Role of Laproscopy in Peritoneal Dialysis Catheter Insertion

Indian Journal of Peritoneal Dialysis 11 Role of Laproscopy in Peritoneal Dialysis Catheter Insertion 1 2 Usman Khalid Cheema, Rajeevalochana Parthasarathy 1 Pakistan Institute of Medical Sciences, Islamabad, Pakistan 2 Madras Medical Mission, Chennai Abstract: Peritoneal dialysis(pd) is regarded as a safe and effective dialysis modality for ESRD. PD catheter insertion using Laproscopic(lap) techniques has gained importance in the recent years especially in difficult and complicated cases. This review focuses on the Lap technique of PD Catheter insertion. Key words: Laproscopy, Mini Laproscopy, Peritoneal dialysis catheter insertion Introduction: Peritoneal dialysis was first used for the management of endstage renal disease (ESRD) by Richard Ruben in 1959(1). In 1968, Henry Tenckhoff developed the indwelling peritoneal catheter, which was placed via an open surgical technique(2). The introduction of the percutaneous (3) and later the laparoscopic technique (4) was a major step towards the implantation of PD catheters. Several advantages of PD over haemodialysis (HD) have been described, including the quality of life due to superior patient mobility and independence, its simplicity in use, along with the clinical advantages like the maintenance of residual renal function and lower mortality in the first years after the beginning of PD. The CAPD catheter therefore becomes a lifeline just as an arteriovenous Fistula is in HD. Address for Correspondence Usman Khalid Cheema, MD Pakistan Institute of Medical Sciences, Islamabad, Pakistan Email:cukc@hotmail.com Several techniques and modifications have been described for the insertion of the PD catheter into the abdominal cavity. In this review we focus on the laproscopic technique of PD catheter insertion, which is gaining momentum. Catheter Type and Design PD catheters come in different varieties - straight, pigtailcurled, swan-neck type with different lengths and number of Dacron cuffs for optimal ingrowth and fixation. It consists of a flexible silicone tube with an open-end port and several side holes for optimal drainage and absorption of the dialysate. The extra peritoneal segment of the PD catheter has either one or two Dacron cuffs. Most catheters used in the Indian population have a double cuff: the proximal one implanted in the pre-peritoneal space just at the level of the rectus sheath for holding it in place and the distal one in the subcutaneous tissue for preventing infection(figure1)(5). Planning the appropriate catheter type and exit location is a must prior to the catheter implantation procedure(6). Preoperatively, patients are examined fully dressed to mark the belt-line location. Catheter selection then begins with the determination of the catheter-insertion site. With the patient in the supine position, the insertion site, which coincides with

12 Indian Journal of Peritoneal Dialysis Once the Veress needle has been introduced, placement of the needle is verified with the hanging drop test (visualized when saline is seen to flow easily down the Veress needle into the peritoneal cavity)(8,11). the deep cuff location, is established by aligning the upper border of the catheter coil with the upper border of the pubic symphysis, which has been recommended as a reliable marker for the ideal location of the catheter tip in the true pelvis, and marking the upper border of the deep cuff in the paramedian plane, 3 cm lateral of midline(6). Catheter-type selection is usually operator dependent and is based on the method and ease of insertion and local expertise. Laproscopic Technique There are several techniques used for PD catheter insertion. Open surgical and laparoscopic techniques are preferred because of their safety and good initial results. Laparoscopy apart from laprotomy yields excellent visualization of the peritoneum during procedures and can accurately delineate intraperitoneal adhesions(7). Percutaneous (radiological) catheter insertion may be less invasive, but bears the risk of unsatisfactory catheter placement and danger of bowel perforation(8). The laparoscopic approach should be done under general anesthesia (GA), as insufflating the peritoneal cavity is uncomfortable to the patient(9, 10). Prophylactic antibiotics are administered prior to the procedure. A Veress needle may be inserted into the abdomen at either the level of the umbilicus or 5-6 cm below the costal margin in the midaxillary line. Figure 1 : Peritoneal dialysis catheter showing the double cuff catheter. After verification of proper needle placement, pneumoperitoneum is obtained to a pressure of 15 mm Hg using carbon dioxide. The Veress needle is then exchanged for a 5 mm port and the laparoscope is introduced into the peritoneum. The peritoneal cavity is examined for pathology and iatrogenic injury(8,11). A 5 mm transverse incision is made at the superior portion of the catheter insertion site. An 18 Guage spinal needle is introduced and a 3-4 cm tract is created between the incision and the entrance site into the peritoneal cavity, taking care to enter the abdomen at a 30-45 angle with infiltration of local anesthetic along the course of this tract(8,11). Prior to entering the peritoneum, a local anesthetic is infiltrated just above the peritoneum to create a flare to aid with postoperative analgesia. A 0.035 J wire is passed through the needle and the needle is removed. The catheter tract is then dilated with the 22 Fr peel-away sheath. The dilator is first passed over the wire to help create the tract and then the dilator with the peel-away sheath is passed over the wire as a unit. The wire and dilator are then removed. The PD catheter is placed over a stiffening stylet and this unit is placed into the peel- away sheath into the peritoneal cavity under direct visualization and the catheter is advanced until the internal cuff is visualized within the peritoneal cavity. The stylet is then pulled back allowing the curl to reform at the end of the PD catheter. The end of the catheter is then positioned in the pelvis under direct visualization. The peel-away sheath is removed and the internal cuff is gently pulled back so the first Dacron cuff rests outside the peritoneum or within the fibers of the rectus muscle. The subcutaneous tract is then created in

