A Laparoscopic Approach under Local Anesthesia for Peritoneal Dialysis Access

Objective

Presented herein is a technical description of a time-proven laparoscopic approach to establishing successful long-term peritoneal dialysis access.

Design

Using a two-port technique, the peritoneal catheter is inserted through a paramedian port site while continuously monitoring the implant procedure with a laparoscope from a second port location. A long rectus sheath tunnel created with a nontrocar port device keeps the dialysis catheter oriented toward the pelvis. Helium abdominal insufflation enables full surgical laparoscopy under local anesthesia. Validation of the effectiveness of the technique is made by comparison to previous implantation experience using an open dissection method.

Patients

Laparoscopic implantation of peritoneal catheters was performed in 150 patients, and placement by open dissection was accomplished in 63 patients.

Main Outcome Measure

The incidence of complications and revision-free catheter survival between implantation methods were compared.

Results

Catheters implanted laparoscopically had a significantly lower incidence of flow dysfunction ( p < 0.05) and better survival ( p < 0.001) than those placed by open dissection.

Conclusions

Compared to implantation by open dissection, the laparoscopic approach provides the patient reduced perioperative discomfort. The procedure can be performed safely with the patient under local anesthesia on an ambulatory basis. Laparoscopic implantation significantly reduces the incidence of catheter flow dysfunction and permits simultaneous identification and correction of other problems that could complicate dialysis therapy.

Malfunctioning Peritoneal Dialysis Catheter and Accompanying Surgical Pathology Repaired by Laparoscopic Surgery

♦ Objectives

To review the laparoscopic salvaging of malfunctioning peritoneal dialysis (PD) catheters, and to present our experience with laparoscopic repair of dysfunctional Tenckhoff catheters and the treatment of accompanying surgical pathologies.

♦ Design

Malfunctioning peritoneal catheters were repaired using laparoscopic rescue techniques. Accompanying surgical problems were treated in the same operation. The effectiveness of these approaches was validated by comparison with other remedial techniques described previously.

♦ Patients

Malfunctioning PD catheters were salvaged by laparoscopic surgery in 8 patients, and accompanying surgical problems were treated in the same operation in 3 of the 8 patients.

♦ Main Outcome Measures

Outcome was measured by the successful return to adequate PD and effective treatment of surgical problems.

♦ Results

Eight patient studies show laparoscopic correction of malfunctioning catheters and the treatment of accompanying surgical pathologies with the return to successful PD.

♦ Conclusion

The salvaging of malfunctioning PD catheters by laparoscopic surgery is an ideal method. This procedure permits simultaneous identification and correction of other surgical problems that could otherwise complicate dialysis therapy.

Minilaparoscopic Extraperitoneal Tunneling with Omentopexy: A New Technique for CAPD Catheter Placement

Background

Continuous ambulatory peritoneal dialysis (CAPD) is an effective form of treatment for patients with end-stage renal disease. Open insertion of peritoneal dialysis (PD) catheters is the standard surgical technique, but it is associated with a relatively high incidence of catheter-related problems. To overcome these problems, different laparoscopic techniques have been presented, being preferable to the open and percutaneous methods.

Objective

To introduce and evaluate the efficiency of laparoscopic omental fixation and extraperitoneal placement of the cuff–coil part (the straight portion) of the catheter to prevent catheter tip migration, pericatheter leakage, severe abdominal pain, and the obstruction caused by omental wrapping.

Setting

The study was carried out in the General Surgery Department, Akdeniz University Medical School, in Turkey.

Patients and Methods

Between November 2001 and March 2005, the technique was applied in 44 consecutive patients (mean age 51.6 years, range 18 – 67 years) with end-stage renal disease. During this laparoscopic technique, the omentum was first fixed onto the parietal peritoneum, and then the catheter was introduced through the subumbilical trocar site into the posterior rectus compartment and advanced toward the symphysis pubis. The catheter was then inserted into the abdominal cavity, passing the peritoneal opening, which was prepared before catheter insertion. The straight portion of the catheter was located into the extraperitoneal area of the anterior abdominal wall. The curled end, which contains the side-holes of the catheter, was placed into the true pelvis. Catheter position and patency were verified under direct vision using a 2 mm telescope.

