Peritoneal dialysis catheter insertion strategies and maintenance of catheter function

It has been more than 40 years since permanent peritoneal dialysis (PD) access with the Tenckhoff catheter was first described, and despite much experimentation with catheter design and insertion techniques, access to timely and skilled PD catheter insertion remains a barrier to more widespread PD use in many centers. This article reviews different insertion techniques with a focus on both mechanical outcomes as well as logistic advantages associated with the embedded catheter and percutaneous techniques. Maintenance of catheter function is discussed with a focus on an organized and evidence-based approach to preventing and treating mechanical catheter problems.     

Venous access in children

Obtaining venous access can be a challenge and it can be the most stressful part of a child’s care. Venous access in childhood may be short or long term, central or peripheral. This paper discusses the devices available, techniques for insertion and the risks.     

Primary access-related complications with laparoscopy: Comparison of blind and open techniques

Background: Severe or fatal complications attributable to gas embolus, major vascular injury, or visceral injury are rare but have been reported after blind access to the abdominal cavity in laparoscopy. The open access technique has been introduced with the aim to reduce these injuries. This report evaluates access-related complications with both blind and open access techniques in a teaching hospital using standardized techniques for both methods. Methods: Two groups of patients at different times from a prospective database were compared. A retrospective analysis of 2,297 patients treated using blind access between 1992 and 1996 were compared with 2,066 patients treated using open step-by-step access between 1999 and 2001 regarding access-related complications. An accreditation program for both techniques was mandatory for the 67 surgeons involved. Results: No case of gas embolus or major vascular injury was seen in either group. Four cases of visceral injuries (0.17%) in the blind access group and one case (0.05%) in the open group were seen (p = 0.337). All the injuries were recognized and repaired intraoperatively with no further postoperative complications. Conclusion: Our educational efforts to make both techniques as safe as possible were successful, as evidenced by a minimum of access-related complications. Because no evidence exists to show that the blind access technique is superior in any aspect, the open technique is recommended for access to the abdominal cavity in laparoscopy.     

Skin incisions and wound closure

The siting of an incision and the choice of wound closure may have profound effects upon the success of an operation and the patients lasting perception of their surgeon. This article discusses site and method of skin incision, access to the abdominal cavity, wound healing, choice of sutures and needles, suture techniques, fascial and skin closure techniques and difficult wound closure. With this information the reader should be able to make a tailored decision about incision and closure technique to achieve the best outcome for the patient.     

Interventional radiology of the biliary system and pancreas

In recent years, newer techniques have become available to the clinician for the diagnosis and treatment of biliary and pancreatic disease. This article emphasizes interventional procedures through the liver, such as percutaneous transhepatic cholangiography, percutaneous transhepatic biliary drainage, and ancillary techniques. Also discussed are the nonsurgical management of bile duct calculi and the diagnosis and treatment of pancreatic tumors, abscesses, and pseudocysts.     

Minimal access surgery of pediatric inguinal hernias: a review

Inguinal hernia is a common problem among children, and herniotomy has been its standard of care. Laparoscopy, which gained a toehold initially in the management of pediatric inguinal hernia (PIH), has managed to steer world opinion against routine contralateral groin exploration by precise detection of contralateral patencies. Besides detection, its ability to repair simultaneously all forms of inguinal hernias (indirect, direct, combined, recurrent, and incarcerated) together with contralateral patencies has cemented its role as a viable alternative to conventional repair. Numerous minimally invasive techniques for addressing PIH have mushroomed in the past two decades. These techniques vary considerably in their approaches to the internal ring (intraperitoneal, extraperitoneal), use of ports (three, two, one), endoscopic instruments (two, one, or none), sutures (absorbable, nonabsorbable), and techniques of knotting (intracorporeal, extracorporeal). In addition to the surgeons’ experience and the merits/limitations of individual techniques, it is the nature of the defect that should govern the choice of technique. The emerging techniques show a trend toward increasing use of extracorporeal knotting and diminishing use of working ports and endoscopic instruments. These favor wider adoption of minimal access surgery in addressing PIH by surgeons, irrespective of their laparoscopic skills and experience. Growing experience, wider adoption, decreasing complications, and increasing advantages favor emergence of minimal access surgery as the gold standard for the treatment of PIH in the future. This article comprehensively reviews the laparoscopic techniques of addressing PIH.     

