Peritoneal Access

Confirmation of the past of the abdominal surgery (standard laparotomy/laparoscopic surgery, decision of the insertion part)

Decision of exit site position (standard abdominal position/previous fort/lower fort/upper abdominal wall/other special exit)

Bacterial culture examination (nasal cavity and umbilicus): In the case of MRSA bacteria carrier, the removal with mupirocin is needed

Disposal of body hair (method, timing)

Take a bath to keep skin clean

Decrease in capacity in the abdominal cavity (stool processing with a laxative, the enema, empty bladder by letting self-urinate or urination by a catheter)

Prescription of infusion, the antibiotic

For patients with diabetes, normalization of blood glucose should be done

Various PD catheters are commercially available from many manufacturers (available products depend on each country). In Japan, a long catheter of 65 or 80 cm in total length is available and an exit site can be established without limitations (Fig. 13.1). Discussion with the patient should be conducted as needed.


Fig. 13.1
Various catheter exit site (kidney and dialysis 66, access 2009 (in Japanese)—part modification)

Since this surgery involves the implantation of an artificial material, special considerations are necessary to prevent infection . In particular, confirmation of the patient being a carrier of methicillin-resistant Staphylococcus aureus (MRSA) is more likely to be associated with subsequent infection . Therefore, it may be effective that the nasal cavity and umbilicus are cultured for bacteria and subsequent bacterial elimination is conducted as needed. As per common surgical procedures, antibiotic agents should be administered just prior to surgery to increase the drug blood concentration level. Regarding preoperative body hair removal, it is desirable to refer to the Centers for Disease Control and Prevention (CDC) guidelines for the USA (Mangram et al. 1999). These guidelines indicate that hair shaving with a razor increases the occurrence of surgical site infection (SSI). In our hospital, as a general rule, hair shaving is not conducted or is conducted using a surgical clipper, as necessary. In addition, sebum and protein deposits that can not be disinfected with swabs done in the operating room on the day of surgery should be washed away with soap during bathing, or washed with soap with a disinfectant before surgery to reduce SSI risk.

For PD, the tip of the catheter is commonly inserted into the Douglas Pouch. Disposal of stool in the rectum and emptying of the bladder are therefore critical to secure a wide Douglas Pouch. These procedures are essential and complications with catheterization may arise when these procedures are not performed. Administration of cathartic drugs and preoperative enema are necessary for disposal of stool in the rectum. Preoperative urination is required for emptying of the bladder. Especially for elderly patients, higher amount of residual urine is present in most cases; therefore, urethral catheterization should be considered, as required.

13.1.2 Surgery: Standard Implantation by Laparotomy

An inconsequential discussion concerning whether surgery should be performed by a surgeon or nephrologist often takes place. As a minimum, the operator must be trained and have mastered surgical procedures. Additionally, if the situation of each country permits it, this surgery should be performed by a physician who manages PD, namely a “specialist of dialysis: ‘Dialysist’.” Therefore, whether the physician is a nephrologist or surgeon becomes irrelevant.

After having confirmed the method of the operative procedure and the exit site, the surgical procedure is initiated. To reduce pain, local anesthesia, lumbar anesthesia, or general anesthesia is considered , and the application varies depending on the system of each institution and the area of surgical wound. However, elevated intraoperative intra-abdominal pressure may lead to prolapsed intestinal tract from the wounded area and may cause damage to the abdominal organs during surgery . Therefore, this author often elects general anesthesia. Access to the Posterior Sheath of the Rectus Muscle After Skin Incision

A catheter with a suitable tip length according to the body type should be selected. To prevent subsequent displacement of the catheter , it is desirable to choose a catheter with a thick-walled cuff to enhance self-recovery. Usually, the site of insertion is set at the breadth of 2–3 fingers inferior to the umbilicus. For incision into the abdomen, we believe that a transabdominal rectus incision should be considered rather than a median section or pararectal incision. First, as will be described later, it is necessary to lay a PD catheter as much as possible in order to insert it along the previous abdominal wall in the abdominal cavity . To achieve this, it is necessary to allow a long catheter to enter beneath the anterior sheath of the rectus abdominis muscle, which is an important factor in preventing dislocation of the catheter in the abdominal cavity. Details of this procedure are described below. Second, a transabdominal rectus incision should be used to prevent the spread of tunnel infection . There are abundant blood vessels in the rectus muscle, and their tissue affinity is also high, which results in the excessive formation of tight capsula fibrosa with many blood vessels around a catheter . This is effective in controlling infections because leukocytes respond to infection when a tunnel infection is spread towards the abdominal cavity beyond an external cuff.

