Laparoscopic-assisted peritoneal dialysis catheter placement: a microinvasive technique

Laparoscopic peritoneal dialysis catheter insertion using nitrous oxide under procedural sedation

BACKGROUND

Laparoscopic peritoneal dialysis catheter (LPDC) implantation using nitrous oxide (N2O) pneumoperitoneum under procedural sedation is a technique that has many advantages over conventional insertion methods. The purpose of this study was to review the LPDC insertion results at our center.

METHODS

Data from 87 consecutive patients who underwent LPDC insertion was retrospectively reviewed. All procedures were attempted under procedural sedation. After patients received intravenous and local anesthesia, a N2O pneumoperitoneum was established. Peritoneal dialysis (PD) catheters were advanced using rectus sheath tunneling. The position of the catheter was confirmed by laparoscope, and adjunct procedures such as omentopexy and adhesiolysis were performed on select patients to prevent catheter flow problems.

RESULTS

Nitrous oxide was well tolerated by 94 % of the patients. Only five patients required conversion to general anesthesia. After a mean follow-up of 18.2 months, mechanical complications included pericatheter/incision leakage (12.62 %), flow obstruction (4.60 %), incision/exit site hernia (3.45 %), hemoperitoneum (2.30 %), pleuroperitoneal fistula (1.15 %), scrotal leak (1.15 %), and migration (1.15 %). Infectious complications included exit site infection (1 episode per 312.95 patient-months) and peritonitis (1 episode per 31.93 patient-months). Revision-free catheter survival was 97.6 % after 1 year.

CONCLUSION

Laparoscopic implantation of a PD catheter with N2O pneumoperitoneum and local anesthesia is safe and effective in patients with severe renal failure. N2O is an inert gas and better tolerated as an insufflation agent, enabling awake procedures. Our results show that catheter-related functional outcomes are comparable to those in the existing literature. This approach can be recommended as a good option for catheter implantation in patients needing dialysis.

A novel adaptation of laparoscopic Tenckhoff catheter insertion technique to enhance catheter stability and function in automated peritoneal dialysis

INTRODUCTION

Automated peritoneal dialysis (APD) normally takes place overnight. Maintaining a stable PD catheter position, independent of body position, omental wrapping or catheter displacement secondary to bowel movements is essential in maintaining effective catheter function.

METHODS

We developed a new procedure of catheter placement through combining and adapting several previously described operative techniques including laparoscopic placement of a curled double cuff Tenckhoff catheter with subcutaneous tunneling superior to the rectus sheet, an oblique course through the abdominal wall, deep entry into the pelvic peritoneum and directed placement of the curled tip within the pouch of Douglas. Retrospective analysis of catheter function was conducted, evaluating catheter position, function, complication rate and catheter survival against findings for current insertion techniques described within literature.

RESULTS

Between March 2009 and November 2011, 54 patients underwent PD catheter insertion. The observation period was an average of 343 ± 273 days. All patients received abdominal plain film showing optimal catheter position in 89 %. Reported catheter function was very good in 85.2 %, with no or few alarms per week during APD, moderate in 9.3 % with occasional minor dysfunctions (≤ 2 alarms per night), and poor in 5.6 %, with regular alarm disturbance. In one case, primary dysfunction led to catheter replacement. At completion, stable catheter function with occasional minor dysfunction was achieved in 52 of 54 cases. Catheter-related complications (leakage, hydrocele formation, infection and need for replacement) were observed in 14.8 %. At the end of the observation period, 55.6 % of catheters remained in use. Patient dropout occurred through death (18.5 %), renal transplantation (7.4 %), renal recovery (1.9 %), removal secondary to infection or dysfunction (9.3 %) and conversion to HD due to poor dialysis quality (7.4 %).

CONCLUSION

The above technique combines and optimises previously described laparoscopic catheter implantation techniques, allowing increased catheter stability resulting in an undisturbed catheter function suitable for APD.

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.

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.

Endoscopic Transluminal Insertion of a Peritoneal Dialysis Catheter

Background

At present there are various more or less invasive surgical and laparoscopic ways to place a catheter suitable for peritoneal dialysis (PD); however, once the catheter is in place, there is no possibility to inspect the peritoneal cavity without de novo laparotomy or laparoscopy.

Patients and Methods

To establish a minimally invasive technique and allowing for maximal options, we used a PD catheter with an extra large inside diameter of 3.5 mm. Because of the enlarged inner diameter of 3.5 mm (compared to 2.6 mm in standard Tenckhoff catheters), this device can be passed by a very thin video-endoscope with an external diameter of 2.8 mm. Using a stepwise approach, we applied this device in placing PD catheters in 2 patients. The procedure could be done without complications. Both patients were doing well 4 and 6 months later, respectively, without any PD-related complications. Intraperitoneal view by the endoscope was limited; an attempt to obtain a peritoneal biopsy failed.

Conclusions

If the drawbacks of this method can be overcome it will have a wide spectrum of applications ( i.e., inspection of the peritoneal cavity and obtaining peritoneal biopsies at any time during PD treatment). In this way it can be used scientifically and clinically when a problem of flow or ultrafiltration occurs or when encapsulating sclerosing peritonitis is suspected.

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.