ORIGINAL ARTICLE
Laparoscopic Peritoneal Dialysis Catheter Implantation With an Intra-abdominal Fixation Technique: A Report of 53 Cases Jun-Jun Ma, MD, PhD, Xue-Yu Chen, MD, Lu Zang, MD, PhD, Zhi-Hai Mao, MD, Ming-Liang Wang, MD, Ai-Guo Lu, MD, Jian-Wen Li, MD, Bo Feng, MD, PhD, Feng Dong, MD, and Min-Hua Zheng, MD
Objective: The purpose of this study was to evaluate the feasibility, the safety, and outcomes of renal replacement therapy with the laparoscopic technique for peritoneal dialysis (PD) catheter implantation with an intra-abdominal fixation. Methods: Medical records of 53 patients with end-stage renal disease who underwent laparoscopic PD catheter implantation with an intra-abdominal fixation in our department from December 2008 to October 2009 were reviewed retrospectively. Their surgical procedure, operative outcomes, postoperative complications, and follow-up outcomes were analyzed. Results: All patients underwent laparoscopic PD catheter implantation with an intra-abdominal fixation successfully. Neither conversion to open surgery nor major intraoperative complications were observed. The median operative time was 24.2 ± 10.5 minutes. The operative cost was 837.3 ± 107.0 US$. Two patients (3.8%) had catheter obstruction peritonitis 12 and 15 months after surgery, respectively, and both of them had the catheter removed. Conclusions: Laparoscopic PD catheter implantation with an intraabdominal fixation of the catheter tip is feasible and safe. It had a low incidence of PD catheter migration and other PD-related postoperative complications with the benefit of minimal invasiveness, a shorter operation time, and quicker postoperative recovery. Key Words: peritoneal dialysis catheter implantation, peritoneal dialysis, laparoscopic technique
(Surg Laparosc Endosc Percutan Tech 2013;23:513–517)
T
he laparoscopic approach has been adopted widely since the success of laparoscopic cholecystectomy in 1987, because of several advantages when compared with conventional open surgery, such as less pain, earlier return of bowel function, shorter hospital stay, greater facilities to resume social activities, and a better cosmetic effect. The success of peritoneal dialysis (PD) depends on the presence of a functional and durable long-term catheter access to the peritoneal cavity. Next to infectious complications, mechanical catheter problems have been considered as the greatest hindrance to the success of PD,
Received for publication August 15, 2012; accepted October 16, 2012. From the Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China. The authors declare no conflicts of interest. Reprints: Lu Zang, MD, PhD, Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai 200025, China (e-mail: [email protected]). Copyright r 2013 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
especially during the first year after catheter implantation by the laparotomy approach without catheter fixation.1 The use of a laparoscope to guide PD catheter implantation antedates the modern surgical laparoscopic era by almost a decade. The goal of our study was to evaluate the feasibility, the safety, and outcomes of renal replacement therapy by laparoscopic PD catheter implantation with an intra-abdominal fixation and to share our experience of the laparoscopic technique for PD catheter implantation.
MATERIALS AND METHODS Patients From December 2008 to October 2009, 53 patients with end-stage renal disease (ESRD) who underwent laparoscopic PD catheter implantation with an intra-abdominal fixation in our department were reviewed retrospectively and analyzed in a prospectively maintained clinical database at the Shanghai Minimally Invasive Surgery Center, Shanghai Ruijin Hospital affiliated to Shanghai Jiaotong University, School of Medicine. Patients with acute renal failure or patients with inadequate data were excluded.
Variables Variables collected included demographic characteristics, primary diseases, laboratory values, history of abdominal surgery, the operative time (the time between starting and completing the operation, excluding the anesthesia time), the operative cost, and intraoperative complications. Postoperative outcomes including the postoperative hospital stay, short-term complications (up to 30 d after the operation), mortality, and long-term (> 30 d after operation) clinical outcomes were also collected. Costs were calculated in US$. As a baseline cost, the cost of a laparoscopic cholecystectomy in Shanghai was 1255.2 US$.
