 2 years was not different (P = 0.13).

Conclusion

Laparoscopic internal fixation of continuous ambulatory peritoneal dialysis catheter significantly reduces migration rates without any addition of complications. Also, laparoscopic technique did not incur patient morbidity or mortality despite the requirement for general endotracheal anesthesia and longer operation time. Therefore, internal fixation can be afforded safely in patients with previous abdominal surgery as either a salvage or preventive measure in patients with repeated catheter migration.

Our long-term results of Tenckhoff peritoneal dialysis catheters placement via laparoscopic preperitoneal tunneling technique

Previously we described the technique to lessen complications of continuous ambulatory peritoneal dialysis (CAPD) and to achieve immediate use of the catheter. In this study we evaluated our long-term results of the technique. A total of 61 procedures were carried out in 58 patients from September 2003 to February 2009. All patients were followed in our hospital CAPD clinic. Demographic, medical, operative, postoperative, and other information regarding complications and continued patient management was obtained retrospectively from the patients' medical records and entered into a computerized database. There were 33 men and 25 women. The mean age was 58 years. In 29 of the 58 patients indication of catheter placement was end stage renal failure combined with diabetes mellitus. Mean follow-up time was 33.31 ± 20.11 months. Catheter related complications were outflow obstruction (n=3, 5.2%) and peritonitis (n=2, 3.4%). Etiologies of catheter removal were out flow obstruction (n=2), recovery from renal disease (n=2), peritonitis (n=1), and pregnancy (n=1). The mean catheter survival time was found 5.57 ± 0.17 years. Our long-term results showed that the method ensured accurate placement, preperitoneal fixation, and immediate use of the catheter for routine peritoneal dialysis. Preperitoneal fixation of the catheter decreased outflow obstruction over long-term follow-up.

A brief recap of tips and surgical manoeuvres to enhance optimal outcome of surgically placed peritoneal dialysis catheters

Background. Peritoneal dialysis (PD) is an effective option of renal replacement therapy for ESRF, offering advantages over haemodialysis. Peritoneal dialysis catheter (PDC) placement is thought to be the key to successful PD and the economic advantages are lost if a patient switches to HD in the 1st year. This paper is a brief document elaborating a recap of published literature, looking at various surgical tips and manoeuvres to enhance optimal outcome of PDC placement. Methods. A search strategy assessing for access team, preoperative antibiotic prophylaxis, type of catheter, catheter exit site, intraoperative catheter trial, optimal time to commence PD, hernia repairs, number of cuffs, catheter-embedding procedures, rectus sheath tunnelling, laparoscopic fixing, omentopexy, omentectomy, the "Y"-Tec system, resection of epiploic appendages, adhesiolysis, a trained surgeon, and perioperative catheter care protocol was used looking at various databases. Findings. The complications of catheterrelated dysfunction can be reduced with advanced planning of access placement, immaculate surgery, and attention to catheter insertion techniques. Conclusion. The success of a peritoneal dialysis programme depends upon functional and durable long term access to the peritoneal cavity; this depends on placement techniques and competent surgeons and psychosocial support to the patient. The various technical tips and manoeuvres elaborated here should be considered options carried out to improve outcome and reduce catheter dysfunction.

Percutaneous CAPD catheter insertion by a nephrologist versus surgical placement: A comparative study

Peritoneal dialysis catheter (PDC) for continuous ambulatory peritoneal dialysis is inserted into the abdominal cavity either by a surgeon, interventional radiologist or nephrologist. Various innovations have been made in the methodology adopted in the placement of the PDC. We compared the percutaneous approach for PDC insertion with the open surgical technique. From January 2006 to May 2007, 25 of the 46 catheters were successfully inserted using the percutaneous Seldinger technique. The incision size (2.6 +/- 0.7 vs 7.3 +/- 0.6 cm) and the length of hospital stay (11.9 +/- 5.9 vs 17.3 +/- 6.8 d) were considerably less in the percutaneously placed group compared to the surgically placed group. Early initiation of exchanges and reduction in the expenses were other important advantages of this method.

