|Year : 2017 | Volume
| Issue : 4 | Page : 131-134
Laparoscopic-assisted peritoneal dialysis catheter insertion with two 5-mm ports: Complications and outcomes of 30 cases
Kung-Ning Hu1, Kun-Hung Shen2, Chih-Chiang Chien3, Chien-Liang Liu1
1 Department of Surgery, Division of Urology, Chi Mei Medical Center, Tainan, Taiwan
2 Department of Surgery, Division of Urology, Chi Mei Medical Center; Center for General Education, Southern University of Science and Technology, Tainan, Taiwan
3 Department of Medicine, Division of Nephrology, Chi Mei Medical Center, Tainan, Taiwan
|Date of Submission||13-Oct-2016|
|Date of Decision||13-Jan-2017|
|Date of Acceptance||15-Feb-2017|
|Date of Web Publication||19-Jul-2017|
901, Tzong.Huang Road, YongKang, Tainan
Source of Support: None, Conflict of Interest: None
Introduction: End-stage renal disease has high prevalence in Taiwan, and peritoneal dialysis (PD) is one of the effective treatments. Although the open catheter placement method is more popular, the laparoscopic method is proven to be superior. We present our initial experience with laparoscopic PD catheter insertion.
Materials and Methods: We set one 5-mm trocar over the periumbilicus with another assisting 5-mm trocar in a region about 3 cm lateral to the umbilicus. Abdominal exploration using laparoscopy is performed, and enterolysis is also performed if needed. The PD catheter is inserted through the assisted trocar deep into the Douglas pouch under vision. Finally, we check the final condition under laparoscopy and close the wound.
Results: A total of thirty patients (median age 56.5 years old, 15 women) underwent this procedure. No intraoperative complications were noted, and the mean operation time was 32 min. Two postoperative complications were found (2/30, 6.7%). Delayed bleeding was noted due to abdominal wall vessel injury while setting the trocar. The vessel was sutured under laparoscopy, which stopped the bleeding. The other complication was tube dysfunction due to omentum wrapping. Laparoscopic revision of the tube was performed. All the complications could be resolved, and the PD was continued. The mid-term tube function at follow-up (at least 16 months) was acceptable in all cases.
Conclusions: Laparoscopic-assisted PD catheter insertion is a feasible procedure that can reduce wound pain with acceptable PD function.
Keywords: End-stage renal disease, laparoscopy, peritoneal dialysis, Tenckhoff catheter
|How to cite this article:|
Hu KN, Shen KH, Chien CC, Liu CL. Laparoscopic-assisted peritoneal dialysis catheter insertion with two 5-mm ports: Complications and outcomes of 30 cases. Formos J Surg 2017;50:131-4
|How to cite this URL:|
Hu KN, Shen KH, Chien CC, Liu CL. Laparoscopic-assisted peritoneal dialysis catheter insertion with two 5-mm ports: Complications and outcomes of 30 cases. Formos J Surg [serial online] 2017 [cited 2017 Sep 19];50:131-4. Available from: http://www.e-fjs.org/text.asp?2017/50/4/131/211083
| Introduction|| |
End-stage renal disease (ESRD) has high prevalence in Taiwan, and peritoneal dialysis (PD) is one of the effective treatments. The success of PD is contingent on the presence of durable and functional catheter access to the peritoneal cavity. Infectious complications, mechanical catheter problems, and catheter implantation by laparotomy without catheter fixation are common disadvantages for the success of PD. Some studies conclude that the laparoscopic technique is feasible and safe for PD catheter implantation with intra-abdominal fixation of the catheter tip. The procedure features low incidence of PD catheter migration, obstruction, and other PD-related postoperative complications. Other benefits also include minimal invasiveness, shorter operation time, and quicker postoperative recovery.
Although the open catheter placement method is more popular, the laparoscopic method is proven to be superior. We present our initial experience with laparoscopic PD catheter insertion. We also discuss problems encountered and how we dealt with the modified technique.
| Materials and Methods|| |
We retrospectively reviewed thirty patients with ESRD who underwent laparoscopic PD catheter implantation with an intra-abdominal fixation by one surgeon in Chi-Mei Hospital from May 2013 to July 2015. We recorded the operation time (the time between starting and completing the operation excluding the anesthesia time) and the postoperative outcomes, including the postoperative hospital stay, short-term complications (<30 days after the operation), and morbidity. Long-term clinical outcomes were also collected (>30 days after operation).
The operation technique
All patients received general anesthesia in a supine position. In all cases, 1 g of cefazolin was used 30 min before surgery. First, we marked three points: (a) the umbilical port site, (b) an insertion site located 3 cm lateral to the umbilicus, and (c) the exit site measured by the Tenckhoff catheter [Figure 1]. Carbon dioxide insufflation of the pneumoperitoneum was established through the umbilical port with a Veress needle, and the intraperitoneal pressure was maintained at 15 mmHg. A 5-mm trocar was inserted, and a 5-mm laparoscope was used to detect the occult inguinal hernia or intra-abdominal adhesion.
|Figure 1: (a) Umbilical port site: 5mm; (b) Insertion site: 20mm, located 3cm to the umbilicus; (c) Exit site: 5mm with the exit part of the Tenckhoff catheter|
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We made a 20-mm skin incision at the insertion site and separated the subcutaneous fat until reaching the anterior rectus sheath. We then obliquely inserted a 5-mm trocar into the abdominal cavity with a 45° angle from the abdominal wall under laparoscopic vision to prevent injury to the abdominal wall vessels, such as the inferior epigastric vessels [Figure 2]a. We inserted a Terumo Guidewire (RADIFOCUS ® M 0.89 mm) into the Douglas pouch through the trocar at the insertion site and then removed the trocar.
