Laparoscopic-assisted peritoneal dialysis catheter placement: a microinvasive technique

Technique Surg Endosc (2007) 21: 825–829 DOI: 10.1007/s00464-006-9148-x Ó Springer Science+Business Media, Inc. 2007

Laparoscopic-assisted peritoneal dialysis catheter placement: a microinvasive technique Sergio A. Carrillo,1 Marcelo M. Ghersi,2 Stephen Wise Unger2 1 2

Department of Surgery, University of Louisville, Louisville, 40202, KY, USA Department of Surgery, Mount Sinai Medical Center, Miami Beach, FL, USA

Received: 1 October 2006/Accepted: 30 November 2006/Online publication: 1 March 2007

Abstract Background: Peritoneal dialysis is an alternate form of dialysis for patients with end-stage renal disease (ESRD). Although not as widely used as hemodialysis, peritoneal dialysis (PD) has clear advantages, especially those related to patient satisfaction and simplicity. The purpose of our study was to describe and look at the results of a microinvasive technique for placement of peritoneal dialysis catheters under laparoscopy. Methods: From August 2003 to January 2006, 12 patients with ESRD underwent laparoscopic-assisted peritoneal dialysis (LAPD) catheter placement with the microinvasive technique at our institution. Data collected included age, gender, underlying renal disease, and length of operation. Followup was completed for all patients (at least 6 months) and catheter-related morbidity and mortality were also analyzed. Results: There were 13 procedures performed (one patient had LAPD catheter placement twice). The average age was 45 years and the most common cause of ESRD was uncontrolled arterial hypertension. Procedural time averaged 33.6 min (range = 24–50 min). Peritoneal dialysis was introduced two weeks after the procedure and no dialysate leaks were observed. There were two catheter-related morbidities; both were catheter exit-site abscesses, one managed surgically with removal of the PD catheter and the other managed conservately with culture-sensitive antimicrobials. Patient satisfaction was beyond acceptable in 92% of the patients (12 of 13). Average longevity of the catheter was 61 weeks (427 days). There were no mortalities. Conclusion: LAPD catheter placement is an easy technique with acceptable catheter longevity and minimal morbidity. The microinvasive technique leads to better patient satisfaction and cosmetic outcome without affecting its function. Therefore, we believe that by promoting microinvasive LAPD catheter placement, PD will gain more acceptance among doctors and patients. Correspondence to: Sergio A. Carrillo

Key words: Laparoscopy — Peritoneal dialysis — Micro-invasive — Peritoneal dialysis catheter

Continuous ambulatory peritoneal dialysis (CAPD) has been an effective method of dialysis for patients with end-stage renal disease (ESRD) for 30 years, since its introduction in 1976 [20, 32, 37, 38]. As of 2004, the National End-Stage Renal Disease program reported a total of 431,284 patients afflicted with ESRD, representing a total cost of $25.2 billion. Of these, 308,910 are prevalent dialysis patients and only 12.31% of these patients receive peritoneal dialysis [12, 46]. The advantages that peritoneal dialysis (PD) has over hemodialysis (HD) include lower costs, simplicity of the technique, increased patient mobility and independence, fewer dietary restrictions, better blood pressure control, and better patient satisfaction [6, 10, 20, 28, 32, 39, 42]. Disadvantages include catheter-related infections (peritonitis, exit-site/subcutaneous tract abscess), catheter malfunction or dislodgement, cuff extrusion, dialysate leakage, hernias, respiratory compromise, or genital edema [13, 18, 20, 25, 28, 41]. Implantation techniques for peritoneal dialysis catheters have shifted from open toward minimally invasive over the past 20 years. The most widely used is the open technique [6, 39], which requires a minilaparotomy [3, 7, 8]. Its simplicity allows placement by surgical residents under supervision at many institutions [34]. However, in patients with previous abdominal surgeries, proper placement of the catheter becomes a challenge given the limited view of the peritoneal cavity and the presence of adhesions [14, 40, 49], leading to incorrect placement and a rate of outflow obstruction as high as 22% [7, 8, 10, 35]. This prompted the development of a new way of placing PD catheters, the peritoneoscopic-assisted technique [1, 9]. Largely used in the early and mid-1980s by nephrologists and surgeons, it easily gained wide acceptance because of better

826 Table 1. Patient demographics and clinical parameters Patient No.

Gender

Age (yr)

Cause of ESRD

Previous abdominal surgeries

Associated surgical procedures

Operative time (min)

Complications (catheter related)

Longevity weeks (days)