The Surgical Technique All patients were operated on under general anesthesia. Patients were asked to lie in the anti-Tredelenburg position, with the surgeon standing on the right side of the patient and the camera holder standing on the left side of the patient. Carbon dioxide pneumoperitoneum was established through the umbilicus with the Veress needle, and the intraperitoneal pressure was maintained at 12 mm Hg. Usually, 3 ports were used: (a) one 10-mm umbilical port for the laparoscopic camera, (b) one 5-mm port in midline 5 cm inferior to the umbilicus, and (c) one 5-mm port about 5 cm lateral to the umbilicus (Fig. 1A). We measured the position of these two 5-mm ports by the Tenckhoff catheter (Fig. 1B): the inferior 5-mm port (port
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Ma et al
Volume 23, Number 6, December 2013
FIGURE 1. Trocar placement. A, One 10-mm umbilical port for the laparoscopic camera (a), one 5-mm port in midline 5 cm inferior to the umbilicus (b), and one 5-mm port about 5 cm lateral to the umbilicus (c). B, Veress needle through umbilicus for pneumoperitoneum establishment (a). The inferior 5-mm port (b) for the deep cuff of the catheter and the lateral one (port “c”) at a distance of at least 2 cm from the subcutaneous cuff, as the exit site of the catheter after surgery.
“b”) for the deep cuff of the catheter and the lateral one (port “c”) at a distance of at least 2 cm from the subcutaneous cuff, as the exit site of the catheter after surgery. After trocar placement, laparoscopic exploration was conducted to detect the occult inguinal hernia and adhesion. After exploration of the abdominal cavity by the scope, the Tenckhoff catheter was inserted into the abdominal cavity through the umbilical 10-mm port. Then the Tenckhoff catheter tip was fixed intracorporeally on the peritoneum of the Douglas pouch with a 3-0 Proline suture (Fig. 2). The other end of the catheter was caught with the grasper and slowly pulled outside the peritoneal cavity through the midline port inferior to the umbilicus. The deep cuff was then located at the midline port site inferior to the umbilicus preperitoneally (Fig. 3). The subcutaneous tunnel tract was directed to the other port site lateral to the umbilicus, and the subcutaneous cuff was positioned at a distance of at least 2 cm from the port site (Fig. 4). Satisfactory catheter irrigation and outflow were confirmed. The laparoscope was finally removed, and the pneumoperitoneum was released. Regular PD was resumed 7 days after surgery.
Three patients who had a history of abdominal surgery had a peritoneal adhesion and underwent adhesiolysis when they had the PD catheter placement. Eight patients who had a previous catheter placement with the open technique experienced mechanical dysfunction due to catheter migration and omental wrapping of the catheter (Fig. 5). They underwent repositioning of the catheter into the pouch of Douglas and omental resection. Neither conversion to open surgery nor major intraoperative complications were observed. The median operative time was 24.2 ± 10.5 minutes. The operative cost was 837.3 ± 107.0 US$ (Table 2).
RESULTS Between December 2008 and October 2009, 53 patients (28 males and 25 females) with ESRD were included in our study. The median age was 57 years (range, 25 to 82 y). Demographic data are summarized in Table 1.
Operative Outcomes All patients underwent laparoscopic PD catheter implantation with an intra-abdominal fixation successfully. Two patients with cholelithiasis underwent laparoscopic cholecystectomy simultaneously. Another 2 cases with occult inguinal hernia were found intraoperatively and had hernia repaired with the total extraperitoneal (TEP) approach at the time of PD catheter placement.
514 | www.surgical-laparoscopy.com
FIGURE 2. Fixation of the catheter. The Tenckhoff catheter tip was fixed intracorporeally on the peritoneum of the Douglas pouch with a 5-0 Proline suture. r
2013 Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
Volume 23, Number 6, December 2013
Laparoscopic PD Catheter Implantation
TABLE 1. Demographics and Other Sample Characteristics
Variables
N = 53
Age [(y) median, range] Sex (male/female) Primary disease Chronic nephritis Diabetic nephropathy Hypertensive nephropathy Interstitial nephritis Polycystic kidney disease Laboratory values Blood urea nitrogen [(mmol/L) mean/SD] Serum creatinine [(mmol/L) mean/SD] Glomerular filtration rate [(%) mean/SD] History of abdominal surgery Follow-up time [(mo) mean/SD]
FIGURE 3. Location of the deep cuff. The deep cuff was located at the midline port site inferior to the umbilicus.
Postoperative Outcomes No postoperative complication up to 30 days after surgery was encountered. With a median follow-up of 31 months (27 to 39 mo), no disease-related death occurred.