Results

All procedures were completed laparoscopically. Operating time ranged between 40 and 100 minutes (median 52 minutes). There was no intraoperative complication or surgical mortality. Peritoneal dialysis was initiated within 15 – 24 hours after catheter implantation. After a median follow-up period of 17.4 months (range 1 – 38 months), early exit-site infection occurred in 1 of 44 patients. All catheters functioned well postoperatively. There was no pain during CAPD.

Conclusion

This new laparoscopic technique using an extraperitoneal approach with omentopexy for PD catheter placement could prove extremely useful for preventing catheter malfunction caused by catheter tip migration, pericatheter leakage, omental wrapping, and periodic catheter movement that causes abdominal pain in CAPD.

Laparoscopic Omentopexy, Rectus Sheath Tunneling and Implantation of the Peritoneal Dialysis Catheter Using a Peritoneal Dialysis Port

BACKGROUND

Prophylactic laparoscopic omentopexy is a safe technique to prevent peritoneal dialysis (PD) catheter obstruction. For the first time, we would like to describe a surgical technique in which the omentopexy is done using a single PD port which is used for the omentopexy, PD catheter insertion, and the rectus sheath tunneling of the catheter.

METHODS

The surgical method of the omentopexy using the PD port (US Patent 20170119430) will be thoroughly described. To evaluate the surgical method, we performed the procedure in 15 consecutive patients with chronic renal failure and followed up the patients.

RESULTS

No intraoperative complication was observed. During the follow-up period, catheter flow failure due to omental wrapping was found in none of the patients. No other complication including exit-site infection, peritonitis, or catheter leakage was detected.

CONCLUSION

Using this technique the catheter can not only be implanted through a proper and long rectus sheath, but the omentopexy can also be done without an additional port. This can reduce port-site complications and dialysis fluid leakage.

Rescue and Salvage Procedures for Mechanical and Infectious Complications of Peritoneal Dialysis

Mechanical and infectious complications are the two most common reasons for removal of peritoneal dialysis catheters and permanent transfer of patients to in-center hemodialysis. Early and appropriate intervention can save many catheters, often without interrupting peritoneal dialysis. If peritoneal dialysis must be interrupted, other strategies may be employed to minimize the time on temporary hemodialysis and preserve peritoneal dialysis as renal replacement therapy. Procedures for managing dialysate leaks, abdominal wall hernias, infusion pain, and catheter flow dysfunction are described. Salvage techniques for catheter-related infections and peritonitis are presented. Clinical conditions are discussed where urgent removal of the dialysis catheter is indicated to protect the future integrity of the peritoneal membrane.

Complications of Peritoneal Dialysis Catheters: Early and Late

The complications of peritoneal dialysis catheters are often due to errors made during the initial catheter insertion procedure. Other complications relate to the improper selection of the catheter type or size. Thus, many complications are preventable. This review summarizes the complications resulting from the insertion or presence of a PD catheter and classifies them as either early or late events. A short comment on early diagnosis and appropriate management is also provided.

A Novel Technique for Laparoscopic Salvage of CAPD Catheter Malfunction and Migration: The Santosh-PGI Hanging Loop Technique

CAPD catheter malfunction is a common problem. Obstruction due to wrapping by appendices epiploicae of sigmoid colon has been rarely reported in literature. We report a case of CAPD catheter malfunction caused by catheter tip migration and obstruction by appendices epiploicae that was successfully managed by laparoscopic hanging loop technique. This case report highlights the ease with which epiplopexy can be performed and catheter tip migration can be prevented by this innovative laparoscopic procedure.

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.

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.

Symptomatic treatment of ascites with a peritoneo-vesical automated fluid shunt system in a dog

A six-year-old Rottweiler with chronic ascites and moderate panhypoproteinaemia that had been treated with large volume paracentesis over several months duration was diagnosed with a large bi-atrial mass and hepatic fibrosis. For palliative treatment, a peritoneo-vesical automated fluid shunt system with an integrated chargeable battery and an integrated computer to control pump function and to transmit data transcutaneously was implanted by coeliotomy. The pump was left in place for 10 weeks, eliminating the need for further paracentesis during this time. At the end of this period, no ascites was discernible and serum protein concentrations had returned to their respective reference intervals. As a complication, decubitus with skin perforation had developed above the pump. Besides palliative treatment of chronic refractory ascites, this pump may have application in other conditions characterised by chronic cavity effusion or in peritoneal dialysis.