Indian Journal of Peritoneal Dialysis 13 a manner identical to the creation of the tract in the open procedure The position of the tip of the catheter is again verified in the pelvis. The catheter is flushed with saline under visualization. The laparoscope is removed, followed by release of the pneumoperitoneum. The catheter is allowed to drain by gravity as with the open procedure. This ensures no mechanical obstruction is present(8,10). Finally, 60-80 ml of saline is left within the peritoneal cavity followed by 3000 units of heparin (3 ml of 1000 units/ml) to prevent fibrin or clot formation in the catheter. The 5 mm port is then removed and the incisions are closed with sutures (8, 11). Another common problem causing catheter dislocation is when the catheter is entering the peritoneal cavity at an acute angle. This problem is best addressed by suturing the catheter to the anterior abdominal wall to change the angle of entry (11-18). Adhesiolysis can also done when deemed necessary (12,18)(Figure 2). A Modified 10 mm Laparoscopic Assisted Approach This technique utilizes the open paramedian trans rectus muscle approach exposing the posterior rectus fascia and peritoneum similar to what has been described above When is the laparoscopic approach considered? Patients who have had previous abdominal surgeries Obese Individuals who may need other simple procedures performed concomitantly. Assessing a malfunctioning catheter (12) This set of indications increases the repertoire of patients who can receive PD catheters(13). Although the laparoscopic approach is associated with longer operative times, it allows for visualization of the precise catheter location in the pelvis. Use of laparoscopy for assessing the malfunctioning PD catheter The etiology of catheter malfunction can be identified and addressed; for example, omentum causing catheter obstruction can be resolved with an omentopexy or omentectomy, and a malpositioned catheter can be easily repositioned into the patient's pelvis(11,18) Figure 2 : Laparoscopy showing dense adhesions in a patient post fungal peritonitis The 10 mm laparoscopic placement developed in the nephrology and Dialysis Unit at Carlo Urbani Hospital(Jesi,Italy) combines the open and the laparoscopic methods and is indicated when additional more complex procedures like hernia repairs, omentopexy and partial omentectomy are required as a larger 10 mm port is used (14-16). It can be done under local anaesthesia too(17). The modified laparoscopic approach allows safe placement of the PD catheter in patients with previous abdominal surgical operations as suggested by the UK 2010 Guidelines(17). Peritoneal access during lap PD insertion should be obtained away from previous scars; surgeons should use the technique

