A Laparoscopic Approach under Local Anesthesia for Peritoneal Dialysis Access

Abstract

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.

Long‐Term Complication Rates and Survival of Peritoneal Dialysis Catheters: The Role of Percutaneous Versus Surgical Placement

“…The catheter loss and survival rates for both our groups generally averaged the results reported in published studies using fluoroscopic (21,22), peritoneoscopic (14,30), laparoscopic (15,17,19), or surgical techniques (7)(8)(9). Laparoscopic insertion has the advantage of adhesiolysis, omentopexy, and repair of abdominal wall hernias (18) (15), in which the replacement rate was reduced to 1% after salvage of malfunctioning PDCs (6%) with laparoscopic revision. Although the design of our study does not allow us to make direct comparisons, it is worth mentioning that our results approached those reported by the above authors, when restricting our analysis to within the last 9 years.…”

“…Although the design of our study does not allow us to make direct comparisons, it is worth mentioning that our results approached those reported by the above authors, when restricting our analysis to within the last 9 years. In a study by Crabtree et al (18), PDC survival probability was higher for the laparoscopic group as compared with their historical control group of open surgery, while adhesiolysis and omentopexy were only rarely needed (6% and 3.3%, respectively) in their laparoscopic series. However, other prospective studies (16,17) showed that the laparoscopic technique was equivalent in terms of PDC survival to the conventional open surgery.…”

“…Although the most commonly used technique is an open surgical approach by minilaparotomy (7-9), percutaneous PDC placement (10-13) has been accepted, as an alternative to surgical placement (1)(2)(3), by the PD community. Other methods employed also include the peritoneoscopic (4,14), laparoscopic (15)(16)(17)(18)(19)(20), and fluoroscopically-assisted percutaneous placement (21,22).…”

Shorter break‐in period is a viable option with tighter PD catheter securing during the insertion

“…1-7 A 2-4 week break-in period between the catheter insertion and its regular use remains the conventional strategy to decrease the risk of pericatheter leak. [8][9][10] Although a break-in period is believed to allow a tight catheter securing through a better tissue growth around the Dacron cuffs; nevertheless, it also delays the start of PD. Such a delay can not only strain hospital and patient resources, but in certain cases can also force a central line insertion and temporary haemodialysis.…”

Wang's Forceps‐Assisted Percutaneous Insertion and Fixation of Peritoneal Dialysis Catheter

“…This leads to the difficulty of implanting the catheter to the appropriate position in the pelvic cavity. Conversely, the late complication of peritoneal catheter migration is frequently unavoidable due to various factors even if the catheter has been properly inserted by doctors with enough expertise (5,(11)(12)(13)(14)(15)(16). Recently, additional catheter fixation has been emphasized by us and others in preventing catheter migration (17)(18)(19)(20)(21)(22)(23).…”