The length of skin incision can be determined according to the operator’s skill. Safe and sufficient implantation, rather than the size of the wound, is priority. The anterior sheath of the rectus abdominis muscle can be accessed by a sharp and blunt dissection of subcutaneous fat after skin incision. Dissection bluntly sideways, rather than an incision, is conducted with a delicate retractor. The surgery time can be shortened by having an image that the stiff site is incised using an electric knife, which prevents damage to the anterior sheath of the rectus abdominis muscle. As shown in Fig. 13.2, the subcutaneous fat processes the head side than caudalis longer in asymmetric. As will be discussed later, this is necessary to insert it to let a catheter comply with the anterior sheath of the rectus abdominis muscle. Then which enables confirmation of the anterior sheath of the rectus abdominis muscle of approximately 5–6 cm. Before a longitudinal incision of this anterior sheath can be made, a pair of traction sutures is placed sideways to make a slight pull to expose the area at a shallow depth, which will allow a surgeon to perform the surgery. Subsequently, a small incision is made at the anterior sheath using an electric knife. The muscle is isolated with a Pean forceps, and then an incision is made while paying attention not to damage the rectus muscle. During this procedure, an incision is also longer in the head side than it is in the caudal side. Furthermore, the incision is oriented asymmetrically. The rectus muscle can thereby be observed under direct visualization. The elderly, particularly elderly women, may have small rectus muscles, which vary with each individual. The rectus muscle, which runs longitudinally, needs no incision as a matter of course. The posterior sheath of the rectus muscle can be exposed, after having isolated it sideways by inserting a Pean forceps into the muscular layer of the rectus muscle. The muscle is easily separable sideways by opening a delicate retractor slowly under this condition. The blood vessels and fibers, which are obstructive for isolation, are incised as needed, while creating a coagulation with an electric knife. Concurrently, attention should be paid to the presence of the inferior epigastric artery that ascends. This artery is wide and can be used for coronary artery bypass. When it is damaged, the visual surgical field is worsened and the occurrence of postoperative hematoma increases a risk of infection. If you recognized the inferior epigastric artery in this phase, you should not hesitate about ligation and cutting. Because it may cause the trouble when this artery is damaged when you have to remove the catheter for any reasons.


Fig. 13.2
Incision approach From Access to the Posterior Sheath of the Rectus Muscle to Catheterization

Once the posterior sheath of the rectus muscle is observed, the cavity in which the operation is performed should be shallow in order to secure a good visual field and a pair of traction suture is put in a similar manner, as described above. In doing so, it is important to create a thin and wide cavity, while taking into account the location of the concealed muscles that are close to the intestinal tract. This traction suture is pulled to make a small incision at the posterior sheath of the rectus muscle. The incision is made caudally, as shown in Fig. 13.2, in order to place a catheter during insertion, as mentioned above. Prior to incision, the peritoneum is pressed sideways and elevated with a small forceps to confirm that it forms a tent-like structure. This procedure is conducted by taking account of intestinal adhesion located under the peritoneum . When there are adhesions of the abdominal contents, such as intestinal tracts, the peritoneum does not become like a tent, but instead forms a thick shape that is easy to find. The fibers of the tent-like posterior sheath are incised gradually in a stepwise manner using a round-edged knife because the risk of damage will be increased if there are adhesions of the abdominal contents while incising it using scissors.

In many cases during this procedure, the peritoneum may also be incised together with the sheath and a small hole may be created that may reach to the abdominal cavity . In patients with severe obesity, pre-peritoneal fat may be observed. In such a case, particularly in patients in whom abdominal adhesions are suspected, it may be difficult to judge whether subcutaneous fat is pre-peritoneal or is in the peritoneal cavity, such as the mesenterium or omentum. A thin layer of peritoneum can be found after having slowly isolated the subcutaneous fat using a small forceps, which is pre-peritoneal fat. By incising its membrane, the abdominal cavity is exposed. It is likely to be peritoneal tissue when a wide blood vessel is observed. Even if peritoneal tissue is encountered, it is not difficult to manage unless vascular is damaged. In that case, insertion is performed from other sites.

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Mar 12, 2018 | Posted by in NEPHROLOGY | Comments Off on Peritoneal Access
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