14 Indian Journal of Peritoneal Dialysis they are most comfortable and experienced with. The surgeon should minimize the size and number of ports used and place them in a manner that optimizes visualization of the catheter peritoneal insertion point and the pelvis(8). Absolute and relative contraindications Ultrafiltration(UF) failure, severe physical and mental instability, active abdominal and skin infections are absolute contraindications. Relative contraindications include decreased capacity of peritoneal cavity, loss of abdominal wall integrity, obesity, intraabdominal foreign body, ostomies and inability to tolerate GA. Comparison of Implantation Techniques Randomized prospective studies show similar outcomes of open surgically and laparoscopically placed PD catheters (19). The conventional procedure is faster than the laparoscopic one (14.3 versus 21.9 min, P < 0.0001), but there is no difference in the early complication rate. In another study, 50 patients were enrolled and randomly allocated to an open surgical technique or laparoscopic placement, with fixation into the pelvis and suture closure of the port wounds. Fluid leakage and tip migration was observed in eight and five patients respectively in the surgical group, but in none in the laparoscopic group.the rate of peritonitis was equal in both the groups Laproscopic technique was associated with the better functioning of the catheter when compared to the open technique It allows immediate start of dialysis without fluid leakage and permits simultaneous performance of other laparoscopic procedures (19). Another advantage is the ability to perform the other procedures, simultaneously like adhesiolysis(20,21,22). These advantages may favour the laparoscopic technique over the open surgical approach. Percutaneous PD-catheter placement by experienced hands is a well-tolerated procedure that allows a rapid initiation of CAPD and avoids the necessity for operating room time, and the requirement for a peritoneal incision. It has a high technical success rate and can be performed on an outpatient basis(23). Catheter survival is comparable with that achieved with the surgical methods of catheter placement. In a retrospective study, the clinical outcome of 230 PD catheters was reviewed. Fifty catheters were placed percutaneously and one hundred and eighty were placed using conventional surgical techniques. Percutaneous insertion was non-elective, and was reserved for patients unfit for GA who were older with high morbidity.. Death and early mechanical failure contributed to a shorter mean duration of catheter use in the percutaneous group. The peritonitis rate was similar in both the groups(24). One metaanalysis could not demonstrate any advantage of one technique over the others, with respect to the risk of peritonitis, catheter removal or replacement, technical failure and all-cause mortality(25). Both the open surgical and laparoscopic techniques can be used in patients who receive a primary PD catheter and have no history of previous abdominal surgery, which could lead to PD catheter malfunction but lap technique having the additional advantage of adhesiolysis. Also, the cause of persistent PD catheter malfunctioning can be elucidated with a diagnostic laparoscopy, and if possible, solved under the same conditions. For instance, adhesions can be dissected and omental wrapping or fibrin clotting can be removed from the catheter. Percutaneous placement is particularly well suited for ailing patients, who cannot tolerate GA(26,27). Complications of PD Catheter Placement Complications after PD catheter placement are defined as those occurring early (<30 days) or late (>30 days), after surgery.

Indian Journal of Peritoneal Dialysis 15 Early complications Bowel perforation occurs rarely in <1% of the patients and is usually initiated during the entry into the abdominal cavity or when advancing the catheter with the stylet into the lower abdomen. Significant perforation is suspected with the onset of pain, nausea or a rigid abdomen. Surgical exploration becomes mandatory with the repair of the perforation and removal of the catheter with administration of IV Antibiotics(8). Bleeding is rarely a significant problem after catheter implantation and usually occurs at the exit site. Blood may be present initially in the effluent drained, owing to the trauma of insertion, but the drainage should return to normal within a few days. Manual pressure or additional suturing can stop persistent bleeding. Wound infection is uncommon and usually antibiotics are sufficient to treat superficial wound infections. Rarely, the entrance site may have to be drained. (8). The outflow failure may be due to multiple causes, including clots or fibrin in the catheter, kink in the subcutaneous tunnel, placement of the catheter in the omentum, development of omental wrap or adhesions in the abdomen. Obstructed catheters may be forcefully irrigated by saline or urokinase (Medicinase: 100 000 IU; 5 cc during 1 h)(8). As an alternative, a stiff guide wire may be advanced into the catheter under direct fluoroscopic control. If the subcutaneous tunnel is kinked, incision over the kink and repositioning of the catheter can be done.laparoscopic diagnosis and treatment of omental wrap or adhesions are advised with the additional advantage of instantaneous omentectomy or adhesiolysis(28). Malpositioning of the catheter into the upper abdomen usually causes pain and sometimes outflow failure which can be diagnosed by a plain X ray or a fluoroscopic contrast examination. Conservative measures with laxatives to activate bowel movements, which will carry the catheter into the right position may not suffice. Catheter repositioning with a stiff guide wire or forceps can be successful and is less morbid(29). Laparoscopic repositioning with catheter fixation into the lower abdomen may be the ultimate therapy to solve this problem. Prevention of catheter malposition remains the major goal and can be adjusted by a laparoscopic insertion technique and correct measurement of catheter length. Leakage of dialysate can be deducted with fluid drainage from the exit site or with the appearance of a bulge beneath the entrance site. Causes of leaks may be due to hernia at the entrance site as a result of very large incision, positioning of the proximal cuff on the rectus muscle, and trauma. Catheter rest without dialysate instillation for some weeks mostly solves this problem. Temporary HD may be required in the interim period. Late complications Late complications include exit-site infection, tunnel infection, cuff protrusion, outflow failure, and dialysate leaks or hernias. The incidence of infections attributable to the exit-site positioning can be reduced by proper placement of the exit site. Irritation and even cuff protrusion can occur when the exit is placed directly beneath the belt line. Superficial cuffs placed close to the skin are prone to extrusion and infection(8). An upward-directed site may collect fluid, leading to an increased incidence of infection. Catheter exchange is indicated in most instances and a different exit site is chosen. Outflow failure beyond 30 days is quite likely due to