57 (25-82) 28/25 23 15 11 3 1
(43.4%) (28.3%) (20.8%) (5.7%) (1.9%)
25.0 ± 8.0 823.0 ± 258.0 7.2 ± 2.6 9 (17.0%) 31 (27-39)
No catheter leakage was encountered. One patient had catheter obstruction and resulted in peritonitis 15 months after surgery, and had the catheter removed. No other catheter-related infectious complication was observed. Catheter obstruction was observed in another case 12 months after surgery, respectively, and the catheter was removed. Both the patients who had catheter obstruction had previous catheter placement with the open technique. Two cases of indirect inguinal hernia were observed in our series 10 and 13 months after operation, respectively. Both of them received reoperation for hernia repair (TEP). After the TEP procedure, the pneumoperitoenium was established and a laparoscopic exploration was implemented to check the position of the catheter. During exploration, no catheter migration was found and the catheter tips were found still in the pouch of Douglas (Table 2).
DISCUSSION With the advantages of the laparoscopic technique, we can complete some procedures that cannot be completed conveniently by the laparotomy approach. In open surgery or the percutaneous technique, it is a blind step to place the catheter within the peritoneal cavity, which cannot warrant an optimal position of the catheter in
FIGURE 4. The outside view of catheter placement after surgery. The subcutaneous tunnel tract was directed to the port site lateral to the umbilicus and the subcutaneous cuff was positioned at a distance of at least 2 cm from the port site. r
2013 Lippincott Williams & Wilkins
FIGURE 5. Intra-abdominal adhesion and omental wrapping of the catheter. One of the patients who had a previous catheter placement with the open technique experienced mechanical dysfunction because of catheter migration and omental wrapping of the catheter.
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TABLE 2. Hospital Parameters and Postsurgical Complications
Variables Conversion Operative time [(min) mean/SD] Operative cost (US$) Intraoperative complications Postsurgical stay [(d) mean/SD] Postoperative complications Catheter-related infectious complication Catheter leakage Catheter obstruction Inguinal hernia Postoperative mortality
N = 53 0 (0%) 24.2 ± 10.5 837.3 ± 107.0 0 (0%) 1.32 ± 0.54 1 0 2 2 0
(1.9%) (0%) (3.8%) (3.8%) (0%)
the cavity. Moreover, it could also result in severe complications including damaging the inferior epigastric vascular or abdominal organs such as the bladder or the intestine.2 The laparoscopic method offers an excellent view of the abdomen and optimal placement of the catheter within the cavity. The other advantage of the laparoscopic technique is that it allows the exploration of the abdominal cavity to find out the existence of occult inguinal hernia and peritoneal adhesions that might interfere with the drainage function. The peritoneal adhesion can be treated with adhesiolysis laparoscopically3,4 to avoid the obstruction of the catheter postoperatively. No damage to abdominal organs was encountered in our study. Two cases with occult inguinal hernia and 3 cases with peritoneal adhesion were found in our study and all of them underwent TEP or adhesiolysis laparoscopically. Two patients with cholelithiasis underwent laparoscopic cholecystectomy simultaneously. An important difference between the laparoscopic technique and open surgery is that the catheter tip can be fixed in the abdominal cavity laparoscopically. The main goal of catheter placement with intra-abdominal fixation was to reduce catheter complications, one of the most common being catheter migration with outflow obstruction. It was reported that the placement of PD catheters with a securing suture yielded an 8.4 months’ longer catheter life than that without a suture.5 There are several options in terms of the position of the fixation of the catheter tip. Copeland et al6 implemented a comparison study and found that laparoscopic placement of PD catheters using a securing suture in the pelvis is a more durable technique when compared with open placement. Soontrapornchai and Simapatanapong7 reported that the catheter was sutured to the pelvic peritoneum at the rectovesical pouch in men and behind the uterus in women. Haralampos reported a 13-case study, and all the catheters were fixed at the lower anterior abdominal wall.8 In our study, all the cases had the PD catheter placement with an intra-abdominal fixation. In our experience, the catheter tip was fixed intracorporeally by the laparoscopic technique in the Douglas Fossa because the Douglas Fossa is known as the lowest location of the peritoneal cavity. Peritoneal catheter malfunction is a common complication of PD. It can result from catheter migration or kinking, malpositioning of the catheter tip, fibrin deposition, omental wrapping, obstruction secondary to intraperitoneal adhesions, or infection. Soontrapornchai and Simapatanapong7 conducted a comparison study between the laparoscopic and the open techniques and found that catheter migration occurred in 12% of the patients in the