Current status of surgery for ventricular tachyarrhythmias

This article outlines the accepted histopathologic and electrophysiologic theories underlying the etiology of medically refractory ventricular tachyarrhythmias. It delineates the indications and techniques for the electrophysiologic study of the ventricle. Finally, the surgical procedures available as well as their indications and results are elucidated.     

Equipment and monitoring in paediatric anaesthesia

Advances in paediatric anaesthetic equipment and monitoring continue to be made. While the mainstay of airway intubating equipment currently is the direct laryngoscope, video laryngoscopes and endoscopes are increasing in their use. These continue to evolve, generating better quality pictures, with more sophisticated yet easier to use equipment. Vascular access in paediatric anaesthesia can be challenging with an increasing number of patients presenting with difficult intravenous access. Ultrasound has become an integral piece of equipment in the management of these children. As the population increases in weight, so the management of the obese paediatric patient is now a reality. This requires thought and careful planning of their perioperative care. Newer techniques such as high-flow nasal oxygen are useful both to prevent hypoxia at induction, but also to facilitate open airway surgery. Neurological monitoring in the form of near infrared spectroscopy and bispectral index are discussed with evidence relevant to paediatric practice. This article will discuss all of these devices and techniques with particular emphasis on paediatric anaesthetic practice.     

Cardiac output measurement in pediatric anesthesia

Maintenance of cardiovascular stability is crucial to safe anesthetic practice, but measurement of cardiac output has been technically challenging, particularly in pediatric patients. Cardiovascular monitoring has therefore generally relied upon pressure-based measurements, as opposed to flow-based measurements. The measurement of cardiac output under anesthesia and in critical care has recently become easier as a result of new techniques of measurement. This article reviews the basic concepts of and rationale for cardiac output monitoring, and then describes the techniques available for monitoring in clinical practice.     

Pediatric gastroesophageal reflux disease

This article reviews the mechanisms responsible for gastroesophageal reflux disease (GERD), available techniques for diagnosis, and current medical management. In addition, it extensively discusses the surgical treatment of GERD, emphasizing the use of minimally invasive techniques.     

Imaging of the adrenal gland

Summary Clinically, the development of highly accurate imaging techniques that define adrenal anatomy and give information concerning adrenal physiology have revolutionized our approach to adrenal disorders [1, 2]. These techniques complement the highly accurate hormonal analyses that lead to the diagnosis of primary hyperaldosteronism, Cushing's syndrome, and pheochromocytoma. In addition, they help distinguish these entities from other adrenal disorders as well as other retroperitoneal processes. Thus, imaging techniques presently play a critical role in confirming the hormonal diagnosis and precisely localizing the specific adrenal lesion.This article reviews the imaging techniques available and attempts to direct the reader to the procedure of choice for each adrenal disorder.     

Rejuvenation of the midface

Mid-face rejuvenation has long been a difficult area for aesthetic facial surgeons. In this article the author reviews the techniques currently available and examines in-depth two techniques that he feels are noteworthy for their efficacy in improving mid-face aging. One of these techniques is the "SMAS division mid-face lift" which targets aging of the mid-face associated with a deep nasolabial fold. The other technique is known as a "SOOF lift blepharoplasty" and helps to improve aging of the lower lid associated with a tear trough deformity. Facial aesthetic surgeons should gain a better appreciation of the approaches available for improving this challenging area after digesting the contents of this review article.     

