Peritoneal dialysis: Laparoscopic-assisted catheter insertion in CAPD

Infraumbilical skin incision, transection of the subcutaneous tissue and exposure of the fascia

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.

Tip:

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.

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.

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.

Tips:

• 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.