1 2

F F

67 60

HTN, DM APKD

TAH, tubal ligation TAH

Adhesiolysis Liver biopsy

45 47

140 (1,050) 132 (924)

3 4 5

F F M

55 40 24

APKD

Liver biopsy Adhesiolysis Adhesiolysis

37 24 50

6 7

M M

19 38

HTN HTN

None None

22 27

None None

72 (504) 52 (364)

8

M

65

HTN

Adhesiolysis

38

F M F F F

26 39 66 26 69

SLE DM DM, HTN SLE DM, HTN

None None None None Adhesiolysis

30 25 33 34 25

Exit-site infection, Subcutaneous tract abscess Infected cath, removed None None None None

16 (112)

9 10 11 12 13

C-section Closed PD cath Closed PD cath, open appendectomy None Closed PD cath, open appendectomy TAA repair, bilateral inguinal hernias None None C-section None Open cholecystectomy

None Abdominal pain with emptying/filling of dialysate None None None

HTN

124 (868) 100 (700) 84 (588)

8 24 24 20 8

(60) (168) (168) (140) (60)

ESRD = end-stage renal disease; HTN = hypertension; DM = diabetes mellitus; APKD = adult polycystic kidney disease; SLE = systemic lupus erythematosus; TAH = total abdominal hysterectomy; PD = peritoneal dialysis; TAA = thoracic aorta aneurysm

outcomes and less outflow obstruction and related infections compared with the open technique [26, 31, 36]. With the advent of laparoscopic surgery, new minimally invasive techniques were developed to reposition malfunctioning catheters [16, 17, 22, 24] and to assess the adequacy of the peritoneal space for dialysis [4, 5, 48]. Reports on new placements in both adults and children followed [3, 7, 8, 27, 29, 32–34] as well as the use of laparoscopy to assist in the diagnosis and correction of associated problems, including umbilical hernias, inguinal hernias, ovarian cysts, and adhesions [15, 20, 34]. The benefits of laparoscopic-assisted PD (LAPD) catheter placements are many, including reduced incidence of pulmonary infections and therefore better postoperative ventilation, less postoperative pain, shortened hospital stay, and earlier resumption of social and personal life [20, 43]. Furthermore, compared with the open approach, LAPD allows better visualization of the peritoneal cavity, improved diagnosis and treatment of associated pathology, less exit-site leakage of dialysate, and less outflow obstruction with the omental fixation technique [3, 20, 33, 34]. Also, it can be performed under local anesthesia [8]. As minimally invasive techniques and better cosmetic outcomes become increasingly important for surgery patients, the surgical community has converted minimally invasive surgeries into even smaller microlaparoscopic techniques, with fewer and smaller incisions [21, 23, 44, 45]. Better optics, smaller instruments, and more experienced laparoscopic surgeons have allowed such changes to take place. We hereby present our experience with a new microinvasive laparoscopic placement technique for PD catheter implantation (Table 1).

Materials and methods The data presented are a retrospective analysis from a total of 13 laparoscopic-assisted peritoneal dialysis (LAPD) catheter placements

from August 2003 to January 2006. Twelve patients underwent the LAPD catheter placement. Demographic data collected included gender, age, underlying renal disease, duration of PD catheter before laparoscopy, indications, time of operation, type of concomitant laparoscopic procedures, postoperative complications, and catheterrelated morbidity and mortality. Followup for all patients was a minimum of six months or until transplantation.

