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

Laparoscopic-Assisted Abdominal Wall Pexy of Peritoneal Dialysis Catheter

BACKGROUND

Peritoneal dialysis (PD) for rural patients with end-stage renal disease (ESRD) is convenient, efficient, and durable. However, patients with a history of previous abdominal surgeries or peritonitis are at an increased risk of PD malfunction. This case highlights the impact of securing the catheter to the abdominal wall laparoscopically to keep the PD catheter in an adhesion-free area to maintain patency and function in a patient with extensive intraperitoneal adhesions.

SUBJECT

A 76-year-old white male was on PD which later was complicated with peritonitis and sepsis and subsequent catheter removal. A year later, the patient desired replacement of the PD catheter. Intraoperatively, diagnostic laparoscopy revealed significant intraperitoneal adhesions mainly located at the left side of the abdomen with the right side of the abdomen spared. The Tenckhoff PD catheter, which was straightened by a steel stylet, was inserted via a 5-mm trocar. The stylet was removed. The pig tail of the PD catheter was navigated away from the adhesion and directed to the right side of the abdomen for internal fixation. The catheter at 9 cm from the PD catheter cuff was attached to the right paramedian peritoneum.

RESULTS

PD started 1 week after placement. The patient had excellent inflow and outflow for 14 months to date without complication or need for revision.

CONCLUSION

The laparoscopic pexy of the PD catheter to the abdominal wall to keep the catheter in an adhesion-free compartment is beneficial in selected patients. A future study with a larger number of patients is needed to further validate this strategy.

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.