Advanced laparoscopic techniques significantly improve function of peritoneal dialysis catheters

BACKGROUND

Continuous ambulatory peritoneal dialysis (CAPD) catheters provide a preferred alternative to hemodialysis in a growing population with chronic kidney disease. However, CAPD catheters traditionally have been associated with a high rate of nonfunction with both open and laparoscopic procedures. New advanced laparoscopic techniques using rectus sheath tunneling and omentopexy have been reported to improve catheter function.

STUDY DESIGN

This study retrospectively reports the Cleveland Clinic experience during the transition from basic to advanced laparoscopic techniques from June 2002 to July 2008. A total of 197 patients were identified: 68 who underwent insertion with basic techniques and 129 who received catheters with advanced techniques. Primary nonfunction, procedural complications, and overall nonfunction rate were analyzed using the most recent follow-up to June 2008.

RESULTS

Primary nonfunction occurred in 25 of 68 (36.7%) patients in the basic group; this occurred in only 6 of 129 patients (4.6%) in the advanced group (p < 0.0001). The overall rate of complications including nonfunction from primary and secondary sources, peritoneal leak, peritonitis, port-site hernia, and bleeding occurred in 31 of 68 (45.6%) patients in the basic group and 21 of 129 (16.28%) patients in the advanced group (p < 0.0001).

CONCLUSIONS

These data clearly show a significant improvement in CAPD catheter function using omentopexy and rectus sheath tunneling. These advanced laparoscopic techniques should become the preferred method of CAPD catheter insertion.

[Experiences with Tenckhoff peritoneal dialysis catheter]

Peritoneal dialysis is a generally accepted method for the treatment of patients with end-stage renal disease. Two main techniques for the insertion of the peritoneal catheter are known: open surgery and the laparoscopic-assisted technique.

AIM

To describe our surgical procedure and implantation technique and to determine the outcome of our patients who underwent the conventional and the laparoscopic assisted placement of a catheter.

METHODS

Between September 2001 and June 2009, 124 patients underwent either conventional or laparoscopic peritoneal dialysis catheter insertion procedure.

RESULTS

52 male, and 70 female patients were studied (mean age: 62 years), 110 conventional and 14 laparoscopic assisted operation were done.

CONCLUSIONS

The traditional method for placement of peritoneal dialysis catheters is by "blind" insertion of the catheter through a small lower abdominal incision. The laparoscopic placement is a new but well-established technique and offers some advantages, such as a safer and accurate placement of the catheter under direct vision, less postoperative pain and complications, and a longer functional survival, compared to the conventional open technique. The functional outcome of the catheters was satisfactory in the majority of patients in this study. The conventional technique is simple, safe and has low costs, and in our opinion, it should be used for the most times, and the laparoscopic technique should be considered as the method of special choice in patients with end-stage chronic renal failure.

Two-port laparoscopic placement of a peritoneal dialysis catheter with abdominal wall fixation

We devised a new laparoscopic technique for peritoneal dialysis catheter (PDC) placement to overcome the common problem of malfunction or migration of the catheter. Between March 2005 and August 2006, 38 patients underwent laparoscopic catheter placement with lower abdominal wall fixation. Using an abdominal scout film, we checked for catheter tip migration regularly. There was no leak in the immediate postoperative period. After follow-up of 21.5 months (range 6-34), all catheters were working properly, although tip migrations were found in the iliac fossa in three patients and in the right upper quadrant in one patient. A port site hernia developed in one patient and peritonitis developed in two patients. Only one remote migration (2.6%) occurred during the study period. Thus, our method of laparoscopic catheter insertion might be a feasible option.

One-Port Laparoscopic Technique for Placement of Tenckhoff Peritoneal Dialysis Catheters: Report of Seventy-Nine Procedures

Background

Laparoscopic techniques for placement of peritoneal dialysis catheters are becoming increasingly popular. In this paper, we report the results of one-port laparoscopic placement of Tenckhoff catheters in 79 patients in our center.