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Volume 23, Number 6, December 2013
open group, as compared with none in the laparoscopic group (P = 0.027). Keshvari and colleagues retrospectively reviewed 175 patients who underwent laparoscopic catheter implantation without fixation using local anesthesia. They found that the overall 1- and 2-year catheter survival rates were 92.7% and 91.3%, respectively. The incidence of catheter tip migration and omental entrapment was 1.7% and 2.9%, respectively.9 Temporary pericatheter leak occurred in 7.4% of the cases. In terms of long-term outcomes, Crabtree and colleagues reported a series of 428 patients with ESRD after a mean follow-up of 21.6 months. The results showed that mechanical outflow obstruction complicated 3.7% of implantation procedures, and the incidence of pericatheter leak was 2.6%. There were no occurrences of pericatheter hernia or subcutaneous cuff extrusion.10 In our series, no catheter leakage was encountered. Only 1 catheter-related infectious complication was observed. Only the patients (2 cases) who had a previous catheter placement with the open technique and who complicated with catheter migration and obstruction had the catheter obstruction again this time in our series. We believe that the main reason for the low rate of catheter migration and obstruction was that the laparoscopic method offers an excellent view of the abdomen and optimal location of the catheter placement within the cavity. Another important reason is that the fixation of the catheter tip in a low site of the pelvis (Douglas Fossa) also contributed to the low migration rate of the catheter. The nonabsorbable suture that was used to fix the catheter tip in our surgery might be helpful to keep the fixation solid. Moreover, kinking, twisting of the catheter tip, omental wrapping, and obstruction secondary to catheter migration also decreased because of the fixation of the catheter tip. In our study, 2 patients who complicated with inguinal hernia postoperatively underwent reoperation. Catheter migration was found in neither of them during the reoperation. In addition, during the follow-up period, 6 out of the 8 patients with catheter migration after the previous catheter placement with the open technique did not complicate with catheter migration and obstruction again after our laparoscopic procedure with the fixation technique.
CONCLUSIONS We concluded that our laparoscopic technique for PD catheter implantation with intra-abdominal fixation of the catheter tip is feasible and safe. It had a low incidence of PD catheter migration, obstruction, and other PD-related postoperative complications with the benefit of minimal invasiveness, a shorter operation time, and quicker postoperative recovery. REFERENCES 1. Guo A, Mujais S. Patient and technique survival on peritoneal dialysis in the United States: evaluation in large incident cohorts. Kidney Int. 2003;64(suppl):S3–S1. 2. Lund L, Jonler M. Peritoneal dialysis catheter placement: is laparoscopy an option? Int Urol Nephrol. 2007;39:625–628. 3. Bensard D, Partrick D, Ford D, et al. Efficacy of laparoscopic peritoneal dialysis catheter placement in children. Pediatr Endosurg Innov Techn. 2001;5:241–246. 4. Stringel G, McBride W, Weiss R. Laparoscopic placement of peritoneal dialysis catheters in children. J Pediatr Surg. 2008; 43:857–860. r
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5. Numanoglu A, Rasche L, Roth MA, et al. Laparoscopic insertion with tip suturing, omentectomy, and ovariopexy improves lifespan of peritoneal dialysis catheters in children. J Laparoendosc Adv Surg Tech A. 2008;18:302–305. 6. Copeland DR, Blaszak RT, Tolleson JS, et al. Laparoscopic Tenckhoff catheter placement in children using a securing suture in the pelvis: comparison to the open approach. J Pediatr Surg. 2008;43:2256–2259. 7. Soontrapornchai P, Simapatanapong T. Comparison of open and laparoscopic secure placement of peritoneal dialysis catheters. Surg Endosc. 2005;19:137–139.
r
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8. Harissis HV, Katsios CS, Koliousi EL, et al. A new simplified one port laparoscopic technique of peritoneal dialysis catheter placement with intra-abdominal fixation. Am J Surg. 2006;192: 125–129. 9. Keshvari A, Najafi I, Jafari-Javid M, et al. Laparoscopic peritoneal dialysis catheter implantation using a Tenckhoff trocar under local anesthesia with nitrous oxide gas insufflation. Am J Surg. 2009;197:8–13. 10. Crabtree JH, Burchette RJ. Effective use of laparoscopy for long-term peritoneal dialysis access. Am J Surg. 2009;198: 135–141.
