William Stewart Halsted: Father of American Modern Surgery

Peritoneal dialysis is an established alternative method for the management of patients with end-stage renal disease. Recently, laparoscopy has been utilized in assisting the insertion of catheters under direct vision. The efficacy of the laparoscopic approach for patients with a history of abdominal surgery remains largely unknown. The purpose of this study is to evaluate laparoscopy in the placement of peritoneal dialysis catheters for selected patients with previous abdominal operation. Laparoscopic assisted placement of peritoneal dialysis catheters was performed in 20 patients, who were carefully selected preoperatively and who also underwent previous abdominal operation between April 1999 and July 2001. Previous abdominal operation included appendectomy, ovarian resection, hysterectomy, cesarean section, open cholecystectomy, segmental resection of the small intestine, and truncal vagotomy with pyloroplasty. The procedure was performed using two 10-mm and one 5-mm abdominal trocar. All of the patients tolerated this procedure without significant surgical complications. However, 3 patients developed temporary hemoperitoneum, and 1 patient developed dialysate leakage. The overall success rate of catheter function (> 30 days after laparoscopy) was 90%, except in 2 cases where the catheter functioned poorly due to severe intra-abdominal adhesions. Simultaneous laparoscopic adhesiolysis was successfully performed in 5 cases. Laparoscopic implantation of peritoneal dialysis catheters appears to be a straightforward procedure, even for patients with previous abdominal operation. We believe that this technique may extend the application of peritoneal dialysis treatment in patients with previous abdominal surgery after discreet evaluation preoperatively.     

Laparoscopic assisted placement of peritoneal dialysis catheters for selected patients with previous abdominal operation.

Peritoneal dialysis is an established alternative method for the management of patients with end-stage renal disease. Recently, laparoscopy has been utilized in assisting the insertion of catheters under direct vision. The efficacy of the laparoscopic approach for patients with a history of abdominal surgery remains largely unknown. The purpose of this study is to evaluate laparoscopy in the placement of peritoneal dialysis catheters for selected patients with previous abdominal operation. Laparoscopic assisted placement of peritoneal dialysis catheters was performed in 20 patients, who were carefully selected preoperatively and who also underwent previous abdominal operation between April 1999 and July 2001. Previous abdominal operation included appendectomy, ovarian resection, hysterectomy, cesarean section, open cholecystectomy, segmental resection of the small intestine, and truncal vagotomy with pyloroplasty. The procedure was performed using two 10-mm and one 5-mm abdominal trocar. All of the patients tolerated this procedure without significant surgical complications. However, 3 patients developed temporary hemoperitoneum, and 1 patient developed dialysate leakage. The overall success rate of catheter function (> 30 days after laparoscopy) was 90%, except in 2 cases where the catheter functioned poorly due to severe intra-abdominal adhesions. Simultaneous laparoscopic adhesiolysis was successfully performed in 5 cases. Laparoscopic implantation of peritoneal dialysis catheters appears to be a straightforward procedure, even for patients with previous abdominal operation. We believe that this technique may extend the application of peritoneal dialysis treatment in patients with previous abdominal surgery after discreet evaluation preoperatively.     

Laparoscopic guidance or revision of ventriculoperitoneal shunts in children.

BACKGROUND: Ventriculoperitoneal shunt is the preferred treatment for hydrocephalus. Known complications include infection, obstruction, and disconnection with the fractured fragment migrating in the peritoneal cavity. We report 17 cases of laparoscopic evaluation and revision of ventriculoperitoneal shunts in children. METHODS: From January 2000 through October 2002, we retrospectively reviewed our experience with laparoscopy and ventriculoperitoneal shunts. RESULTS: Laparoscopy was performed in 17 children with a malfunctioning shunt, presumed shunt dislodgment or disconnection, reinsertion of a shunt after externalization, and primary shunt placement. Six patients (35%) were converted to an open laparotomy due to dense adhesions. Eleven patients (65%) underwent successful laparoscopic-assisted ventriculoperitoneal shunt placement: 5/11 (45%) had lysis of adhesions or pseudocyst marsupialization with repositioning of a functional shunt, or both; 3/11 (27%) had successful retrieval of a disconnected catheter with reinsertion of a new catheter; 2/11 (18%) had laparoscopic confirmation of satisfactory placement and function, requiring no revision; 1/11 (9%) had an initial shunt placed with laparoscopic guidance due to the obesity. Operative time for the laparoscopic procedure ranged from 30 minutes to 60 minutes. All laparoscopic procedures used 1-mm or two 5-mm ports. Perioperatively, no adverse neurological sequelae occurred due to the pneumoperitoneum. CONCLUSIONS: Laparoscopic guidance or revision of ventriculoperitoneal shunts permits (1) direct visualization of catheter insertion within the peritoneal cavity, (2) satisfactory positioning, (3) lysis of adhesions or marsupialization with catheter repositioning, or both, and (4) retrieval of fractured catheters.     

