Peritoneal dialysis: Open catheter insertion in CAPD

  • MVZ St. Marien Köln - Ärztliche Leiterin

  • Universitäts Klinik Witten Herdecke

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  • Surgical anatomy of the anterior abdominal wall

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    Superficial layer

    The superficial layer of the abdominal wall comprises the skin and the fatty tissue underneath (panniculus adiposus telae subcutaneae abdominis).

    Middle layer

    The middle layer primarily comprises the anterior and posterior abdominal muscles with their fascias.

    Anterior abdominal muscles and rectus sheath

    The anterior abdominal muscles comprise three rather flat muscles and the rectus abdominis. Anteromedially the flat muscles fuse with the rectus sheath and insert there with a broad tendon (aponeurosis). The muscles course in the following anteroposterior order:

    • External oblique: Posteriorly, it originates at the thoracolumbar fascia and the inferior 7 ribs and then courses as anterior lamina of the rectus sheath to the median linea alba and the iliac crest of the pelvis. Its oblique fibers run superolaterally to inferomedially.
    • Internal oblique: It courses from the linea alba to the iliac crest and the anterior margin of the pubic bone. Its oblique fibers run superomedially to inferolaterally (continuing the contralateral external oblique). Thus, both muscles crisscross obliquely in the anterior abdominal wall. Superior to the arcuate line, the internal oblique fuses with both the anterior and posterior lamina of the rectus sheath, and inferior to the arcuate line only with the anterior lamina.
    • Transversus abdominis: Its fibers course anteriorly from the thoracolumbar fascia or the cartilage of the inferior ribs and the pelvis to the linea alba. In the superior region of the anterior abdominal wall it primarily constitutes the posterior lamina of the rectus sheath. Together with the oblique abdominal muscles it constitutes the anterior lamina inferior to the arcuate line. The transversalis fascia constitutes the posterior wall of these three muscles.
    • On both sides the rectus abdominis originates at the cartilage of ribs 5-7 and inserts in the pubic bone near the symphysis pubis. Tendinous intersections divide the long muscles into several bellies (“six-pack”). The pyramidalis muscle is an inconsistent muscle coursing anterior to the rectus abdominis and bracing the linea alba. Thus, the rectus sheath is a tendinous canal investing the flat abdominal muscles and comprising the rectus abdominis and pyramidalis muscle as well as various vessels and nerves (inferior and superior epigastric artery and vein, intercostal nerves 5-12).

    Function

    For flexion and rotation of the trunk and abdominal straining both oblique abdominal muscles (m. obliquus externus and internus abdominis - oblique cross) and the rectus abdominis plus transversus abdominis (upright cross) brace the anterior abdominal wall in the fashion just described.

    The cremaster muscle derives from the internal oblique and transversus abdominis. It is the muscular investment of the spermatic cord and can lift the testicles (cremasteric reflex).

    Deep layer

    The transversalis fascia is the deep posterior layer of the abdominal wall. As the most internal layer of connective tissue (only separated from the free abdominal cavity by the peritoneum), it covers the internal aspect of the rectus abdominis and transversus abdominis and conjoins with the arcuate line and inguinal ligament. The deep inguinal ring with the entry to the inguinal canal is situated inferolaterally.

    Posterior muscles

    The major posterior muscle of the abdominal wall is the quadratus lumborum, which courses below the transversus abdominis from the lowermost rib and costal processes of the lumbar spine to the iliac crest.

    Blood supply and innervation

    The arterial blood supply follows the above layers of the abdominal wall:

    • The superficial and middle layers are supplied by the
    • → inferior posterior intercostal arteries (including the subcostal artery),
    • → superficial epigastric artery,
    • → superficial circumflex iliac artery and the
    • → external pudendal artery.
    • The deep layer is supplied by the
    • → lumbar arteries,
    • → inferior epigastric artery,
    • → deep circumflex iliac artery and the
    • → iliolumbar artery.

    The venous blood of the abdominal wall drains via veins (primarily → inferior vena cava) eponymic with their corresponding arteries:

    Via the superficial epigastric vein (→ great saphenous vein) and the inferior epigastric vein (→ external iliac vein). The venous blood only enters the superior vena cava via the thoracoepigastric veins and the azygos and hemiazygos veins.

