Single-port laparoscopic placement of peritoneal dialysis catheter: A safe and effective technique

Single-port laparoscopic placement of peritoneal dialysis catheter: A safe and effective technique

Ahmed Kamal Gabra, MD; Mohamed M. Tawfika, MD; HosamSaleha, MD; AmgadAwadh, MD

a) Department of Vascular Surgery, Ain Shams University,  Cairo, Egypt. b) Department of Internal Medicine, Al-Azhar  University,  Cairo, Egypt.

Background/Aim: Laparoscopic techniques  for placement  of peritoneal  dialysis catheters are becomingincreasingly popular. Currently, there are several techniques for such laparoscopic approach. The aim ofthis study is to describe our technique and outcomes of using single port laparoscopic placement of peritoneal dialysis catheters.

Patients  and methods:  Laparoscopic implantation of peritoneal dialysis catheters  was performed in 64 consecutive patients.The technique was performed via a single port inserted in the supra-umbilical region. The tip of the catheter was placed in the true pelvis while its deep cuff was placed into the rectus sheath. A subcutaneous tunnel was created to the selected exit site of the catheter. Mean duration of surgery, hospital stay, morbidity, mortality, and catheter survival were assessed.

Results:  The mean operating time was 22 ± 7 minutes.  The mean post-operative hospital stay  was 2 ± 1 days.There  were no  conversions  from laparoscopy  to conventional  catheter insertion  methods.  No exit-site or tunnel infections,  hemorrhagic  complications,  abdominal wall hernias, or catheter cuff extrusions were detected. No mortality occurred in this series of patients. Catheter survival was 100% and 96.8% at 6 months and one year respectively

Conclusion: The laparoscopic method described in this study is compliant with consensus guidelines   for the best-demonstrated  practices in peritoneal  dialysis access placement.  The results reported in this paper support the opinion that laparoscopic  placement  of peritoneal dialysis catheter should become the standard care for clinical practice. The use of single-port technique is safe, effective and reproducible method.

Key words: Laparoscopy; peritoneal dialysis catheters.

Introduction:

Continuous ambulatory peritoneal dialysis (CAPD) has become a widespread mode of dialysis for patients with chronic renal failure. The surgeon's role in caring for these patients is to provide access to the peritoneal  cavity via a peritoneal dialysis (PD) catheter and to diagnose and treat catheter complications.

In     1968,     Tenckhoff    and     Schechterl

described a percutaneous  nonvisualized method   of  catheter   placement.   However, this was associated with a risk of bowel or vessel injury, as well as a high incidence  of malpositioned catheters resulting in failure rates ofupto 65%at2 years. Subsequently, the

gold standard became open placement under direct surgical  vision  via mini laparotomy.2

However, placement of the catheter tip into the  pelvis  is  essentially  a  blind  technique. This technique  has resulted  in up to  a 22% incidence  of drainage  dysfunction.3  Two major factors that may be involved in catheter dysfunction are inadequate placement of the catheter tip into the pelvis, which allows the catheter to migrate and become entrapped within the omentum, and the presence of intraabdominal   adhesions,   which   interfere with correct catheter placement. 4

In an attempt to improve catheter function

and decrease  complications,  in 1981 Ash et

Am-Shams] Surg 2014; 7(16):1-10

aP  reported on a peritoneoscopic  technique. He used a special needlescope (YTEC, Medigroup, Inc., North Aurora, IL) with surrounding cannula and catheter guide. This method reduced the early failure rate to 3% in his hands. However, it does not allow for adhesiolysis, and furthermore, it requires specialized  equipment.

Over   the   last   decade,   several   reports have  described  laparoscopic6-16 or minilaparoscopicl 7-19     placement    of    PD catheters. This approach addresses many concerns  by allowing  direct visualization  of the peritoneal cavity and exact placement of the catheter tip deep into the pouch ofDouglas. It also   allows   laparoscopic    adhesiolysis and  omentopexy  or  omentectomy.  One  of the described laparoscopic techniques of placement  of peritoneal  dialysis  catheter  is the  single-  port technique.Z0-21  The aim  of this study is to describe our technique and outcomes of using a single-port laparoscopic placement of peritoneal dialysis catheters.

