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Peritoneal dialysis: Laparoscopic-assisted catheter insertion in CAPD - general and visceral surgery
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Exposure of the umbilical orifice
Whenever present, use the umbilical orifice for trocar insertion (as demonstrated in this video clip). To do so, circumvent the umbilicus with a finger or blunt instrument and expose its insertion at the level of the fascia. Here, the umbilicus is sharply dissected off its insertion, thereby exposing the umbilical orifice. Now clamp the edges of the fascia with Mikulicz clamps.
In planned peritoneal dialysis, the umbilical orifice must be carefully closed because otherwise the dialysate instilled into the abdominal cavity may result in herniation. If there is no umbilical orifice which may double as trocar access, the latter is established as usual in laparoscopy.
Initiation of pneumoperitoneum and inspection of the abdominal cavity
Insert the trocar for the camera through a small incision of the peritoneum and establish the pressure controlled pneumoperitoneum. Insert the camera and inspect the abdominal cavity, paying particular attention to any adhesions which may affect the choice on which side the catheter will be inserted. While the video clip demonstrates adhesions after previous open appendectomy, these do not have to be taken down and the catheter may be inserted on the right side.
Threading the catheter
Slip the catheter over the stylet. Accidental twisting of the catheter during this maneuver is best prevented by keeping the visible marker line on the catheter straight.
- It is easier to slip the catheter over the stylet once it has been flushed with or soaked in saline.
- The catheter coiling should always point laterally (i.e., in the video clip with insertion in the right lower quadrant to the right). If after insertion the catheter coiling is located medially, the catheter tends to reposition the coil laterally which may result in catheter dislocation from the lesser pelvis.
Pararectal access at the level of the umbilicus
Between the umbilicus and the planned catheter exit site incise the skin above the rectus muscle in the right lower quadrant. Transect the subcutis, expose and then split the anterior rectus sheath. Bluntly split the rectus muscle, and with a long-term absorbable suture preplace a purse-string suture on the posterior rectus sheath/peritoneum.
A well-established pneumoperitoneum will prevent accidental capture of the greater omentum or intestines when placing the purse-string suture.
Insert the stylet with its mounted catheter through the posterior rectus sheath / peritoneum incised within the purse-string suture and place it in the lesser pelvis under laparoscopic view. Injuries in the lesser pelvis are best prevented by advancing the catheter with one hand while keeping the stylet stationary with the other hand. Remove the stylet once the catheter has been placed correctly. When tightening the purse-string suture ensure that the catheter cuff is in close contact with the peritoneum. Mount the free end of the catheter on a tunneling stylet (16 French) and advance the latter deep in the subcutis in curved fashion until it punches through the marked site of the planned catheter exit. Remove the stylet, mount the titanium adapter and attach the transfer unit. As a final step, inspect the peritoneum and catheter placement laparoscopically.
- Before tightening the purse-string suture reduce the intraabdominal pressure of the pneumoperitoneum somewhat because this will prevent the rectus sheath and peritoneum from tearing while the suture is tied.
- If after tying the purse-string suture the catheter can still be pushed/pulled, but only with difficulty, it is well anchored and will not have become compressed.
- Once the tunneling stylet has emerged at the planned catheter exit site, check laparoscopically for possible iatrogenic perforation of the peritoneum by the stylet.
Infraumbilical suture of the peritoneum/fascia and catheter trial run
After a running infraumbilical suture of the peritoneum/fascia and definite closure of the umbilical orifice, test the patency of the catheter by instilling and then draining about 1.5 l dialysate (spiked with 5000 IU heparin). This maneuver also serves to detect any leakage at the peritoneal incisions.
Layered wound closure and refixation of the umbilicus
The pararectal incision of the right anterior rectus sheath is closed with a running suture, taking care not to compress the catheter. After resuturing the umbilicus to the fascia, close both access sites in layered fashion. Close the transfer unit with a cap that has been wetted with iodine disinfectant.