Operative procedure The procedure used was the same for all patients. Patients were placed in a supine position, and general anesthesia via endotracheal intubation was attained, as well as nasogastric intubation. The entire abdomen was prepped and draped from the nipples to the symphysis pubis. The surgeon stood at the patientÕs right side. Surgeries were performed by a surgical resident as the operating surgeon (usually second- or third-year residents) with a surgical attendant assisting. In patients without previous surgeries, a 5-mm vertical umbilical incision is made and a Veress needle is used to enter the abdominal cavity. In patients with previous surgeries, a marking pen is used to indicate reference points and intended sites for incisions; the initial incision is made in the right or left upper quadrant, away from scars to avoid possible adhesions. Proper position of the Veress needle is confirmed with the water-drop test, followed by insufflation of CO2 to create a pneumoperitoneum of 12-13 mmHg. For port placement, a 5mm incision is made, followed by blunt introduction of Versa-Step port (US Surgical, Norwalk, CT) device with expandable plastic sleeves. After placing patients in Trendelenburg position, a diagnostic laparoscopy is performed with a 5-mm 0° camera (Karl-Zeiss, Jena, Germany), allowing direct visualization of the peritoneal cavity and assessment of adequacy for peritoneal dialysis. An accessory 5-mm port is placed in one of the lower quadrants for a 5-mm instrument. Adhesions, if any, are lysed using the Ligasure device (US Surgical, Norwalk, CT) or endoscopic scissors. A double-cuff, curled-tip PD catheter is then inserted through the umbilical port under direct visualization after removal of the trocar device. The tip of the catheter is directed toward the pelvic cavity and away from any area with previous adhesions, with the inner Dacron cuff left just at the fascial level. A 3-mm incision is made in the opposite lower quadrant 2 cm below the level of the umbilicus along the midclavicular line. With the aid of a 3-mm metal-bladed port, the desired subcutaneous tunnel is fashioned, and a grasper is pushed through, where the proximal end of the catheter is grasped and pulled out through the newly made incision along with the port, leaving the outer Dacron cuff in the subcutaneous tissue path. The pelvic position of the catheter is confirmed after this maneuver. The position of the inner Dacron cuff at the level between the peritoneum and posterior rectus muscle sheath is also confirmed.

827 Ports are then removed under direct visualization. The pneumoperitoneum is evacuated and the patency of the PD catheter is confirmed by a rapid in-and-out exchange of normal saline. All skin incisions are closed with a single-stitch subcuticular closure with 4-0 monocryl and injected with 0.5% marcaine. In our 12 patients no stitches were deemed necessary to close the fascia nor were any used at the catheter exit site for fixation. Liquid tissue adhesive is used in cases where PD is needed before two weeks time to prevent leakage of dialysate.

Results The decision to use peritoneal dialysis instead of hemodialysis was determined by patient or nephrologist preference, inability to undergo hemodialysis, and vascular access problems (i.e., central stenosis). Our study group consisted of five males and seven females with an average age of 45 (range = 19–69) years. The causes of renal failure included diabetes mellitus, arterial hypertension, systemic lupus erythematosus, and polycystic kidney disease. Of the 12 patients, nine (70%) had previous abdominal surgery, including hysterectomy, cesarean section, open cholecystectomy, and previous attempts at closed peritoneal catheter placement. Also, we performed associated laparoscopic procedures, more commonly, adhesiolysis and liver biopsies, in seven patients (58%). Procedural time ranged from 24 to 50 min (average = 33.6 min). Complications included one catheter that needed to be removed two months after its placement because of a scheduled living-donor kidney transplant (patient 13). An episode of severe acute pancreatitis (unrelated to dialysis) prompted the removal of the PD catheter in patient 4. There were no deaths. Patient satisfaction was beyond acceptable for 12 of the 13 procedures (92%). Catheterrelated morbidity included two episodes of catheter exitsite infection. This prompted catheter removal in one case for fear of contamination of the peritoneal cavity (patient 9). Another LAPD catheter was placed once the infection cleared. The other case (patient 8) was managed conservatively with culture-sensitive antibiotics and incision and drainage of abscess. Another patient (patient 2) underwent a laparoscopicassisted sigmoid colectomy with pneumoperitoneum inflation through the catheter, re-establishing peritoneal dialysis two weeks after the abdominal procedure. There were no observed dialysate leaks from fascial defects. In one case (patient 2), there was temporary discomfort with the dialysate cycles that resolved spontaneously after a few cycles. In all the cases, PD was started two weeks after surgery. Longevity of the catheter ranged from 8 to 140 weeks (60–1050 days) with an average of 61 weeks (427 days). Followup was a minimum of six months, after which catheter-related morbidity and function and skin incision appearance were assessed.

Discussion Peritoneal dialysis (PD) is an alternate, affordable, feasible, and readily available form of dialysis [28, 34].