Patients and methods:

Patients: Between January 2010 and December    2012,   64   patients   with   end­ stage renal disease underwent laparoscopic placement of Tenckhoff peritoneal catheters were included in the present study, 40 males and  24 females  with  mean age  36 ±8.1,  at three tertiary referral hospitals in the eastern province of Saudi Arabia, each ofthem is 250 beds size, approximately 24 patients per year have been enrolled. All these  patients either exhausted all hemodialysis vascular access or some of them asked for ambulatory peritoneal dialysis.   Pre-operative   investigations   were done (blood tests) and all patients had been assessed   by  anesthesiologist.   All  patients were  eligible  to  receive  general  anesthesia and  pneumoperitoneum.  Prophylactic antibiotic, cefazoline - or vancomycin in case of cephalosporin  allergy - was administered at the time of induction of anesthesia. All patients signed terms of informed consent.

Method: The exit site in the right or left

1ower abdomen accordingto patient preference was marked. The patient was subsequently placed on the operating room table in a supine

position with both arms tucked, and general anesthesia is administered. Perioperative prophylactic intravenous antibiotics were administered, the abdomen was prepped in a sterile fashion. A supraumblical  1.5 em was done and an open insertion technique was utilized  Figure (1).  Pneumoperitoneum  was created  with  pressure  limits for  abdominal gas insufflation set between 10 and 12 mmHg.

We used a 10-mm trocar  and zero-degree

laparoscope    and   preliminary   laparoscopy was performed to look for adhesions or other anatomical  abnormalities  that  could  hinder the performance of the peritoneal dialysis catheter Figure (2).

Once the  pelvis  was inspected,  attention was turned  to the  anterior  abdominal  wall. The entrance and exit sites are marked. It was helpful to lay the catheter on the abdomen to estimate the entrance site based on the length of the patient's  torso.  The tip should  easily reach the cull-desac, thus the top of the curl should  be at the pubic symphysis.  We used a   point  midway   between  anterior   suprior iliac spine and umblicus on the lateral border or rectus  muscle as entrance  site. We use a percutaneous  insertion  kit. A 1-cm  incision was made at the insertion site, and the needle was  inserted  through  the  abdominal   wall under direct laparoscopic vision. The needle was oriented obliquely to position the catheter in a caudad direction. The wire was advanced through the needle into the pelvis. The needle was removed, and the sheath and dilator were inserted over the wire by using the Seldinger technique.  A 0.5 em incision  in the midline just above the symphysis pubis was done and a loop of proline 3.0 was inserted through a wide bore needle under vision and the sheath and dilator were manipulated till it passed through the loop Figure (3).

The dilator was removed and the peritoneal

dialysis catheter was fed through the sheath toward  the  pelvis.  Once  the  catheter  was inside  the  abdomen,  the  sheath  was teared apart leaving the catheter in place. The loop was advanced till it gently fixed the catheter to the anterior abdominal wall Figure (4). The external end was tunneled and pulled through an exit site lateral to the insertion site. It was

Figure (I): Hasson port (it) ana open tecnnique for pneumoperitoneum (B)

Figure (2): Operative photograph shows 10- mm Single-port in place.

Figure  (4):  Operative  photograph  shows the peritoneal dialysis catheter in  the true pelvis and find by gently-pulled percutaneous prolineloop (arrowed).

important that the distal cuff was greater than

2 em from the skin incision. The proximal or internal cuff was then buried under the anterior

Figure       {3):      Operative      photograph shows passage of the dilator through the percutaneously inserted proline loop.