Method

Videoscopic monitoring was performed via a port inserted in the left upper quadrant and the catheter was placed via a pull-apart sheath through an incision near the umbilicus. The tip and the deep cuff of the catheter were placed into the true pelvis (on the urinary bladder) and into the rectus sheath respectively. A subcutaneous tunnel was created and a point midway on the umbilico-crestal line was selected as the exit site of the catheter. Catheters were capped for 2 weeks before initiation of peritoneal dialysis. Mean duration of the operation was 25 minutes.

Results

Four patients died during the follow-up period, all due to other medical problems, and 4 patients underwent renal transplantation. During a 48-month follow-up, catheter-related complications were catheter migration (1.3%; month 1), dialysate leakage (1.3%; month 1), port-site hernia (3.8%; after 6 months), exit-site infection (2.5%; months 1 and 9), and bacterial peritonitis (2.5%; after 6 months). Catheter survival was 97.2% in our series.

Conclusion

We obtained a low complication rate and a high catheter survival rate with this one-port laparoscopic technique.

Laparoscopic peritoneal dialysis catheter implantation using a Tenckhoff trocar under local anesthesia with nitrous oxide gas insufflation

BACKGROUND

Laparoscopic implantation of peritoneal dialysis catheters has many advantages over conventional methods. The ability to perform laparoscopy with the patient under local anesthesia allows renal failure patients, who ordinarily might not be considered candidates for general anesthesia, an opportunity to undergo this procedure.

METHODS

Using local anesthesia and nitrous oxide pneumoperitoneum, 175 catheters were implanted in long musculofascial tunnels under laparoscopic guidance to minimize the risk of catheter migration and flow dysfunction.

RESULTS

Nitrous oxide pneumoperitoneum was well tolerated, allowing all procedures to be safely completed with the patients under local anesthesia. The overall 1- and 2-year catheter survival rates were 92.7% and 91.3%, respectively. The incidence of catheter tip migration and omental entrapment was 1.7% and 2.9%, respectively. Temporary pericatheter leak occurred in 7.4% of cases.

CONCLUSIONS

Nitrous oxide insufflation enables safe performance of laparoscopic surgery with the patient under local anesthesia. Patients benefit from a minimally invasive technique with the assurance of obtaining successful long-term catheter function.

Laparoscopic-assisted placement of peritoneal dialysis catheters: implantation technique and results

BACKGROUND

Peritoneal dialysis is a generally accepted method for the treatment of patients with end-stage renal failure. The laparoscopic placement of peritoneal dialysis catheters is a well-established technique and offers some advantages, such as a safer placement of the catheter, less post-operative complications, and a longer functional survival, compared to the conventional open technique. The aim of this study was to describe our implantation technique and to determine the results of our approach.

PATIENTS AND METHODS

Between January 2000 and February 2006, 47 patients with end-stage chronic renal failure underwent a laparoscopic peritoneal dialysis catheter insertion procedure. Perioperative and follow-up data were collected prospectively.

RESULTS

The mean operating time was 35 minutes (range, 16-100). There was no perioperative morbidity. Nine (19.1%) patients experienced 10 mechanical complications: fluid leakage in 6 (12.8%) patients, acute hydrothorax in 1 (2.1%), catheter tip migration in 2 (4.3%), and catheter obstruction in 1 (2.1%) patient. Episodes of peritonitis were observed in 5 (10.6%) patients. One (2.1%) patient developed a catheter infection. In 3 (6.4%) patients, a port site hernia occurred that required surgical repair, 5 (10.6%) patients underwent laparoscopic revisions owing to mechanical complications, 9 (19.1%) patients underwent renal transplantation, and 6 (12.8%) patients died during the later follow-up. After a mean follow-up time of 17 months (range, 2-76), 30 (63.8%) catheters are still in use for dialysis.

CONCLUSIONS

The functional outcome of the dialysis catheters was satisfactory in the majority of patients in this study. The described technique for catheter implantation is simple and safe, and in our opinion, the laparoscopic technique should be considered as the method of choice in patients with end-stage chronic renal failure.