    The abdominal wall is innervated by intercostal nerves and branches of the lumbar plexus:

    • As noted above, the inferior intercostals (including the subcostal nerve) innervate the external oblique abdominal muscle and the rectus abdominis.
    • The iliohypogastric nerve, originating at the lumbar plexus, innervates all anterior abdominal muscles, as does the ilioinguinal nerve except for the rectus abdominis, while the genitofemoral nerve supplies the transversus abdominis.
    • The iliohypogastric and ilioinguinal nerves also course between the muscles innervated by them and supply the skin of the anterior abdominal wall.

    Superior to the umbilicus, lymph from the anterior abdominal wall drains cephalad (into the axillary and parasternal lymph nodes), while inferior to the umbilicus it drains caudad (into the inguinal and iliac lymph nodes). Lymph from the lateral abdominal wall drains into the lumbar lymph nodes.

  • Peritoneal dialysis: Effects on the peritoneum and the resultant changes in morphology, function and clinical picture

    Following are the possible modalities in renal replacement therapy:

    • Peritoneal dialysis (PD)
    • Hemodialysis (HD)
    • Renal transplantation

    While PD is reserved for acute dialysis in infants and toddlers and those situations where hemodialysis is not possible, it excels in chronic dialysis settings and today is the most common modality in home dialysis.

    In CAPD (Continuous Ambulatory Peritoneal Dialysis) the patient changes the dialysate 3 – 5 times daily by draining spent dialysate from the abdominal cavity into an empty bag and instilling new dialysate. This takes about 20 minutes. The times when the dialysate must be changed can be adapted to the daily routine of the patient; usually, 3 – 4 changes are easily integrated into the daily routine and these times may vary by 1 – 2 hours.

  • Marien Hospital Euskirchen

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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  • Marien Hospital Euskirchen

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  • Incising the pararectal skin and exposing the anterior rectus sheath lamina

    Pararectal skin incision of about 6 cm inferior to the line connecting the umbilicus with the marked catheter exit. Divide the subcutaneous tissue by electrosurgery and expose the anterior lamina of the rectus sheath.

  • Exposing the posterior rectus sheath lamina and dividing the peritoneum

    Incise the anterior lamina of the rectus sheath in a sagittal direction and dissect the rectus muscle in blunt fashion. Open the peritoneum superior to the arcuate line and preplace a peritoneal suture (PDS 3/0) at the inferior pole of the incision.

    Tip:

    • For better stability, the catheter should be inserted superior to the arcuate line.
    • Use a monofilament suture when closing the peritoneum and anchoring the catheter because this helps avoid suture hole laceration.
  • Placing the dialysis catheter and closing the peritoneum

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    Insert the CAPD catheter into the Douglas pouch with dressing forceps. When closing the peritoneum subsequently with a running suture (PDS 3-0), the latter incorporates the catheter such that the intra-abdominal silicone bead of the catheter adheres to the peritoneum, while the extraperitoneal felt plate rests anterior to the posterior lamina of the rectus sheath. This ensures secure catheter fixation and “watertight” closure of the peritoneum.

  • Exiting the dialysis catheter

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    Figure on right: (1) Skin, (2) subcutaneous tissue, (3) rectus muscle, (4) peritoneum/fascia, (5) felt cuff, (6) silicone bead, (7) felt plate

    Mount the free end of the catheter on the tunneling stylet, pull the catheter through the rectus muscle in staggered fashion and let it exit through the skin at the previously marked location. With this maneuver the second felt cuff will rest within the rectus muscle. Mount the titanium adapter.

    Tip:

    • The submuscular course of the catheter should be smooth avoiding any kinking.
  • Checking the correct catheter placement by fluoroscopy

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    Check the position of the catheter in the pouch of Douglas by injecting contrast agent under brief fluoroscopy.

  • Function testing the dialysis catheter

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    Check the catheter function and watertight closure of the peritoneum by instilling and draining about 500 mL of physiological saline.

  • Wound closure, dressing

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    Close the anterior lamina of the rectus sheath with interrupted sutures (Vicryl CT-1), followed by subcutaneous sutures and a running subcuticular suture (Monocryl 5/0). Sterile dressing.

    Tip:

    Avoid any contact of the catheter come with the adhesive of the dressing material because this might result in accidental catheter dislocation.

  • Marien Hospital Euskirchen

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  • Prevention and management of intraoperative complications

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  • Prevention and management of intraoperative complications

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  • Prevention and treatment of catheter specific complications

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  • MVZ St. Marien Köln - Ärztliche Leiterin

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  • Literature summary

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  • Ongoing trials on this topic

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  • Reviews

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  • References on this topic

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  • literature search

    Literature search under: http://www.pubmed.com