Figure (5): Operative photograph shows using a hemostat  to bury  the internal  cuff under the anterior rectus sheath.

rectus sheath by using a hemostat Figure (5). The entrance site was inspected internally using the laparoscope  to verify that the cuff

was   not   advanced   through   the   posterior sheath into the abdomen. Once the procedure was completed, the pneumoperitoneum was evacuated  and  the trocar  was removed  and the fascia was closed with a 2.0 Vicryl suture. The PD catheter was then tested by infusing

250cc of normal saline into the abdomen and

then  draining  making sure that the  catheter was functioning  properly, it was locked with heparin  100 units/cc.  The catheter was used no sooner than 2 weeks later.

Results:

The  study  group  of  patients  compnsmg

64 consecutive laparoscopically implanted Tenckhoff   catheters   included   24   women and 40 men, with  a mean age of 36 (range

19  -55) years.   2  patients  had  undergone prevwus      mmor   intraperitoneal surgery (appendicectomy).  The   average   operative time  was 22 ±7 minutes  and mean duration of  hospital  stay  was 2 ±1 day. All patients started  oral intake 2 hours  post operatively. No         post-operative     antibiotic    prophylaxis given.   Postoperative   pain   was   controlled with   paracetamol   tablets.   There  were   no conversions  from  laparoscopy  to  any  other conventional  method  of catheter  placement. There  were  no  hemorrhagic  complications, no abdominal wall hernias, and no extrusion of the superficial catheter cuff were detected. Duration  of  postoperative  follow-up  was  1 year. No mortality occurred in this series of patients. Catheter survival was 64/64 (100%) at 6 months  and 62/64  (96.8%)  at one year. Early  complications   as  leakage  was   1164 (1.6%), exit-site  infection  was 2/64 (3.1%), and catheter migration was 1/64 (1.6%). Late complications   as  bacterial  peritonitis  were

2/64 (3.1%), port-site hernia was 0/64 (0 %),

and exit-site  infection  was 3/64  (4.7%).  So, the total complications were 9/64 (14.1%).

Discussion:

The  laparoscopic  approach  to  placement of  Tenckhoff  PD  catheters,  introduced   in the  1980s,22 has advantages  over open  and percutaneous   surgical  techniques,   such  as a lower incidences of flow obstruction and visceral   injury.23  The  method   by   which

PD catheters are placed has a significant influence on catheter function, incidence of catheter-related complications, and technique survival. The single-port approach was developed later for management of obstructed catheters and placement of catheters into complicated  abdomens. A competent  and experienced  operator  must  perform  the catheter implantation procedure. Peritoneal catheter placement must be regarded as an important surgical intervention, demanding care  and attention  to detail  equal to that  of any other surgical procedure.Z0-21

Although the same single-port method has been used in previous studies, on both adults and children,16,18,25 and one of the ports in some two-port studies has been actually been used in the same manner as the pull-apart introducer_26,27 The distinctive  characteristic of our technique is that we used of only one

10 mm  port  & the  fixation  of the  catheter to the anterior abdominal wall. While obstruction of dialysate flow, port-site hernia, and leakage are three major causes of PD catheter failure,13,27,28,29 these complications were rare in our study and intermediate-term catheter survival was 96.8%.

Due to its characteristics (simple, quick, efficient,  andminimally  invasive  to  the patient), together with our results support the opinion that laparoscopicperitoneal catheter placement should become thepreferred approach.  In  addition,  the  laparoscopic method offers an excellent view of the abdomen  and optimal placement  of the catheter within the cavity.

We did not experience intraoperative complications  such as intra-abdominal organ injury, as has been reported for conventional techniques.25-26 In fact, in our series we had no intra-abdominal catastrophes and the incidence of catheter displacement was 0% lower than thatreported using open surgery technique24 or any laparoscopic technique. Furthermore, we did not encounter problems commonly reported for open catheter placement,    such   as   hematoma,    seroma, or infections. No perioperative mortality occurred in this case series.

Conclusion:

The laparoscopic method  described in this study is compliant with consensus  guidelines for  the  best-demonstrated  practices   in peritoneal dialysis  access placement. The results   reported  in  this   paper   support   the opinion  that   laparoscopic placement of peritoneal  dialysis   catheter   should   become the standard care for clinical practice.  The use of single-port technique is safe, effective  and reproducible method.

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