Mini-laparoscopic placement of peritoneal dialysis catheter: New technique

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1 Blackwell Publishing AsiaMelbourne, AustraliaASHSurgical Practice The Authors; Journal compilation 2006 College of Surgeons of Hong Kong? Surgical TechniqueMini-laparoscopic placement of PDCMI Seleem and AM Al- Hashemy doi: /j x Mini-laparoscopic placement of peritoneal dialysis catheter: New technique Mohamed I. Seleem* and Ahmed M. Al-Hashemy Department of General Surgery and Renal Transplantation, Armed Forces Hospitals Southern Region, Khamis Mushayt, Kingdom of Saudi Arabia. Background: Leakage remains a problem with all methods of catheter placement. We describe our experience with a new mini-laparoscopic technique for catheter placement in patients with end-stage renal failure. Patients and methods: Between May 2002 and March 2004, 24 patients underwent mini-laparoscopic placement of peritoneal dialysis catheters. All patients had end-stage renal failure with difficult vascular access for haemodialysis. There were 11 men and 13 women with a mean age of 51.4 years (range: years). Operative time, interval to initiation of successful peritoneal dialysis, postoperative pain management, resumption of diet and postoperative complications were recorded. Results: The mean operative time was 32.3 min (range: min). All patients were given a normal diet on the day of surgery. Postoperative pain was controlled with paracetamol tablets three times daily for 2 3 days. The mean hospital stay was 3.2 days (range: 3 4 days). No patients developed leakage either from the ports or around the catheter. Two (8.3%) patients had blockage of the catheter and underwent diagnostic laparoscopy and laparoscopic correction. Two (8.3%) patients had migration of the catheter which required laparoscopic repositioning. The follow-up range was between 2 and 22 months. Conclusion: Mini-laparoscopic technique for placement of peritoneal dialysis catheter is unique because it uses only two ports. The catheter is made to exit via a 2 mm port site and does not require specially designed instruments. Key words: placement. continuous ambulatory peritoneal dialysis, mini-laparoscopic, peritoneal dialysis catheter, Introduction Laparoscopic techniques for the salvage or repositioning of malfunctioning peritoneal dialysis catheters (PDC) have been very successful. 1 4 Laparoscopic salvage and lysis of adhesions for malfunctioning PDC are well-established procedures in adult patients. 5 7 Leakage remains a problem with all methods of catheter placement. The leakage rate with the open method has been reported in 13 27% of patients, especially with early peritoneal dialysis 8 10 and in the laparoscopic method the rate is 16 22%. 11,12 For this reason, we have started a new mini-laparoscopic technique, using 10 mm and 2 mm ports with a special design to improve the leakage rate. Mini-laparoscopic access allows faster recovery and same day use of the PDC without any leakage problem. *Author to whom all correspondence should be addressed. saleem_1961@hotmail.com Received 23 April 2006; accepted 6 October Methods Patients Between May 2002 and March 2004, 24 patients (11 men and 13 women) with a mean age of 51.4 years (range: years) underwent mini-laparoscopic placement of PDC. All patients had end-stage renal failure with difficult vascular access for haemodialysis. All patients had initiation of peritoneal dialysis, using 1 L dialysis solution on the day of surgery followed by 1.5 L on the 2nd postoperative day and full successful peritoneal dialysis on the 3rd postoperative day. Operative time, interval to initiation of successful peritoneal dialysis, postoperative pain management, resumption of diet and postoperative complications were recorded. The procedures were carried out using aseptic precautions and under general anaesthesia with the patient in the supine position. A cm supra-umbilical

Mini-laparoscopic placement of PDC 37 incision was made and pneumoperitoneum was created using a Veress needle and insufflation of carbon dioxide at a pressure of 12 14 mmhg.

A 2 mm port was then placed through an incision midway between the umbilicus and symphysis pubis. The patient was then placed in a 30 Trendelenburg position.