Despite these advantages, PD has not gained wide acceptance and hemodialysis is still preferred. We believe that this is largely due to less education about and less promotion of PD. The catheter placement technique for PD has changed over the past three decades from the open technique to the now more accepted laparoscopic-assisted technique. With the aid of laparoscopy, one can rescue a malfunctioning catheter, place a new catheter [1, 3–5, 7, 8, 11, 16, 17, 19, 20, 22, 29, 31, 32, 34, 36, 47, 50], and simultaneously perform other laparoscopic procedures, as reported by us and others [20, 34]. For this reason laparoscopy has widened the indications for PD. Now that laparoscopy is moving toward microinvasiveness with the use mini-incisions and smaller and thinner instruments [21, 45, 50], procedures can be performed with smaller incisions and even less trauma to the patient with the same results. The findings of our study show that minilaparoscopy can be performed easily and renders better aesthetic results with no increase in the morbidity or mortality of the procedure nor compromise of catheter function. Laparoscopy has been shown to be superior to closed techniques because it enables direct visualization of the entire peritoneal cavity. Hence, it is the ideal method for evaluating the peritoneal cavity for the purpose of dialysis [15, 20, 30, 34, 47]. In our study we performed diagnostic laparoscopy at the beginning of the procedure and deemed the peritoneal cavity adequate after adhesions were taken down, if necessary. The PD catheter placement technique entails the use of two or three ports [7, 32, 34], one umbilical of 10 mm and two lower-quadrant ports of 5 mm. We recommend the use of only two 5-mm trocars, one umbilical (which will be the entry point of the catheter to the peritoneum) and one 5-mm working port, thus minimizing tissue trauma. Finally, a 3-mm incision in a lower quadrant is made from which the catheter exits after being pulled through the subcutaneous tissue from the umbilical incision. The use of radially expanded tissue tract ports leaves a smaller hole than the one produced by cutting blades, therefore reducing the risks of hernias and postoperative leaks [2, 7]. We believe that the use of smaller incisions coupled with the use of radially expandable dilatation yielded no occurrence of dialysate leaks, less bleeding, and no hernias in our study. Outflow obstruction is seen in 4.5%–13% of LAPD placements, mainly due to migration, omental wrapping, malpositioning at operation, and adhesions [3, 20, 29, 34]. In our series there was only one case (7%) of outflow obstruction and it resolved spontaneously without additional procedures. We believe that the obstruction was secondary to temporary catheter migration. The leakage rate can range between 5% and 25% and remains a major concern, especially with larger incisions and institution of early peritoneal dialysis [3, 4, 8, 15, 29, 32]. We failed to identify a single dialysate leak after a minimum of six months of followup. That could be explained by the use of smaller incisions, radially expandable port sleeves, and institution of PD two weeks after the procedure. Long-term followup will be needed to confirm these early results.

828

Procedural time using the LAPD technique ranged from 24 to 50 min (average = 33.6 min), which is comparable to the duration of an open technique (average = 30.9 min), as reported by O¨g˘u¨nc¸ et. al. [34]. For patients who needed adhesiolysis, the duration of the procedure increased by 5–10 min, as seen in patients who undergo simultaneous omentopexy or other procedures (i.e., hernia repair, ovarian cystectomy) [34]. In our study the procedure was performed by a team consisting of a junior surgical resident and a senior attendant, yielding faster times from sufficient knowledge of basic laparoscopic skills. Infectious complications are not frequently seen; these range from simple skin infections to more lifethreatening situations, like secondary peritonitis with a mortality rate of 40%–60% if diagnosed late [18, 20]. In our study there were two catheter-related infections. The first one was an exit-site and subcutaneous tract abscess managed with local incision and drainage and culturesensitive antibiotics without the need to stop PD. The other case was gross contamination of the catheter site with early secondary peritonitis; the catheter was removed and the infection was treated. That same patient underwent new LAPD catheter placement 45 days later and has remained free of infections. At completion of the first six months of followup, 77% (10 of 13) of the catheters were being used without difficulties. Three cases did not complete the six-month followup. In one case (patient 8) the catheter was removed after four months because of a living-related kidney transplant. In another case (patient 9) the catheter needed to be removed secondary to gross contamination from an exit-site abscess. In the third case (patient 13) the catheter was removed because of patient preference to go back to hemodialysis despite adequate function of PD. As seen in the study by O¨g˘u¨nc¸ et al. [34], catheters placed laparoscopically have better-long term survival after six months compared with open technique. In our study longevity ranged from 8 to 140 weeks (average = 61 weeks). We believe that catheters that survive longer than six months will ultimately function properly without any difficulties.

Conclusions Peritoneal dialysis is still second choice to hemodialysis for patients suffering from ESRD. With the advent of laparoscopy, placement of catheters is easier and more reliable than conventional open surgery, rendering better function and longevity. Furthermore, additional procedures deemed necessary can be performed at the same operative time. With the advent of new and smaller instruments, the benefits of laparoscopic placement of catheters are greater, causing minimal trauma. In our practice, we perform only the laparoscopic technique because of it is superior to open procedures and is easy to perform. Therefore, we recommend the laparoscopic procedure at all times and we encourage our patients to consider the option of PD over hemodialysis.

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