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Laparoscopic Peritoneal Dialysis Catheter Implantation With an Intra-abdominal Fixation Technique: A Report of 53 Cases Jun-Jun Ma, MD, PhD, Xue-Yu Chen, MD, Lu Zang, MD, PhD, Zhi-Hai Mao, MD, Ming-Liang Wang, MD, Ai-Guo Lu, MD, Jian-Wen Li, MD, Bo Feng, MD, PhD, Feng Dong, MD, and Min-Hua Zheng, MD
Objective: The purpose of this study was to evaluate the feasibility, the safety, and outcomes of renal replacement therapy with the laparoscopic technique for peritoneal dialysis (PD) catheter implantation with an intra-abdominal fixation. Methods: Medical records of 53 patients with end-stage renal disease who underwent laparoscopic PD catheter implantation with an intra-abdominal fixation in our department from December 2008 to October 2009 were reviewed retrospectively. Their surgical procedure, operative outcomes, postoperative complications, and follow-up outcomes were analyzed. Results: All patients underwent laparoscopic PD catheter implantation with an intra-abdominal fixation successfully. Neither conversion to open surgery nor major intraoperative complications were observed. The median operative time was 24.2 ± 10.5 minutes. The operative cost was 837.3 ± 107.0 US$. Two patients (3.8%) had catheter obstruction peritonitis 12 and 15 months after surgery, respectively, and both of them had the catheter removed. Conclusions: Laparoscopic PD catheter implantation with an intraabdominal fixation of the catheter tip is feasible and safe. It had a low incidence of PD catheter migration and other PD-related postoperative complications with the benefit of minimal invasiveness, a shorter operation time, and quicker postoperative recovery. Key Words: peritoneal dialysis catheter implantation, peritoneal dialysis, laparoscopic technique
(Surg Laparosc Endosc Percutan Tech 2013;23:513–517)
T
he laparoscopic approach has been adopted widely since the success of laparoscopic cholecystectomy in 1987, because of several advantages when compared with conventional open surgery, such as less pain, earlier return of bowel function, shorter hospital stay, greater facilities to resume social activities, and a better cosmetic effect. The success of peritoneal dialysis (PD) depends on the presence of a functional and durable long-term catheter access to the peritoneal cavity. Next to infectious complications, mechanical catheter problems have been considered as the greatest hindrance to the success of PD,
Received for publication August 15, 2012; accepted October 16, 2012. From the Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China. The authors declare no conflicts of interest. Reprints: Lu Zang, MD, PhD, Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai 200025, China (e-mail: [email protected]). Copyright r 2013 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
especially during the first year after catheter implantation by the laparotomy approach without catheter fixation.1 The use of a laparoscope to guide PD catheter implantation antedates the modern surgical laparoscopic era by almost a decade. The goal of our study was to evaluate the feasibility, the safety, and outcomes of renal replacement therapy by laparoscopic PD catheter implantation with an intra-abdominal fixation and to share our experience of the laparoscopic technique for PD catheter implantation.
MATERIALS AND METHODS Patients From December 2008 to October 2009, 53 patients with end-stage renal disease (ESRD) who underwent laparoscopic PD catheter implantation with an intra-abdominal fixation in our department were reviewed retrospectively and analyzed in a prospectively maintained clinical database at the Shanghai Minimally Invasive Surgery Center, Shanghai Ruijin Hospital affiliated to Shanghai Jiaotong University, School of Medicine. Patients with acute renal failure or patients with inadequate data were excluded.
Variables Variables collected included demographic characteristics, primary diseases, laboratory values, history of abdominal surgery, the operative time (the time between starting and completing the operation, excluding the anesthesia time), the operative cost, and intraoperative complications. Postoperative outcomes including the postoperative hospital stay, short-term complications (up to 30 d after the operation), mortality, and long-term (> 30 d after operation) clinical outcomes were also collected. Costs were calculated in US$. As a baseline cost, the cost of a laparoscopic cholecystectomy in Shanghai was 1255.2 US$.