2 Mini-laparoscopic placement of PDC 37 incision was made and pneumoperitoneum was created using a Veress needle and insufflation of carbon dioxide at a pressure of mmhg. A 10 mm port was then inserted, a laparoscopic camera introduced and abdominal cavity exploration was carried out. A 2 mm port was then placed through an incision midway between the umbilicus and symphysis pubis. The patient was then placed in a 30 Trendelenburg position. A 0-nylon thread was attached to the external end of the Tenckhoff PDC (Fig. 1). The entire Tenckhoff PDC was then passed into the abdominal cavity through the supra-umbilical 10 mm port after removal of the camera. The pigtail tip of the catheter was directed into the Pouch of Douglas in female patients and into the rectovesical pouch in male patients assisted by a 2 mm forceps placed through the 2 mm port (Fig. 2) The thread attached to the external end of the catheter was grasped and brought out through the 2 mm port site up to the inner Teflon cuff. This step was performed under laparoscopic guidance (Figs 3,4). A small incision was made at the level of the umbilicus in the mid-clavicular line. A Maryland forceps was passed deep subcutaneously towards the 2 mm port site, the thread was grasped and the PDC was brought through the tunnel (Fig. 5). The 10 mm port site was closed with a purse-string suture using non-absorbable 0-nylon. The catheter was secured in the correct position with a 2 0 nylon stitch. Fig nylon thread attached to the external end of a Tenckhoff catheter. Fig mm grasper is used to direct the pigtail end of a Tenckhoff catheter towards the rectovesical pouch.

38 MI Seleem and AM Al-Hashemy Fig. 3. 2 mm grasper is used to bring the thread via a 2 mm port site, outside the abdominal cavity. Fig. 4.

3 min (range: 15 40 min). All patients were started on a normal diet on the day of surgery. Postoperative pain was controlled with paracetamol tablets three times daily for 2 3 days.

3 38 MI Seleem and AM Al-Hashemy Fig mm grasper is used to bring the thread via a 2 mm port site, outside the abdominal cavity. Fig. 4. Catheter is brought outside the abdominal cavity up to the inner Teflon cuff. The PDC was tested on the table with normal saline (Fig. 6). Results The mean operative time was 32.3 min (range: min). All patients were started on a normal diet on the day of surgery. Postoperative pain was controlled with paracetamol tablets three times daily for 2 3 days. The mean hospital stay was 3.2 days (range: 3 4 days). No patients developed leakage either from the ports or around the catheter. Two (8.3%) patients had blockage of the catheter and they underwent diagnostic laparoscopy; one had laparoscopic omentectomy and the other had clearance of the catheter from a fibrin plug. Two (8.3%) patients had migration of the catheter which was adjusted laparoscopically. The mean follow up was 8.6 months (range: 2 22 months). Discussion The laparoscopic approach has been used to place peritoneal dialysis catheters since the early 1980s. 13 Peritoneal dialysis has now become an established and increasingly popular form of therapy in end-

Mini-laparoscopic placement of PDC 39 (a) (b) Fig. 5. Maryland grasper is passed subcutaneously to create a tunnel and to bring the thread and the catheter to the lateral incision.

15 It has advantages over percutaneous and open surgical placement including: (i) a lower incidence of flow dysfunction and visceral injury; 16 (ii) the ability to perform concomitant procedures

a day procedure. 17,18 Catheter malfunction is a common mechanical complication of peritoneal dialysis.

4 Mini-laparoscopic placement of PDC 39 (a) (b) Fig. 5. Maryland grasper is passed subcutaneously to create a tunnel and to bring the thread and the catheter to the lateral incision. stage renal disease. 14 However, the percentage of continuous ambulatory peritoneal dialysis (CAPD) used in Saudi Arabia is lower than 3%. 15 It has advantages over percutaneous and open surgical placement including: (i) a lower incidence of flow dysfunction and visceral injury; 16 (ii) the ability to perform concomitant procedures including division of adhesions, omentectomy and hernia repair; 11,17 (iii) the establishment of peritoneal dialysis within 24 h of catheter insertion; 16 and (iv) scheduling of catheter placement as a day procedure. 17,18 Catheter malfunction is a common mechanical complication of peritoneal dialysis. It can result from catheter migration or kinking, malposition of the catheter tip, fibrin deposition, omental wrapping, obstruction secondary to intraperitoneal adhesions, or infection. In the present study, one patient had catheter malfunction due to omental wrapping and he underwent laparoscopic omentectomy. Catheter migration resulting in poor return of dialysate can occur. 19 In our series, two patients had catheter migration and they underwent laparoscopic catheter repositioning. Brandt and Ricanati reported a success rate of 96% when laparoscopy was used for the management of malfunctioning catheters. 20 It was 100% in our series. The leakage rate through an abdominal incision has been reported as 13 27% if early peritoneal dialysis is performed, 8 10 and 16 22% with the laparoscopic technique. 11,12 With the mini-laparoscopic technique the incidence of leakage was zero, and the establishment of peritoneal dialysis was performed on the same day of surgery. This new mini-laparoscopic technique for placement of peritoneal dialysis catheters is simple, safe, easy to perform and learn, and it results in rapid postoperative recovery. Early use of peritoneal dialysis obviates the need for intermediary haemodialysis. Fig. 6. Catheter is observed to drain satisfactorily during the operative test.