Laparoscopic-Assisted Peritoneal Dialysis Catheter Implantation in Pediatric Patients

OBJECTIVES

To assess the feasibility and complications of laparoscopic-assisted placement of peritoneal dialysis catheters (PDCs) in pediatric patients.

METHODS

A total of 15 patients undergoing laparoscopic-assisted PDC insertion were studied. A single 10-mm epigastric port was used, unless concomitant diseases were present. A double-cuffed straight Tenckhoff catheter was implanted, with the deep cuff placed within a preperitoneal tunnel underneath the left rectus muscle. The catheter tip was positioned in the left iliac fossa by stylet wire manipulation under laparoscopic control, with the exit site oriented laterally or downward. Subtotal omentectomy was performed by way of the epigastric port site. The findings were compared with those of a group of patients undergoing open PDC insertion.

RESULTS

The median operating time was not different in the two groups. In the laparoscopic group, a single port was used in 9 cases, and adhesiolysis was performed in 2. The median time to PD initiation was not different in the two groups, nor were any significant differences found in the infectious complications, leak or obstruction rates, or need for secondary surgical revisions between the two groups. Surgical revision was necessary because of peritonitis in 1, persistent leak in 1, and dislodgement in 2 in the open group and because of blockages in 3 in the laparoscopic group. Laparoscopy allowed for the rescue of two such catheters.

CONCLUSIONS

The results of our study have shown that laparoscopy allows for careful assessment of the abdominal cavity, recognition and treatment of intraabdominal diseases, and precise placement of PDCs. However, it does not seem to reduce the early catheter-related complication rate. Mechanical obstruction remains a common cause of early catheter malfunction. However, laparoscopy can allow for the rescue of blocked catheters.

Selected best demonstrated practices in peritoneal dialysis access

Many burdensome interventions that adversely affect the utilization of peritoneal dialysis as renal replacement therapy and patient satisfaction with this treatment modality can be avoided by early peritoneal access placement with embedded catheters, implantation techniques that preempt common catheter complications, and the use of access devices that provide flexibility in exit site location. Catheter embedding consists of subcutaneously burying the external limb of the catheter tubing at the time of the insertion procedure. Interval exteriorization of the catheter is performed when dialysis is needed. Earlier commitment by patients to peritoneal dialysis can be achieved by elimination of catheter maintenance until dialysis is necessary. Catheter embedding is a practical strategy to avoid temporary hemodialysis with vascular catheters and reduces stress on operating room access by allowing more efficient scheduling as non-urgent procedures. Laparoscopic catheter placement enables proactive techniques not available to other conventional insertion methods. These techniques include rectus sheath tunneling to prevent catheter tip migration, selective prophylactic omentopexy to prevent omental entrapment, selective resection of epiploic appendages to prevent catheter obstruction, adhesiolysis to eliminate compartmentalization, and diagnosis and simultaneous repair of previously undiagnosed abdominal wall hernias. Both standard and extended 2-piece catheter systems are necessary to customize the peritoneal access to a variety of body configurations. Catheters should be able to produce lower abdominal, mid-abdominal, upper abdominal, and upper chest exit site locations that facilitate management by the patient without sacrificing deep pelvic position of the catheter tip or resulting in excessive tubing stress during passage through the abdominal wall.

The comparison in terms of early complications of a new technique and percutaneous method for the placement of CAPD catheters

BACKGROUND

Starting continuous ambulatory peritoneal dialysis (CAPD) immediately after insertion of a peritoneal dialysis catheter is essential in end-stage renal disease (ESRD). In relation to the insertion methods, various mechanical and infectious complications may arise. In this study, we aimed to compare early complications of the laparoscopic tunneling method of CAPD placement that we developed recently in order to minimize the complications, with those of the conventional percutaneous method.

SUBJECTS AND METHOD

Included in this study were 12 consecutive patients with ESRD to whom we introduced catheters for CAPD by way of laparoscopic tunneling between April 2003 and July 2003 and followed up for at least 6 months, and 30 patients to whom the catheters were placed percutaneously in the same time period with the same follow-up time. The complications seen during the first 6 months after catheter placement with these two different methods were compared.