Laparoscopic placement of peritoneal dialysis catheters: 7 years experience

Background: Since 1994 we have placed all peritoneal dialysis (Tenckhoff) catheters at our hospital laparoscopically using a technique that incorporates suture fixation into the pelvis. The purpose of this study was to determine the long‐term outcome of this approach. Method: Perioperative and follow‐up data for all patients undergoing placement of a peritoneal dialysis catheter at the Royal Adelaide Hospital were collected prospectively and managed on unit specific and hospital wide computerized databases. A total of 148 procedures were carried out in 123 patients from March 1994 to November 2001. Follow‐up ranged from 3 to 68 months (median, 42 months). All procedures were undertaken or supervised by one surgeon, and catheters were routinely sutured into the pelvis at laparoscopy. Results: There was no perioperative mortality in this series, and only one catheter could not be placed laparoscopically. This was in a patient with extensive intra‐abdominal adhesions. Mean operative time was 27 min (range, 10?100 min), and mean postoperative stay was 2.8 days (range, 1?12 days). Seven (5%) patients experienced peri/postoperative haemorrhage, and four of these underwent surgical re‐exploration. Twenty‐five (17%) catheters are still used for dialysis. Thirty‐four (23%) catheters were removed when the recipient received a subsequent renal transplant, and 42 (28%) patients died during follow‐up. Forty‐six (31%) patients required catheter revision or removal because of technical problems; 26 (18%) recurrent peritonitis or exit site infection; and 20 (14%) catheter blockage. Twenty‐eight reinsertion procedures were carried out in 25 patients. Ten (7%) patients developed port site hernias at late follow‐up, and required hernioplasty. Catheter migration leading to malfunction (poor drainage) occurred in eight (5%) patients only. Conclusions: Laparoscopic placement of peritoneal dialysis catheters is a safe and effective procedure. The majority of patients will dialyse successfully using this technique. Suturing the catheter tip into the pelvis is associated with a low rate of catheter migration.     

The adequacy of laparoscopy for continuous ambulatory peritoneal dialysis procedures

The aim of this study was to determine the safety and efficacy of diagnostic/therapeutic laparoscopy in the management of peritoneal Tenchoff catheter placement in end-stage renal disease patients who had previous abdominal surgery and malfunctioning peritoneal dialysis catheters. From 1999 to 2004, 16 videolaparoscopic procedures were performed in 16 patients who had previous laparotomies. Laparoscopy was performed before peritoneal catheter placement in seven (group 1) and in 9 patients with peritoneal dialysis catheters in place, laparoscopy was performed for the management of catheter dysfunction (group 2). All laparoscopic procedures were performed under general anesthesia. The mean follow-up was 31.5 (range, 11 to 60) months. In group 1, six patients (85.7%), and in group 2, seven patients (77.7%) are still on peritoneal dialysis. Laparoscopy resulted in the placement/salvage of peritoneal dialysis catheter dysfunction. Placement of catheter was accomplished in patients who would have been previously designated as unsuitable candidates. Laparoscopy is a useful tool in every step of a peritoneal dialysis program.     

Laparoscopic placement of the Tenckhoff catheter for peritoneal dialysis

Continuous ambulatory peritoneal dialysis catheters can be inserted by open laparotomy as well as by laparoscopy. A prospective randomized study was scheduled to investigate the results of the laparoscopic versus open laparotomy technique for placement of continuous ambulatory peritoneal dialysis catheters. Fifty patients were enrolled and randomly allocated into two groups of 25 patients each. Group A underwent continuous ambulatory peritoneal dialysis catheter placement via the open laparotomy technique. In 22 patients, catheters were inserted via midline incision, and in 3 patients with histories of previous catheterization, a paramedian incision was used. Continuous ambulatory peritoneal dialysis was started 24 to 48 hours later. Group B underwent laparoscopic placement of the catheter with fixation into the pelvis and suture closure of the port wounds. In 21 patients, this catheter placement was the first such placement, and in 4 patients, a previous catheter had been inserted by the open technique and removed for dysfunction. Continuous ambulatory peritoneal dialysis was started at the end of the procedure. The mean operative time was 22 minutes in group A and 29 minutes in group B (P < 0.001). Fluid leakage was observed in eight patients in group A, but in no patients in group B (P < 0.005). Peritonitis occurred in five patients in group A and in three patients in group B (P > 0.1). Tip migration occurred in five patients in group A and no patients in group B (P < 0.005). In group B, two patients underwent a simultaneous cholecystectomy and one underwent incisional hernia repair. Laparoscopic placement of a Tenckhoff catheter leads to better function than does the open procedure; it allows immediate start of dialysis without fluid leakage and permits simultaneous performance of other laparoscopic procedures.     