|Figure 2: (a) Insert a 5-mm trocar into the abdominal wall obliquely; (b) Insert the Tenckhoff catheter into the Douglas pouch via the guidewire; (c) Fix the deep cuff of the Tenckhoff catheter by the rectus muscle|
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The Tenckhoff catheter was inserted through the Guidewire into the Douglas pouch [Figure 2]b. A 1-cm long incision of the anterior rectus sheath was made to bury the deep cuff, which was then closed with 3-0 Dexon sutures. The Tenckhoff catheter was fixed by the rectus muscle with a length of 3–4 cm to prevent catheter migration [Figure 2]c. Satisfactory catheter irrigation and outflow were confirmed. The Tenckhoff catheter exited from the exit site (point c) under the subcutaneous route by the curved trocar as in the open method [Figure 3]. Regular PD could be initiated 2 weeks later.
|Figure 3: The Tenckhoff catheter exited from the exit site by the curved trocar as in the open method|
Click here to view
The study was conducted in accordance with the Declaration of Helsinki and was approved by the local ethics committee of the institute. Informed written consent was obtained from all patients prior to their enrollment in this study.
| Results|| |
Our study included thirty patients (15 males and 15 females) with ESRD from May 2013 to July 2015. The median age was 56.5 years (range 30–77 years). The mid-term tube function at follow-up (at least 16 months) was acceptable in all cases. Demographic data are summarized in [Table 1].
No intraoperative complications were noted, and the mean operation time was 32 min. Two postoperative complications were found (2/30, 6.7%). Delayed bleeding at one trocar site was noted due to injury to the abdominal wall vessel when setting the trocar. Emergent surgery was arranged immediately. The vessel was sutured with a punch needle from the insertion site (point B) without another trocar under laparoscopic view.
The other complication was a tube dysfunction due to coating by the omentum. Laparoscopic revision of the tube was arranged. All of the complications could be resolved, and the PD could be continued smoothly. One male patient with a history of appendectomy had peritoneal adhesion, which was treated laparoscopically with adhesiolysis without a third trocar site at the same time. The hospital parameters and postsurgical complications are summarized in [Table 2].
| Discussion|| |
In open surgery or the percutaneous technique, placing the catheter within the peritoneal cavity is a blind step that cannot provide the optimal position of the catheter in the cavity. Moreover, it could also result in severe complications, including damage to the inferior epigastric vascular artery or abdominal organs such as the bladder or intestine. Previous studies revealed the benefits of the laparoscopic PD catheter insertion technique compared with the open method. The advantages include higher catheter survival at 1 year, lower incidence of catheter migration, higher patient comfort, reduced morbidity, reduced postoperative pain, and reduced hospital stay.,, Furthermore, laparoscopic PD insertion can reduce hospital costs compared to the open method. Thus, we tried to shift from the open method to laparoscopic PD catheter insertion.
Another advantage of the laparoscopic technique is that it allows for exploration of the abdominal cavity to determine the existence of occult inguinal hernia and intra-abdominal adhesions that might interfere with drainage function. Furthermore, we can perform adhesiolysis to avoid obstruction of the catheter postoperatively if needed., We encountered no damage to abdominal organs in our study, and no inguinal hernia or peritoneal adhesion was found in our patients.
Intra-abdominal catheter malfunction is a common complication of PD. It can result from catheter migration, malposition of the catheter tip, fibrin deposition, omental wrapping, obstruction secondary to intra-abdominal adhesions, or infection. A comparison study between the laparoscopic and open techniques found that catheter migration occurred in 12% of patients in the open group, whereas none occurred in the laparoscopic group (P < 0.05). One retrospective study found that the incidence of catheter tip migration and omental entrapment was 1.7% and 2.9%, respectively. Only one patient in our study (3.3%) had a postoperative complication of PD dysfunction due to omentum-related adhesion to the Tenckhoff catheter. Another surgery with laparoscopic revision of the Tenckhoff catheter was arranged to resolve the complication.
Ma et al. reported that a temporary pericatheter leak occurred in 7.4% of cases. In terms of long-term outcomes, Crabtree and Burchette reported on a series of 428 patients with ESRD after a mean follow-up of 21.6 months. The results showed that mechanical outflow obstruction complications occurred in 3.7% of the implantation procedures, and the incidence of pericatheter leak was 2.6%. There was no exit-site leakage in our cases.
A meta-analysis by Xie et al. concluded that laparoscopic catheter placement is not superior to the open method. However, the studies in the analysis did not include criteria that should be used for a meta-analysis regarding this specific topic, and there was possible selection bias; hence, false conclusions could have been drawn. In addition, the papers by Lund and Jønler were not included in the study., One case of delayed bleeding at the trocar site was noted in our study (3.3%) due to abdominal wall vessel injury when setting the trocar. However, we stopped the bleeding easily by simply suturing the vessel under laparoscopic view.
Compared to blind insertion, we could place the catheter in the appropriate region under vision, which could lead to better function. Compared to multiple previous cases reports, we used a smaller trocar (5 mm). Another modification is that we reduced the number of incisions using the assisting trocar in addition to the tube-inserted incision. Only one case report by Hori et al. used two trocar ports before our case series.
| Conclusions|| |
The laparoscopic technique for PD catheter implantation with two 5-mm ports is feasible and safe. The mid-term results showed the benefits of minimal invasiveness, shorter operation time, quicker postoperative recovery, and low incidence of PD catheter obstruction and migration.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]