RESULTS

In all of the subjects, dialysis was started soon after catheter placement. No peroperative morbidity was seen in any of the patients. While with laparoscopic tunneling method no mechanical problem was seen, the percutaneous method resulted in early leakage in 10%, pericatheter bleeding in 3.3%, and hernia in 3.3% of the patients. As infectious complications, peritonitis occurred as one episode/36 patient-months in laparoscopic tunneling and one episode/22.5 patient-months in percutaneous method; catheter insertion site infection was seen in none in the laparoscopic method, while one episode/90patient-months was seen with the percutaneous method. Tunnel infection did not arise in any of the subjects.

CONCLUSION

The authors of this study think that the peritoneal tunneling method for introducing CAPD, which has been recently developed and began to be routinely used by them, is rather safe in terms of early complications.

Single-port laparoscopic insertion of peritoneal dialysis catheters in children

PURPOSE

To assess the effectiveness and complication rate of laparoscopically placed peritoneal dialysis catheters using the single-port technique.

MATERIAL AND METHODS

This is a prospective study conducted from 2002 to 2004. Children with established renal failure requiring insertion of a peritoneal dialysis catheter were included. The insertion was performed by a single surgeon using a single-port laparoscopic technique. Partial omentectomy was performed and the catheter accurately placed in the pelvis under vision. The catheter could then be used immediately postoperatively.

RESULTS

Twenty-two children (13F:9M) with a mean age of 9 years (range 1.0-17.5) had a peritoneal dialysis catheter inserted laparoscopically between 2002 and 2004. Mean time for insertion was 26 min (range 23-29 min). Ten (45%) catheters were used within 4 h. Early complications included a minor leak that resolved within 24 h, one exit-site infection that resolved with oral flucloxacillin, one blockage due to a fibrin clot that resolved with urokinase, and one blockage after 2 weeks due to adhesions (not omentum) that was revised.

CONCLUSIONS

Laparoscopic insertion of a peritoneal dialysis catheter allows accurate placement of the catheter under direct vision, immediate use postoperatively with minimum morbidity, and good cosmesis. The single-port laparoscopic technique is a safe, effective and quick technique for use in children.

Videolaparoscopy as rescue therapy and placement of peritoneal dialysis catheters: a thirty-two case single centre experience

BACKGROUND

Malfunction of the peritoneal catheter is a frequent complication in peritoneal dialysis (PD). Videolaparoscopy is a minimal invasive technique that allows rescue therapy of malfunctioning catheters and consecutive immediate resumption of PD. Furthermore, Tenckhoff catheters can be safely positioned in patients with previous abdominal surgery. We analysed the clinical diagnosis, videolaparoscopic treatment and the outcome of PD patients on whom videolaparoscopic interventions had been performed at our centre.

METHODS

Thirty-two cases of videolaparoscopic interventions were performed for salvage of malfunctioning peritoneal catheters, implantation and abdominal surgical interventions in 25 PD patients. The videolaparoscope was inserted through a mini-laparotomy site of 15 mm diameter which was closed with purse-string sutures at the end of the intervention.

RESULTS

Videolaparoscopy was used in 21 cases of catheter malfunction mostly due to omental wrapping (12 cases) and dislocation (five cases). In eight patients with previous surgical abdominal interventions, laparoscopic placement of the PD catheter was performed. In two cases the gall bladder was removed. One case of intestinal occlusion was evaluated laparoscopically in an attempt to minimize invasive surgery. Leakage of the peritoneal fluid presented the only complication caused by insufficient closure of one mini-laparotomy site. Minimal follow-up time of rescued catheters was 5 months. Videolaparoscopy prolonged PD catheter function by a median of 163 days (range 5-1469 days).

CONCLUSIONS

Videolaparoscopy prolongs peritoneal catheter survival by treating directly the causes of malfunction. In patients with preceding abdominal interventions, the PD catheter can be placed safely even in cases necessitating surgical preparation like adhesiolysis.