Laparoscopic salvage of malfunctioning peritoneal catheters

Background: Malfunction of peritoneal catheters due to mechanical outflow problems is an annoying complication in patients undergoing chronic peritoneal dialysis (PD). Correction often involves catheter replacement or revision via laparotomy. Methods: Twenty-five patients undergoing PD who developed mechanical catheter flow restriction underwent 28 laparoscopic procedures. Preoperative diagnoses were made by contrast catheter radiography and were: catheter sequestration (36%), omental wrap (64%). Pneumoperitoneum was induced after general anesthesia and laparoscopy was performed using a Storz laparoscope. The catheter was then identified and manipulation was attempted using instruments placed percutaneously. Results: In 26 cases (93%), the catheter was freed and function restored. In two cases (7%), adhesions were so numerous and dense that the distal catheter could not be visualized. Four episodes of peritonitis occurred in the perioperative period. Four patients developed subcutaneous leakage of peritoneal fluid which responded to cessation of PD for 2 weeks. Four patients had recurrent occlusions; three of these were managed laparoscopically. Two patients developed late hernias at the site of insertion of the laparoscope. Catheter patency averaged 9.2 months postoperatively. Conclusions: Laparoscopic revision is a successful technique for salvage of occluded peritoneal catheters.     

Peritoneal dialysis catheters: laparoscopic versus traditional placement techniques and outcomes

BACKGROUND: Peritoneal dialysis is used for renal replacement therapy in over 25,000 patients in the United States. Some authors have recommended laparoscopic guidance for peritoneal dialysis catheter (PDC) placement, although consensus statements have not favored a specific technique. This study reviews outcomes in patients in whom placement was performed by the traditional "blind" technique (B-PDC) versus the laparoscopic technique (L-PDC). METHODS: Records were retrospectively reviewed of 25 consecutive PDC patients in each of 3 university-affiliated tertiary medical center hospitals. Data for PDCs placed by B-PDC (n = 30) or L-PDC (n = 45) technique were reviewed and the outcomes compared. RESULTS: L-PDCs offered 97.8% immediate functional success as opposed to 80% with B-PDC placement (P = .014). In addition, laparoscopic placement of peritoneal dialysis catheters had a lower incidence of PDC revision or replacement (P = .035). CONCLUSION: L-PDCs were found to have a higher immediate functional success rate than B-PDCs and a lower incidence of catheter revision or replacement.     