The Surgical Technique All patients were operated on under general anesthesia. Patients were asked to lie in the anti-Tredelenburg position, with the surgeon standing on the right side of the patient and the camera holder standing on the left side of the patient. Carbon dioxide pneumoperitoneum was established through the umbilicus with the Veress needle, and the intraperitoneal pressure was maintained at 12 mm Hg. Usually, 3 ports were used: (a) one 10-mm umbilical port for the laparoscopic camera, (b) one 5-mm port in midline 5 cm inferior to the umbilicus, and (c) one 5-mm port about 5 cm lateral to the umbilicus (Fig. 1A). We measured the position of these two 5-mm ports by the Tenckhoff catheter (Fig. 1B): the inferior 5-mm port (port
Volume 23, Number 6, December 2013
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Surg Laparosc Endosc Percutan Tech
Ma et al
Volume 23, Number 6, December 2013
FIGURE 1. Trocar placement. A, One 10-mm umbilical port for the laparoscopic camera (a), one 5-mm port in midline 5 cm inferior to the umbilicus (b), and one 5-mm port about 5 cm lateral to the umbilicus (c). B, Veress needle through umbilicus for pneumoperitoneum establishment (a). The inferior 5-mm port (b) for the deep cuff of the catheter and the lateral one (port “c”) at a distance of at least 2 cm from the subcutaneous cuff, as the exit site of the catheter after surgery.
“b”) for the deep cuff of the catheter and the lateral one (port “c”) at a distance of at least 2 cm from the subcutaneous cuff, as the exit site of the catheter after surgery. After trocar placement, laparoscopic exploration was conducted to detect the occult inguinal hernia and adhesion. After exploration of the abdominal cavity by the scope, the Tenckhoff catheter was inserted into the abdominal cavity through the umbilical 10-mm port. Then the Tenckhoff catheter tip was fixed intracorporeally on the peritoneum of the Douglas pouch with a 3-0 Proline suture (Fig. 2). The other end of the catheter was caught with the grasper and slowly pulled outside the peritoneal cavity through the midline port inferior to the umbilicus. The deep cuff was then located at the midline port site inferior to the umbilicus preperitoneally (Fig. 3). The subcutaneous tunnel tract was directed to the other port site lateral to the umbilicus, and the subcutaneous cuff was positioned at a distance of at least 2 cm from the port site (Fig. 4). Satisfactory catheter irrigation and outflow were confirmed. The laparoscope was finally removed, and the pneumoperitoneum was released. Regular PD was resumed 7 days after surgery.
Three patients who had a history of abdominal surgery had a peritoneal adhesion and underwent adhesiolysis when they had the PD catheter placement. Eight patients who had a previous catheter placement with the open technique experienced mechanical dysfunction due to catheter migration and omental wrapping of the catheter (Fig. 5). They underwent repositioning of the catheter into the pouch of Douglas and omental resection. Neither conversion to open surgery nor major intraoperative complications were observed. The median operative time was 24.2 ± 10.5 minutes. The operative cost was 837.3 ± 107.0 US$ (Table 2).
RESULTS Between December 2008 and October 2009, 53 patients (28 males and 25 females) with ESRD were included in our study. The median age was 57 years (range, 25 to 82 y). Demographic data are summarized in Table 1.
Operative Outcomes All patients underwent laparoscopic PD catheter implantation with an intra-abdominal fixation successfully. Two patients with cholelithiasis underwent laparoscopic cholecystectomy simultaneously. Another 2 cases with occult inguinal hernia were found intraoperatively and had hernia repaired with the total extraperitoneal (TEP) approach at the time of PD catheter placement.
514 | www.surgical-laparoscopy.com
FIGURE 2. Fixation of the catheter. The Tenckhoff catheter tip was fixed intracorporeally on the peritoneum of the Douglas pouch with a 5-0 Proline suture. r
2013 Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
Volume 23, Number 6, December 2013
Laparoscopic PD Catheter Implantation
TABLE 1. Demographics and Other Sample Characteristics
Variables
N = 53
Age [(y) median, range] Sex (male/female) Primary disease Chronic nephritis Diabetic nephropathy Hypertensive nephropathy Interstitial nephritis Polycystic kidney disease Laboratory values Blood urea nitrogen [(mmol/L) mean/SD] Serum creatinine [(mmol/L) mean/SD] Glomerular filtration rate [(%) mean/SD] History of abdominal surgery Follow-up time [(mo) mean/SD]
FIGURE 3. Location of the deep cuff. The deep cuff was located at the midline port site inferior to the umbilicus.
Postoperative Outcomes No postoperative complication up to 30 days after surgery was encountered. With a median follow-up of 31 months (27 to 39 mo), no disease-related death occurred.
