Perioperative management - Peritoneal dialysis: Laparoscopic-assisted catheter insertion in CAPD

• End-stage renal disease with planned peritoneal dialysis

• Patient not suited for peritoneal dialysis
• Abdominal cavity filled with polycystic kidneys

• Clinical examination: Abdominal wall hernia? History of abdominal surgery?
• Abdominal ultrasound study: Ruling out malignancies, assessing the size of polycystic kidneys and renal cysts

Sitting position: Mark possible catheter exit sites outside of waistband and skin folds in red

1 week before surgery

• No more heparin or insulin injections into the abdominal wall, thereby sparing the surgical site and reducing the risk of infection

Day before surgery

• Standard preparation for surgery including umbilical care
• Enema the evening before the procedure
• Last meal the evening before surgery
• Preoperative markup with the patient standing and sitting

Since the CAPD is performed by the patient the catheter exit site must be easily visible for him/her. Thus, the exit site must not be located at the level of the waistband (outerwear/underwear), in skin folds or below a pendulous abdomen. Since most patients change the dialysate while sitting, the planned catheter exit site should also be checked before surgery with the patient sitting. The side of the catheter exit site – right or left – should not be specified beforehand because it may depend on possible adhesions discovered during the procedure.

Day of surgery

• Single-shot antibiotic before anesthesia is initiated
• Possibly Foley catheter for the duration of surgery

• Primarily for laparoscopy with assessment of the abdominal cavity
• Possibly for laparoscopic adhesiolysis

Complications

• Injury to the small and large intestines
• Injury to parenchymal organs
• Wound infection, abscess, peritonitis, revision surgery
• Abdominal wall hematoma, cutaneous emphysema
• Postoperative shoulder pain
• Thromboembolism

Catheter specific complications

• Catheter kinking
• Catheter malposition, leakage

Postoperative care

• Strict bed rest for 2 days
• Getting up only permitted when going to the bathroom

Intubationsnarkose bei Kapnoperitoneum

Supine, one arm abducted

As demonstrated in this video, here the catheter is inserted in the lower right quadrant:

• Surgeon: To the left of the abdomen
• Assistant: To the right of the abdomen
• Scrub nurse: On same side as surgeon, at patient thigh level

• Standard surgical tray including stylet for drains (16 French)
• Laparoscopy unit
• Possibly laparoscopic instruments for adhesiolysis
• CAPD catheter set

Postoperative analgesia

• Follow this link to PROSPECT (Procedure Specific Postoperative Pain Management)
• Follow this link to the International Guideline Library.

Wound care, dressing changes

• Daily wound care
• Dressing at catheter exit site changed on postoperative day 2 or 3
• Dialysis catheter flushed daily by trained staff experienced in dialysis

Medical deep venous thrombosis prophylaxis

• Starting the evening before surgery and continued for the duration of the hospital stay
• Follow this link to the to the International Guideline Library.

Postoperative ambulation

• Strict bed rest for 2 days, breathing and metabolic physiotherapy
• On days 3 and 4 the patient may only get up for the bathroom

Diet

• The evening before surgery: Tea
• Postoperative day 1: Liquid diet
• Starting postoperative day 2: Regular diet
• Possibly laxatives on postoperative day 3

Work disability

2–4 weeks, depending on the patient’s profession