Laparoscopic omentectomy for salvage of peritoneal dialysis catheters

BACKGROUND AND PURPOSE: Maintaining long-term peritoneal catheter function for peritoneal dialysis is commonly threatened by problems with catheter obstruction. Multiple methods have been used to salvage nonfunctioning catheters, including omentopexy, catheter repositioning, and omentectomy. We report on our experience with a laparoscopic method of omentectomy and catheter fixation for salvage of nonfunctioning peritoneal dialysis catheters. PATIENTS AND METHODS: Thirteen patients with nonfunctioning peritoneal dialysis catheters underwent 16 laparoscopic procedures with the intent to restore function. Clinically, all patients presented with outflow obstruction. At initial presentation, all patients underwent diagnostic laparoscopy and a definitive procedure. In 12 patients, catheters were enveloped by omentum, and we performed laparoscopic omentectomy and catheter fixation to the anterior pelvic wall. In one patient, we identified a broken catheter and performed a laparoscopic omentectomy at the time of catheter replacement. One 10-mm and two 5-mm trocars were utilized. Omentectomy was performed using either endo-GIA stapled resection (2 patients) or the Harmonic Scalpel (11 patients). All trocar incisions (including the 5-mm site) were closed with a suture-passing (Carter-Thomason) device to provide water-tight closure in anticipation of immediate return to peritoneal dialysis. Patients were followed postoperatively for an average of 17 months (range 4-35 months). RESULTS: All patients' catheter function was restored intraoperatively with laparoscopic omentectomy and catheter fixation. Eight catheters remained functioning following omentectomy without further intervention. Five patients (38%) experienced repeat catheter malfunction and underwent laparoscopic exploration. Of these, three catheters (60%) were restored to function with laparoscopic manipulation alone. Three catheters were found encased in extensive adhesions. Laparoscopic adhesiolysis was successful in one patient and unsuccessful in one patient, who converted to hemodialysis. One patient failed laparoscopic salvage and required open laparotomy and fibrin clot removal to restore catheter function. One catheter was found to be obstructed within a pericolic hematoma. One catheter was found within residual omentum at the hepatic flexure. Both of these catheters were freed laparoscopically and continued to function at 12 and 16 months' follow-up. Complications included one episode of peritonitis, one case of postoperative ileus, and one trocar site hernia necessitating repair. The nephrologists were instructed that they could begin peritoneal dialysis on postoperative day 1. Seven patients resumed peritoneal dialysis without leak from trocar sites. The remaining patients received temporary hemodialysis through a central venous catheter and returned to peritoneal dialysis at the discretion of their nephrologists. CONCLUSIONS: Laparoscopic omentectomy with catheter fixation is a minimally invasive means of salvaging peritoneal dialysis catheters with outflow obstruction. Complications are few, and closure of laparoscopic incisions in water-tight fashion allows rapid return to peritoneal dialysis.     

Technique for laparoscopy-assisted complicated peritoneal dialysis catheter placement

Peritoneal dialysis is widely accepted for the chronic management of end-stage renal disease. Especially in patients suspected of having intra-abdominal adhesions, the application of laparoscopic surgical techniques has significantly changed our surgical approach to dialysis catheter placement. The blind placement of peritoneal dialysis catheters in this patient group can be both dangerous, because of the higher risk of bowel injuries, and unsuccessful, because of immediate catheter misplacement or entrapment. We describe a relatively simple step-by-step approach to laparoscopy-assisted peritoneal dialysis catheter placement with omentectomy in these more complicated cases.     

Laparoscopic placement of peritoneal dialysis catheters in children

Background

Peritoneal dialysis (PD) is preferred over hemodialysis. The aim of this study was to evaluate our experience with laparoscopic PD catheter placement and omentectomy in children.

Methods

We reviewed all children (N = 21) who underwent laparoscopic placement of PD catheters and omentectomy. Ages ranged from 3 months to 16 years. Five children had previous major abdominal surgery and required extensive lysis of adhesions. During the same intervention, other surgical procedures were performed using laparoscopy or open technique, including umbilical hernia repair in 3, bilateral inguinal hernia repair in 3, ventral hernia repair in 2, gastrostomy in 4, kidney biopsy in 2, and cholecystectomy in 1.

Results

Thirteen children received successful kidney transplantation and no longer needed dialysis. Two children still have functioning PD catheters. One patient developed membrane failure and was converted to hemodialysis. Four patients recovered enough renal function and no longer need dialysis. There were no complications related to the laparoscopic procedure.

Conclusion

Laparoscopy is ideal for PD catheter placement. It facilitates omentectomy, and it allows for the catheter to be placed in the proper position under direct vision and for lysis of adhesions to increase peritoneal surface. Other abdominal procedures can be performed laparoscopically at the same time.     

Mini‐laparoscopic placement of peritoneal dialysis catheter: New technique

Background: Leakage remains a problem with all methods of catheter placement. We describe our experience with a new mini‐laparoscopic technique for catheter placement in patients with end‐stage renal failure. Patients and methods: Between May 2002 and March 2004, 24 patients underwent mini‐laparoscopic placement of peritoneal dialysis catheters. All patients had end‐stage renal failure with difficult vascular access for haemodialysis. There were 11 men and 13 women with a mean age of 51.4 years (range: 18–75 years). Operative time, interval to initiation of successful peritoneal dialysis, postoperative pain management, resumption of diet and postoperative complications were recorded. Results: The mean operative time was 32.3 min (range: 15–40 min). All patients were given a normal diet on the day of surgery. Postoperative pain was controlled with paracetamol tablets three times daily for 2–3 days. The mean hospital stay was 3.2 days (range: 3–4 days). No patients developed leakage either from the ports or around the catheter. Two (8.3%) patients had blockage of the catheter and underwent diagnostic laparoscopy and laparoscopic correction. Two (8.3%) patients had migration of the catheter which required laparoscopic repositioning. The follow‐up range was between 2 and 22 months. Conclusion: Mini‐laparoscopic technique for placement of peritoneal dialysis catheter is unique because it uses only two ports. The catheter is made to exit via a 2 mm port site and does not require specially designed instruments.     