57 (25-82) 28/25 23 15 11 3 1
(43.4%) (28.3%) (20.8%) (5.7%) (1.9%)
25.0 ± 8.0 823.0 ± 258.0 7.2 ± 2.6 9 (17.0%) 31 (27-39)
No catheter leakage was encountered. One patient had catheter obstruction and resulted in peritonitis 15 months after surgery, and had the catheter removed. No other catheter-related infectious complication was observed. Catheter obstruction was observed in another case 12 months after surgery, respectively, and the catheter was removed. Both the patients who had catheter obstruction had previous catheter placement with the open technique. Two cases of indirect inguinal hernia were observed in our series 10 and 13 months after operation, respectively. Both of them received reoperation for hernia repair (TEP). After the TEP procedure, the pneumoperitoenium was established and a laparoscopic exploration was implemented to check the position of the catheter. During exploration, no catheter migration was found and the catheter tips were found still in the pouch of Douglas (Table 2).
DISCUSSION With the advantages of the laparoscopic technique, we can complete some procedures that cannot be completed conveniently by the laparotomy approach. In open surgery or the percutaneous technique, it is a blind step to place the catheter within the peritoneal cavity, which cannot warrant an optimal position of the catheter in
FIGURE 4. The outside view of catheter placement after surgery. The subcutaneous tunnel tract was directed to the port site lateral to the umbilicus and the subcutaneous cuff was positioned at a distance of at least 2 cm from the port site. r
2013 Lippincott Williams & Wilkins
FIGURE 5. Intra-abdominal adhesion and omental wrapping of the catheter. One of the patients who had a previous catheter placement with the open technique experienced mechanical dysfunction because of catheter migration and omental wrapping of the catheter.
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515
Surg Laparosc Endosc Percutan Tech
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TABLE 2. Hospital Parameters and Postsurgical Complications
Variables Conversion Operative time [(min) mean/SD] Operative cost (US$) Intraoperative complications Postsurgical stay [(d) mean/SD] Postoperative complications Catheter-related infectious complication Catheter leakage Catheter obstruction Inguinal hernia Postoperative mortality
N = 53 0 (0%) 24.2 ± 10.5 837.3 ± 107.0 0 (0%) 1.32 ± 0.54 1 0 2 2 0
(1.9%) (0%) (3.8%) (3.8%) (0%)
the cavity. Moreover, it could also result in severe complications including damaging the inferior epigastric vascular or abdominal organs such as the bladder or the intestine.2 The laparoscopic method offers an excellent view of the abdomen and optimal placement of the catheter within the cavity. The other advantage of the laparoscopic technique is that it allows the exploration of the abdominal cavity to find out the existence of occult inguinal hernia and peritoneal adhesions that might interfere with the drainage function. The peritoneal adhesion can be treated with adhesiolysis laparoscopically3,4 to avoid the obstruction of the catheter postoperatively. No damage to abdominal organs was encountered in our study. Two cases with occult inguinal hernia and 3 cases with peritoneal adhesion were found in our study and all of them underwent TEP or adhesiolysis laparoscopically. Two patients with cholelithiasis underwent laparoscopic cholecystectomy simultaneously. An important difference between the laparoscopic technique and open surgery is that the catheter tip can be fixed in the abdominal cavity laparoscopically. The main goal of catheter placement with intra-abdominal fixation was to reduce catheter complications, one of the most common being catheter migration with outflow obstruction. It was reported that the placement of PD catheters with a securing suture yielded an 8.4 months’ longer catheter life than that without a suture.5 There are several options in terms of the position of the fixation of the catheter tip. Copeland et al6 implemented a comparison study and found that laparoscopic placement of PD catheters using a securing suture in the pelvis is a more durable technique when compared with open placement. Soontrapornchai and Simapatanapong7 reported that the catheter was sutured to the pelvic peritoneum at the rectovesical pouch in men and behind the uterus in women. Haralampos reported a 13-case study, and all the catheters were fixed at the lower anterior abdominal wall.8 In our study, all the cases had the PD catheter placement with an intra-abdominal fixation. In our experience, the catheter tip was fixed intracorporeally by the laparoscopic technique in the Douglas Fossa because the Douglas Fossa is known as the lowest location of the peritoneal cavity. Peritoneal catheter malfunction is a common complication of PD. It can result from catheter migration or kinking, malpositioning of the catheter tip, fibrin deposition, omental wrapping, obstruction secondary to intraperitoneal adhesions, or infection. Soontrapornchai and Simapatanapong7 conducted a comparison study between the laparoscopic and the open techniques and found that catheter migration occurred in 12% of the patients in the