Omental Folding: A Novel Laparoscopic Technique for Salvaging Peritoneal Dialysis Catheters

Background

Omental wrap is a common cause of catheter obstruction. Current laparoscopic techniques for correcting obstruction include omentopexy and omentectomy. This study evaluates the efficacy of a new laparoscopic technique for revision of obstructed peritoneal dialysis catheters.

Methods

Between November 2005 and November 2006, the technique was applied in 18 patients (6 female, 12 male; median age 50 years, range 16 – 73 years) on continuous ambulatory peritoneal dialysis with catheter malfunction secondary to omental wrap. Pneumoperitoneum was induced under general anesthesia. Three ports were inserted. The catheter was released from the omentum and repositioned in the pelvis. The omentum was then folded onto itself in a cephalad direction using silk sutures. This shortened the omentum. The risk of catheter migration was minimized with a polypropylene sling passed through the abdominal wall and around the catheter, then knotted subcutaneously. The sling allowed catheter removal without a new laparoscopy. The outcomes were prospectively evaluated.

Results

Median operating time was 90 minutes (range 35 – 160 minutes). Adhesiolysis was performed in 4 patients: 1 patient had port-site leakage of dialysate, which settled with abdominal rest; 1 patient had bleeding during adhesiolysis and laparoscopic hemostasis was successful; 1 patient had recurrent catheter obstruction 2 weeks post-operatively and was converted to hemodialysis; and 1 patient had recurrent malfunction secondary to small bowel wrap after 5.5 months; re-salvage was successful. The success rate of the first salvage procedure was 89%(16/18). The catheters were still functioning after a mean follow-up of 16.5 ± 6.3 months (range 0.5 – 24 months). The 1-year catheter survival rate was 83.3%.

Conclusions

Omental folding is a safe and effective technique for salvaging peritoneal dialysis 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.

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.

Selective performance of prophylactic omentopexy during laparoscopic implantation of peritoneal dialysis catheters

Omental entrapment of the peritoneal dialysis catheter remains a common cause of flow dysfunction. Prophylactic omentectomy during catheter implantation is still followed with an incidence of flow obstruction as high as 10%. We describe indications and a technique for selective performance of omentopexy during laparoscopic catheter implantation that resulted in only a 0.7% obstruction rate in 153 consecutive patients as compared with a 12.8% rate in a preceding group of 78 consecutive patients. Laparoscopic omentopexy was performed during 9.2% of implant procedures and only when the omentum was found to extend to the retrovesical space. The procedure is simple, quick, and inexpensive to perform. Employing selective criteria for omentopexy eliminates the performance of unnecessary procedures. Actuarial analysis demonstrates that an operative strategy of selectively performing omentopexy for redundant omentum significantly improves catheter survival free of flow dysfunction (P < 0.0001).

Laparoscopic omentectomy for salvage of peritoneal dialysis catheters

BACKGROUND AND PURPOSE

Maintaining long-term peritoneal catheter function for peritoneal dialysis is commonly threatened by problems with catheter obstruction. Multiple methods have been used to salvage nonfunctioning catheters, including omentopexy, catheter repositioning, and omentectomy. We report on our experience with a laparoscopic method of omentectomy and catheter fixation for salvage of nonfunctioning peritoneal dialysis catheters.

PATIENTS AND METHODS

Thirteen patients with nonfunctioning peritoneal dialysis catheters underwent 16 laparoscopic procedures with the intent to restore function. Clinically, all patients presented with outflow obstruction. At initial presentation, all patients underwent diagnostic laparoscopy and a definitive procedure. In 12 patients, catheters were enveloped by omentum, and we performed laparoscopic omentectomy and catheter fixation to the anterior pelvic wall. In one patient, we identified a broken catheter and performed a laparoscopic omentectomy at the time of catheter replacement. One 10-mm and two 5-mm trocars were utilized. Omentectomy was performed using either endo-GIA stapled resection (2 patients) or the Harmonic Scalpel (11 patients). All trocar incisions (including the 5-mm site) were closed with a suture-passing (Carter-Thomason) device to provide water-tight closure in anticipation of immediate return to peritoneal dialysis. Patients were followed postoperatively for an average of 17 months (range 4-35 months).

