CHAPTER 18 Peritoneal dialysis catheter placement
Step 1. Surgical anatomy
♦ The peritoneal dialysis (PD) catheter should enter the abdomen through the rectus muscle medial to the epigastric vessels, with the inner cuff positioned at the level of the parietal peritoneum.
♦ The PD catheter should exit the skin lateral to the abdominal entrance site, with the external cuff positioned approximately 2 cm from the exit site in a subcutaneous tunnel.
♦ The sites for catheter placement should be evaluated in the supine and sitting positions and in relation to undergarments to ensure that the patient can easily access the catheter. Placement below the belt line, within a skin fold, or in a location where body habitus and clothing cause catheter kinking or rubbing should be avoided.
♦ Previous abdominal incisions are not a contraindication to the laparoscopic approach but may direct the safest location for port placement.
♦ The course of the epigastric arteries must be visualized during port insertion through the rectus abdominis.
Step 2. Preoperative considerations
♦ The indications for laparoscopic PD catheter placement are identical to those of PD catheter placement via conventional minilaparotomy, blind percutaneous Seldinger, or peritoneoscopic technique. Indications include an inability to tolerate hemodialysis (e.g., heart disease or extensive vascular disease) or a stated preference for peritoneal dialysis. The benefit of peritoneal dialysis is the ability to perform dialysis at home as long as the patient or an assistant has the capacity to perform exchanges properly.
♦ Laparoscopic PD catheter placement allows complete visualization of precise intra-abdominal implantation, the ability to perform adhesiolysis if required, and the ability to secure the catheter in the pelvis if desired. For these reasons, both surgeons and nephrologists increasingly prefer laparoscopic PD catheter placement in comparison to the older methods of percutaneous Seldinger technique, peritoneoscopic approach, and open placement via minilaparotomy.
♦ Contraindications to PD include the extensive adhesions that would prohibit adequate dialysate flow, an irreparable abdominal wall hernia, diaphragmatic defects predisposing to hydrothorax, and severe lung disease to a degree that increased intra-abdominal volume would compromise respiratory function. Morbid obesity is a relative contraindication.
♦ Most experts feel that the initial higher cost of laparoscopic PD catheter placement is more than offset by the lower incidence of costly later complications in comparison with open surgical placement or blind percutaneous placement.
♦ Appropriate preoperative teaching and arrangements for initial supervised sterile dressing changes should be made before operation.
Patient preparation and anesthesia
♦ Patients wash their abdomen with chlorhexidine the evening prior to surgery.
♦ In the setting of known constipation, an enema or suppository can be given preoperatively to facilitate rectosigmoid emptying.
♦ Hair is removed with electric clippers.
♦ Patients who continue to make urine empty their bladder immediately before operation or have a Foley catheter inserted.
♦ One to 2 grams of cefazolin IV is given 30 minutes before the operation.
♦ The patient is placed supine on a bed capable of Trendelenburg positioning.
Step 3: Operative steps
♦ The operative goals of PD catheter placement, all of which maximize function and prevent complications, include placement of the catheter tip deep in the dependent portion of the pelvis, appropriate positioning of the dual felt cuffs and subcutaneous portion of the catheter, and creation of a functional exit site.
♦ Multiple laparoscopic PD catheter placement techniques have been described, using a range of 1 to 3 laparoscopic ports. All techniques that allow for placement under continuous direct vision, including descriptions of a “1-port” approach, require at least 2 fascial defects. Although some surgeons call their technique “one-port”, they use one port for a camera and then another hole is made in the abdominal wall to insert the catheter without placing an actual laparoscopic trocar.
♦ Conventional minilaparotomy should be considered in patients with severe cardiopulmonary disease who may not tolerate pneumoperitoneum.
♦ The abdomen is widely prepped from the xiphoid to the pubis, allowing for the possibility of a midline laparotomy.
Two-port technique
Access and port placement
♦ Incision locations are marked on the patient after placing the PD catheter in the desired location on the abdomen as a guide. With the distal catheter coil overlying the superior pubis, the eventual location of the deep cuff is marked on the skin. This point corresponds to the anticipated trocar entry point through the fascia into the peritoneum.
♦ A 5-mm curvilinear incision is made just below the umbilicus, and the subcutaneous tissue is spread bluntly. If previous periumbilical or midline incisions are present, this initial port placement can be made lateral to the rectus muscle near the level of the umbilicus. In patients who have had previous extensive abdominal surgery, placement of the initial trocar is best performed with a cutdown under direct vision.
♦ With upward traction on the abdominal wall, a Veress needle is placed via this incision through the midline fascia. The intraperitoneal position is confirmed with a hanging drop test and low-pressure readings on initiation of insufflation. The peritoneal cavity is then insufflated to 15 mmHg with carbon dioxide (Figure 18-1).
♦ A 5-mm trocar is placed into the abdomen through the infraumbilical incision, through which a 5-mm 30-degree laparoscopic camera is placed.
♦ Diagnostic laparoscopy is undertaken with attention directed to identifying any inguinal or abdominal wall hernias requiring prophylactic repair or adhesions or omental redundancy that could potentially obstruct pelvic placement or catheter drainage.
♦ In the event that adhesiolysis, omentectomy, or tacking up of redundant omentum proves necessary to allow pelvic placement of the catheter, a third 5- to 10-mm working port is placed through the contralateral abdominal wall.
♦ A second 8-mm horizontal stab incision is made 4 to 5 cm lateral and 2 to 3 cm inferior to the umbilicus. An 8-mm nonbladed trocar (Ethicon Excel B8LT; Ethicon, Somerville, New Jersey) is advanced subcutaneously in a medial and slightly caudal trajectory toward the pelvis. A 5- to 6-cm subcutaneous tunnel is created before angling the trocar perpendicular to the abdominal wall and piercing the intervening fascia and peritoneal envelope. Care should be taken to direct the trocar through the rectus abdominis muscle medial to the epigastric vessel, which can often be visualized with the laparoscope. All intraperitoneal manipulations should be done under direct vision.
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