516 | www.surgical-laparoscopy.com
Volume 23, Number 6, December 2013
open group, as compared with none in the laparoscopic group (P = 0.027). Keshvari and colleagues retrospectively reviewed 175 patients who underwent laparoscopic catheter implantation without fixation using local anesthesia. They found that the overall 1- and 2-year catheter survival rates were 92.7% and 91.3%, respectively. The incidence of catheter tip migration and omental entrapment was 1.7% and 2.9%, respectively.9 Temporary pericatheter leak occurred in 7.4% of the cases. In terms of long-term outcomes, Crabtree and colleagues reported a series of 428 patients with ESRD after a mean follow-up of 21.6 months. The results showed that mechanical outflow obstruction complicated 3.7% of implantation procedures, and the incidence of pericatheter leak was 2.6%. There were no occurrences of pericatheter hernia or subcutaneous cuff extrusion.10 In our series, no catheter leakage was encountered. Only 1 catheter-related infectious complication was observed. Only the patients (2 cases) who had a previous catheter placement with the open technique and who complicated with catheter migration and obstruction had the catheter obstruction again this time in our series. We believe that the main reason for the low rate of catheter migration and obstruction was that the laparoscopic method offers an excellent view of the abdomen and optimal location of the catheter placement within the cavity. Another important reason is that the fixation of the catheter tip in a low site of the pelvis (Douglas Fossa) also contributed to the low migration rate of the catheter. The nonabsorbable suture that was used to fix the catheter tip in our surgery might be helpful to keep the fixation solid. Moreover, kinking, twisting of the catheter tip, omental wrapping, and obstruction secondary to catheter migration also decreased because of the fixation of the catheter tip. In our study, 2 patients who complicated with inguinal hernia postoperatively underwent reoperation. Catheter migration was found in neither of them during the reoperation. In addition, during the follow-up period, 6 out of the 8 patients with catheter migration after the previous catheter placement with the open technique did not complicate with catheter migration and obstruction again after our laparoscopic procedure with the fixation technique.
CONCLUSIONS We concluded that our laparoscopic technique for PD catheter implantation with intra-abdominal fixation of the catheter tip is feasible and safe. It had a low incidence of PD catheter migration, obstruction, and other PD-related postoperative complications with the benefit of minimal invasiveness, a shorter operation time, and quicker postoperative recovery. REFERENCES 1. Guo A, Mujais S. Patient and technique survival on peritoneal dialysis in the United States: evaluation in large incident cohorts. Kidney Int. 2003;64(suppl):S3–S1. 2. Lund L, Jonler M. Peritoneal dialysis catheter placement: is laparoscopy an option? Int Urol Nephrol. 2007;39:625–628. 3. Bensard D, Partrick D, Ford D, et al. Efficacy of laparoscopic peritoneal dialysis catheter placement in children. Pediatr Endosurg Innov Techn. 2001;5:241–246. 4. Stringel G, McBride W, Weiss R. Laparoscopic placement of peritoneal dialysis catheters in children. J Pediatr Surg. 2008; 43:857–860. r
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5. Numanoglu A, Rasche L, Roth MA, et al. Laparoscopic insertion with tip suturing, omentectomy, and ovariopexy improves lifespan of peritoneal dialysis catheters in children. J Laparoendosc Adv Surg Tech A. 2008;18:302–305. 6. Copeland DR, Blaszak RT, Tolleson JS, et al. Laparoscopic Tenckhoff catheter placement in children using a securing suture in the pelvis: comparison to the open approach. J Pediatr Surg. 2008;43:2256–2259. 7. Soontrapornchai P, Simapatanapong T. Comparison of open and laparoscopic secure placement of peritoneal dialysis catheters. Surg Endosc. 2005;19:137–139.
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8. Harissis HV, Katsios CS, Koliousi EL, et al. A new simplified one port laparoscopic technique of peritoneal dialysis catheter placement with intra-abdominal fixation. Am J Surg. 2006;192: 125–129. 9. Keshvari A, Najafi I, Jafari-Javid M, et al. Laparoscopic peritoneal dialysis catheter implantation using a Tenckhoff trocar under local anesthesia with nitrous oxide gas insufflation. Am J Surg. 2009;197:8–13. 10. Crabtree JH, Burchette RJ. Effective use of laparoscopy for long-term peritoneal dialysis access. Am J Surg. 2009;198: 135–141.
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