16 Indian Journal of Peritoneal Dialysis constipation and is relieved by laxatives. Leaks and hernias may become symptomatic because of the increased intraabdominal pressure. In patients with residual renal function, temporary nocturnal automatic PD can be applied to decrease leakage. Leaks can also result from umbilical hernias or the presence of a patent processus vaginalis, resulting in scrotal oedema. Surgical repair of hernias or processus vaginalis may be indicated with a temporary shift to HD for adequate wound healing. Peritonitis can occur both in the early and late period and requires immediate management. Laproscopy and peritoneal biopsy may be needed to diagnose TB peritonitis(30). Limitations of the available literature The available literature on laparoscopic peritoneal dialysis catheter insertion and salvage has several limitations. Most studies are retrospective in nature and many differences in techniques were observed. Trials comparing insertion techniques, there are small numbers and an increased risk for bias and other confounding factors. In addition, the expertise of the operators may vary significantly. The reporting of outcome measures varies also as some papers split up catheter migration and outflow obstruction as causes for dysfunction. Additionally, protocols vary such as the time period between surgery and the start of PD(8,11). This can make a comparison of leak rates inaccurate. Finally, the follow-up periods vary greatly and makes it difficult to compare data on one technique versus another. CONCLUSION Laproscopic technique of PD catheter insertion is the preferred method when rescuing malfunctioning catheters and may increase the PD patient population in patients with previous abdominal surgeries. However it is also associated with longer operative times and the need for GA The dialysis access surgeon should be familiar with both open and laparoscopic techniques and appropriately choose the ideal method based upon the individual patient and institutional resources. REFERENCES 1. Blagg CR. The early history of dialysis for chronic renal failure in the United States: a view from Seattle. Am J Kidney Dis. 2007 Mar. 49(3):48296. 2. Tenckhoff H, Curtis FK. Experience with maintenance peritoneal dialysis in the home. Trans Am Soc Artif Intern Organs. 1970. 16:905. 3. Allon M, Soucie JM, Macon EJ. Complications with permanent peri- toneal dialysis catheters: experience with 154 percutaneously placed catheters. Nephron 1988; 48: 8 11 4. Amerling R, Cruz C. A new laparoscopic method for implantation of peritoneal catheters. ASAIO J 1993; 39: M787 M789 5. Shetty A, Oreopoulos G. Peritoneal dialysis: Its indications and contraindications. Dialysis & Transplantation. 2000. 29(2):7177. 6. Crabtree JH. Selected best demonstrated practices in peritoneal dialysis access. Kidney Int Suppl 2006; 103: S27 S37 7. Stephen Ash. Laparoscopy For Pd Catheter Placement: Advantages And Disadvantages Versus Peritoneoscopy. Peritoneal Dialysis International, Vol. 25, pp. 541 543 8. Arnoud Peppelenbosch, Willy H. M. van Kuijk, Nicole D. Bouvy, Frank M. van der Sande,Jan H. M. Tordoir.P eritoneal dialysis catheter placement technique and

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