Long-term outcome of chronic dialysis in children

As the prevalence of children on renal replacement therapy (RRT) increases world wide and such therapy comprises at least 2% of any national dialysis or transplant programme, it is essential that paediatric nephrologists are able to advise families on the possible outcome for their child on dialysis. Most children start dialysis with the expectation that successful renal transplantation is an achievable goal and will provide the best survival and quality of life. However, some will require long-term dialysis or may return intermittently to dialysis during the course of their chronic kidney disease (CKD). This article reviews the available outcome data for children on chronic dialysis as well as extrapolating data from the larger adult dialysis experience to inform our paediatric practice. The multiple factors that may influence outcome, and, particularly, those that can potentially be modified, are discussed.     

Bladder augmentation. Options, outcomes, future

Remarkable progress has been made in lower urinary tract reconstruction in children. Nowhere is this more valuable than in augmentation cystoplasty, where there are several available options. This article discusses the current techniques and the benefits and limitations of these procedures. A section on tissue regeneration techniques and the author's current recommendations are included.     

Modified two-stage basilic vein transposition for hemodialysis access

Background

Various techniques for basilic vein transposition have been described, including endovascular, 1-stage, and 2-stage transposition. However, none of these 2-stage techniques include a new arteriovenous anastomosis during the second stage. This study adds to the current literature as well as introducing a new and innovative technique for hemodialysis access.

Methods

Forty-nine basilic vein transpositions were performed. Data were collected retrospectively. Primary and secondary patency was calculated using life table methods. Complications and interventions were recorded.

Results

Primary patency was 72% at 1 year, 54% at 2 years, and 54% at 3 years. Secondary patency was 95%, 80% and 65% at 1, 2, and 3 years, respectively. Twenty-nine patients experienced complications related to the fistula, and 15 required intervention to maintain patency. Patency was achieved in 100% of the procedures using percutaneous techniques.

Conclusions

This 2-stage procedure should be strongly considered when planning brachial basilic fistulas for hemodialysis access.     

Collagen substances.

Soft tissue enhancement has become increasingly important as more patients seek aesthetic improvement without major surgical procedures. Injectable Zyderm bovine collagen has come to be regarded as the "gold standard" of injectable or implantable fillers, against which all other fillers are measured. This article describes the techniques of injection for bovine collagen and discusses the indications, allergenicity, and adverse responses. Other types of available collagen substances are also discussed.     

Minimally invasive parathyroid surgery

The standard bilateral neck exploration in primary hyperparathyroidism (HPTH) has been challenged in the recent years by the general trend toward less invasive surgery. The development of more reliable preoperative imaging techniques such as Sestamibi scanning and high definition ultrasonography coupled with improvements in intraoperative rapid assays of intact parathyroid hormone have allowed unilateral explorations in most patients with primary HPTH. This article reviews the currently available preoperative parathyroid localization studies as well as the currently used minimally invasive parathyroidectomy (MIP) techniques, such as open approaches, radioguided surgery and endoscopic procedures. While some techniques are more popular than others, careful selection of patients with primary HPTH has resulted in comparable cure rates to the standard bilateral parathyroid exploration.     

Choledocholithiasis, endoscopic retrograde cholangiopancreatography, and laparoscopic common bile duct exploration

With the litany of advances in laparoscopy and endoscopy, much has improved regarding management of choledocholithiasis. This article examines the different approaches currently available to remove common bile duct stones, with an examination of the literature supporting different approaches and the techniques involved.     

Nipple reconstruction

Creation of the nipple-areolar complex is the final and important component of the breast reconstruction process. Various techniques using a variety of local flaps are available. This article covers the pre- and postoperative care of the woman having nipple reconstruction, reviews the author's preferred techniques, discusses the use of supplemental materials for nipple augmentation, and comments on the common complications.     

Basic microvascular techniques and principles

This article will discuss the advantages and disadvantages of the various types of optical magnification currently available. The instruments necessary for performing most operations will also be presented. Attention will be focused on the physical properties and technical considerations of microvascular anastomosis. The principles and techniques employed for joining small blood vessels are almost always valid and transferable to reconstructive surgery of other small tubes such as the ureter, bowel, etc.