5 40 MI Seleem and AM Al-Hashemy Conclusion Mini-laparoscopic technique for placement of peritoneal dialysis catheter is unique and maximizes the advantages of laparoscopic surgery because it uses only two ports. The catheter is made to exit via a 2 mm port site and does not require specially designed instruments. References 1. Chano SH, Tsai TJ. Revision of dysfunctional Tenckhoff catheters by laparoscopic technique in continuous ambulatory peritoneal dialysis patients. J. Formos. Med. Assoc. 1993; 92: Kittur DS, Gazaway PM, Abidin MR. Laparoscopic repositioning of malfunctioning peritoneal dialysis catheters. Surg. Laparosc. Endosc. 1991; 1: Mutter D, Marichal JF, Heibel F. Laparoscopy: an alternative to surgery in patients treated with continuous ambulatory peritoneal dialysis. Nephron 1995; 68: Selgas R, Beberide JM, Gonzales P. Use of laparoscopy in CAPD. Perit. Dial. Int. 1980; 1: Hughas CR, Angotti DM, Jubelirer RA. Laporoscopic repositioning of a continuous ambulatory peritoneal dialysis (CAPD) catheter. Surg. Endosc. 1994; 8: Kimmelstiel FM, Miller RE, Molinelli BM, Lorch JA. Laparoscopic management of peritoneal dialysis catheters. Surg. Gynecol. Obstet. 1993; 176: Owens LV, Brader AH. Laparoscopic salvage of Tenckhoff catheters. Surg. Endosc. 1995; 9: Spence PA, Mathews RE, Khanna R. Improved results with a paramedian technique for the insertion of peritoneal dialysis catheters. Surg. Gynecol. Obstet. 1985; 161: Nahman NS, Middendorf DF, Bay WH. Modification of the percutaneous approach to peritoneal dialysis catheter placement under peritoneoscopic visualization: clinical results in 78 patients. J. Am. Soc. Nephrol. 1992; 3: Stone MM, Fankalsrud EW, Salusky IB. Surgical management of peritoneal dialysis catheter in children: five year experience with 1800 patient month follow up. J. Pediatr. Surg. 1986; 21: Lessin MS, Luks FI, Brem AS, Wesselhoeft CW. Primary laparoscopic placement of peritoneal dialysis in children and young adults. Surg. Endosc. 1999; 13: Al-Hashemy AM, Seleem MI, Al-Ahmary AM, Bin-MahfooZ. AA. A two-port laparoscopic placement of peritoneal dialysis catheter: a preliminary report. Saudi J. Kidney Dis. Transplant. 2004; 15 (2): Ash SR, Wolf GC, Bloch R. Placement of Tenckhoff peritoneal dialysis catheter under peritoneoscopic visualisation. Dial. Transplant. 1981; 10: Oreopaulos DG, Robson M, Izatt S, Clayton S, de Veber GA. A simple and soft technique for continuous ambulatory peritoneal dialysis. Trans. Am. Soc. Artif. Intern. Organs 1978; 24: Abu-Aisha H, Paul TT. CAPD: is it a viable mode of renal replacement therapy in Saudi Arabia? Saudi J. Kidney Dis. Transplant. 1994; 5 (2): Crabtree JH, Fishman A. A laparoscopic approach under local anaesthesia for peritoneal dialysis access. Perit. Dial. Int. 2000; 20: Skipper K, Dickerman R, Dunn E. Laparoscopic placement and revision of peritoneal dialysis catheters. J. Soc. Laparosc. Surg. 1999; 3: Crabtree JH, Fishman A, Uuen IT. Videolaparoscopic peritoneal dialysis catheter implant and rescue procedures under local anaesthesia with nitrous oxide pneumoperitoneum. Adv. Perit. Dial. 1998; 14: Hwang TL, Chen MF, Leu ML. Comparison for four techniques of catheters insertion in patients undergoing continuous ambulatory peritoneal dialysis. Eur. J. Surg. 1995; 161: Brandt CP, Ricanati ES. Use of laparoscopy in the management of malfunctioning peritoneal dialysis catheters. Adv. Perit. Dial. 1996; 12:

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