Perioperative management - Peritoneal dialysis: Open catheter insertion in CAPD

• End-stage renal disease with planned peritoneal dialysis
• Hemodialysis not possible because of technically insufficient vascular access

Patient not suited for peritoneal dialysis:

• Due to intra-abdominal adhesions or masses
• When proper handling of the catheter is not ensured

• Clinical examination: Ruling out any type of hernia
• History of abdominal surgery and inspection of all present scars
• Abdominal ultrasound study: Ruling out malignancies, assessing the size of polycystic kidneys and renal cysts

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
• Enema the evening before the procedure
• Preoperative markup with the patient standing and sitting. Waistband (1), abdominal fold/pendulous abdomen (2), planned catheter exit site (3)

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.

Day of surgery

• Single-shot antibiotic (e.g., cefazolin) before anesthesia is initiated
• Possibly Foley catheter for the duration of surgery.

General complications

• Injury to the small and large intestines
• Injury of parenchymal organs
• Wound infection, abscess, peritonitis, revision surgery
• Bleeding within the abdominal cavity and/or abdominal wall
• Positioning injuries
• Thromboembolism

Specific catheter complications

• Catheter kinking
• Catheter malposition, leakage, cuff dislocation.

General anesthesia with muscular relaxation of the abdominal wall

Patient in standard supine position with arms abducted or adducted.

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

• Surgeon: On same side as planned catheter insertion
• Assistant: Contralateral side
• Scrub nurse: On same side as surgeon, at patient thigh level

• Standard surgical tray
• CAPD catheter, e.g., Tenckhoff, Missouri, Orelopoulos-Zellerman, 41 cm (Covidien™)
• Special tunneling stylet, e.g. Faller tunneling stylet (Covidien™)

Postoperative analgesia

• Follow these links to PROSPECT (Procedure Specific Postoperative Pain Management) and the International Guideline Library.

Wound care, dressing changes

• Daily wound care
• Dressing at catheter exit site changed on postoperative day 2 or 3
• Dialysis catheters 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 International Guideline Library.

Postoperative ambulation

• Limited bed rest for 2 days

Diet

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

Work disability

• 2–6 weeks, depending on the patient’s profession
• No heavy straining for 6 weeks