RESULTS

All patients' catheter function was restored intraoperatively with laparoscopic omentectomy and catheter fixation. Eight catheters remained functioning following omentectomy without further intervention. Five patients (38%) experienced repeat catheter malfunction and underwent laparoscopic exploration. Of these, three catheters (60%) were restored to function with laparoscopic manipulation alone. Three catheters were found encased in extensive adhesions. Laparoscopic adhesiolysis was successful in one patient and unsuccessful in one patient, who converted to hemodialysis. One patient failed laparoscopic salvage and required open laparotomy and fibrin clot removal to restore catheter function. One catheter was found to be obstructed within a pericolic hematoma. One catheter was found within residual omentum at the hepatic flexure. Both of these catheters were freed laparoscopically and continued to function at 12 and 16 months' follow-up. Complications included one episode of peritonitis, one case of postoperative ileus, and one trocar site hernia necessitating repair. The nephrologists were instructed that they could begin peritoneal dialysis on postoperative day 1. Seven patients resumed peritoneal dialysis without leak from trocar sites. The remaining patients received temporary hemodialysis through a central venous catheter and returned to peritoneal dialysis at the discretion of their nephrologists.

CONCLUSIONS

Laparoscopic omentectomy with catheter fixation is a minimally invasive means of salvaging peritoneal dialysis catheters with outflow obstruction. Complications are few, and closure of laparoscopic incisions in water-tight fashion allows rapid return to peritoneal dialysis.

Laparoscopic management of malfunctioning peritoneal dialysis catheters

BACKGROUND

Continuous ambulatory peritoneal dialysis (CAPD) is an established alternative method to hemodialysis for treating end-stage renal disease patients. However, this method is associated with a significant number of complications, such as catheter malposition, omental wrapping, and infection. The purpose of this study was to determine the efficacy of laparoscopy in the treatment of malfunctioning CAPD catheters.

METHODS

Between November 1994 and June 1999, a total of 16 patients with CAPD underwent laparoscopy for the evaluation and management of CAPD catheter dysfunction. Two trocars (10-mm and 5-mm) were used. Recorded data included patient demographics, catheter implantation method, date of malfunction, cause of dysfunction, procedure performed, complications, and catheter outcome.

RESULTS

The primary etiology of dysfunction was omentum and/or small bowel wrapping with adhesions in eight cases, malpositioning in five cases, and infection in the remaining three cases. Adhesiolysis was performed in the eight cases with adhesions. In the five cases with malpositioning but no adhesions, the catheters were repositioned in the pelvic cavity. Two catheters had to be withdrawn because of infection. In one case with tunnel infection, the catheters were exchanged simultaneously. There was only one perioperative complication, consisting of temporary dialysate leakage. There were no mechanical or infection problems. The overall success rate of catheter function (>30 days after laparoscopy) was 100%, except for two cases in which the catheters had to be removed.

CONCLUSION

Laparoscopy is a highly effective and successful method for the evaluation and management of peritoneal dialysis catheter dysfunction.

Laparoscopic Tenckhoff catheter insertion: a prospective study of a new technique

BACKGROUND

This study describes a new technique of laparoscopic Tenckhoff catheter insertion.

METHODS

During a 12-month period, 53 consecutive patients requiring insertion of peritoneal dialysis catheters were studied prospectively. A new technique of laparoscopic insertion was developed.

RESULTS

Forty-eight patients out of 49 (98%) had successful insertion. Four patients were excluded with active peritonitis. There was an early complication rate of 8% (4/49) and a late complication rate of 14% (7/49). There was 12% overall failure of catheter with a mean follow up of 6 (1-13) months.

CONCLUSION

This new laparoscopic technique maximizes the advantages of laparoscopic surgery and has complication rates which compare favourably with other open and laparoscopic techniques.

A practical approach to laparoscopic surgery for malfunctioning peritoneal dialysis catheters

Peritoneal dialysis is widely accepted for the chronic management of end-stage renal disease but is associated with as high as a 70% complication rate including a significant problem with peritoneal dialysis catheter flow obstruction. The application of laparoscopic surgical techniques has revolutionized the surgical approach to peritoneal dialysis catheter-related dysfunction. However, the specific laparoscopic surgical technique varied among the reported literature. This lack of a standard laparoscopic surgical approach to obstructed peritoneal dialysis catheters prompted us to review and compare our specific technique and experience in 17 patients with 10 recent reported series. We specifically examined for insufflation techniques, access port placements and closures, timing postoperatively for reinstituting peritoneal dialysis, wound complications, and overall long-term success rates for peritoneal dialysis catheter salvage.