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Many burdensome interventions that adversely affect the utilization of peritoneal dialysis as renal replacement therapy and patient satisfaction with this treatment modality can be avoided by early peritoneal access placement with embedded catheters, implantation techniques that preempt common catheter complications, and the use of access devices that provide flexibility in exit site location. Catheter embedding consists of subcutaneously burying the external limb of the catheter tubing at the time of the insertion procedure. Interval exteriorization of the catheter is performed when dialysis is needed. Earlier commitment by patients to peritoneal dialysis can be achieved by elimination of catheter maintenance until dialysis is necessary. Catheter embedding is a practical strategy to avoid temporary hemodialysis with vascular catheters and reduces stress on operating room access by allowing more efficient scheduling as non-urgent procedures. Laparoscopic catheter placement enables proactive techniques not available to other conventional insertion methods. These techniques include rectus sheath tunneling to prevent catheter tip migration, selective prophylactic omentopexy to prevent omental entrapment, selective resection of epiploic appendages to prevent catheter obstruction, adhesiolysis to eliminate compartmentalization, and diagnosis and simultaneous repair of previously undiagnosed abdominal wall hernias. Both standard and extended 2-piece catheter systems are necessary to customize the peritoneal access to a variety of body configurations. Catheters should be able to produce lower abdominal, mid-abdominal, upper abdominal, and upper chest exit site locations that facilitate management by the patient without sacrificing deep pelvic position of the catheter tip or resulting in excessive tubing stress during passage through the abdominal wall.

Both medical benefits to the patient and financial incentives to the health care system exist to increase the use of peritoneal dialysis as renal replacement therapy. Providing long-term peritoneal access free of mechanical dysfunction continues to represent a major challenge to the success of this modality. Variable outcomes result from the lack of standard implantation methodology and failure to address persistent problems associated with current implantation techniques. This prospective case study compared noninfectious procedural complications of three approaches to establish peritoneal dialysis access. The groups consisted of 63 catheters implanted by traditional open dissection, 78 catheters implanted by basic laparoscopy without associated interventions, and 200 catheters implanted by advanced laparoscopic methods including rectus sheath tunneling, selective prophylactic omentopexy, and selective adhesiolysis. Mechanical flow obstruction, the major outcome indicator, followed only 1 of 200 (0.5%) implantation procedures in the advanced group and was significantly better ( P < 0.0001) than the open dissection (17.5%) and basic laparoscopic (12.5%) groups. A low rate of pericannular leaks (1.3–2%) was not different for the three groups. One pericannular hernia occurred in the open group. Catheter mechanical dysfunction attributable to the surgical technique can nearly be eliminated through adjunctive procedures made possible only by a laparoscopic approach.

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Objective Presented herein is a technical description of a time-proven laparoscopic approach to establishing successful long-term peritoneal dialysis access. Design Using a two-port technique, the peritoneal catheter is inserted through a paramedian port site while continuously monitoring the implant procedure with a laparoscope from a second port location. A long rectus sheath tunnel created with a nontrocar port device keeps the dialysis catheter oriented toward the pelvis. Helium abdominal insufflation enables full surgical laparoscopy under local anesthesia. Validation of the effectiveness of the technique is made by comparison to previous implantation experience using an open dissection method. Patients Laparoscopic implantation of peritoneal catheters was performed in 150 patients, and placement by open dissection was accomplished in 63 patients. Main Outcome Measure The incidence of complications and revision-free catheter survival between implantation methods were compared. Results Catheters implanted laparoscopically had a significantly lower incidence of flow dysfunction ( p < 0.05) and better survival ( p < 0.001) than those placed by open dissection. Conclusions Compared to implantation by open dissection, the laparoscopic approach provides the patient reduced perioperative discomfort. The procedure can be performed safely with the patient under local anesthesia on an ambulatory basis. Laparoscopic implantation significantly reduces the incidence of catheter flow dysfunction and permits simultaneous identification and correction of other problems that could complicate dialysis therapy.

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Implantation of peritoneal dialysis catheters by traditional laparotomy or trocar/guidewire techniques leaves the operator blind to the actual location and configuration of the peritoneal catheter tubing; it is associated with drainage dysfunction from catheter obstruction in 10-22% of catheter placements. This report presents a laparoscopic technique that allows accurate tube placement with complete visualization of the implant procedure. The peritoneal dialysis catheter was implanted through a port inserted in a paramedian location. Videoscopic monitoring was performed through a second port inserted in a pararectus location on the opposite side of the abdomen. Nitrous oxide gas was utilized for peritoneal insufflation thus permitting the procedure to be accomplished under local anesthesia. Follow-up of