COMPARATIVE EXPERIENCE OF A SIMPLE TECHNIQUE FOR LAPAROSCOPIC CHRONIC AMBULATORY PERITONEAL DIALYSIS CATHETER PLACEMENT

Background : Chronic ambulatory peritoneal dialysis (CAPD) is now an established technique for renal dialysis. Patients with renal failure cope poorly with major surgery and it is vital that the dialysis catheter tip is sited accurately in the pelvis if long-term catheter function is to be achieved. Laparoscopic placement of CAPD catheters may have potential advantages for renal patients by avoiding the morbidity of a laparotomy. Methods : A retrospective audit was performed of all CAPD catheters inserted at the John Hunter Hospital over a 2-year period. Results of laparoscopically inserted catheters and those placed at laparotomy were compared. Results : Sixty catheters were inserted, 30 laparoscopically and 30 at laparotomy. The mean operative time was 41 min in the laparoscopic patients and 57 min in the laparotomy patients (P= 0.0001). The mean total dose of narcotic administered postoperatively was significantly less in the laparoscopic group (5 mg vs 65 mg, P= 0.00002). There were three minor peri-operative complications in the laparoscopic group and seven peri-operative complications in the laparotomy group, three required reoperation and one resulted in the patient'death. There were no significant differences in the incidence of exit-site infection, catheter blockage, peritonitis, and overall catheter survival, although the laparoscopically placed catheters had been followed up for a shorter period (10 vs 16 months). Conclusions : This laparoscopic technique is safe and effective. Postoperative pain was less than for open placement. Laparoscopically placed catheters had a low incidence of peri-operative complications. Medium-term patency is similar to conventionally placed catheters. This procedure requires no additional equipment to that available for laparoscopic cholecystectomy and takes less time than the open operation.     

Laparoscopic management of peritoneal dialysis catheters

Continuous ambulatory peritoneal dialysis catheter could be placed also by open laparotomy as well as by laparoscopic techniques. We did a retrospective study on cases to compare the results of laparoscopies. There were included 42 patients which we divided in two groups of 21. Group A underwent 21 cases in which catheters was inserted by open laparotomy. Continuous ambulatory peritoneal dialysis was started in 24 to 48 hours later. Group B incharged 21 patients underwent laparoscopic placement of the catheter between 2000 and 2001. Continuous peritoneal dialysis was started early (after 6 hours). The mean operative time was 28 minutes in group A and 30 minutes in group B. Fluid leakage was noticed in 4 patients in group A and in 3 patients in group B. Peritoneal reactions occurred in 5 patients in group A and in 2 patients in group B. Tip migration occurred in 5 patients in group A (one of which was mobilized accidentaly early after intervention) in which was necessary 4 open reinterventions, and no patients in group B. In group B one patient underwent a simultaneous liver biopsy for cirosis and another female patient underwent ovariectomy for a giant ovary cyst. Laparoscopic placement of dialysis catheter leads to better function than does open procedure, it allows immediate start of dialysis and permits simultaneous performance of other laparoscopic procedures.     

Laparoscopic management of malfunctioning peritoneal dialysis catheters

BACKGROUND: Continuous ambulatory peritoneal dialysis (CAPD) is an established alternative method to hemodialysis for treating end-stage renal disease patients. However, this method is associated with a significant number of complications, such as catheter malposition, omental wrapping, and infection. The purpose of this study was to determine the efficacy of laparoscopy in the treatment of malfunctioning CAPD catheters. METHODS: Between November 1994 and June 1999, a total of 16 patients with CAPD underwent laparoscopy for the evaluation and management of CAPD catheter dysfunction. Two trocars (10-mm and 5-mm) were used. Recorded data included patient demographics, catheter implantation method, date of malfunction, cause of dysfunction, procedure performed, complications, and catheter outcome. RESULTS: The primary etiology of dysfunction was omentum and/or small bowel wrapping with adhesions in eight cases, malpositioning in five cases, and infection in the remaining three cases. Adhesiolysis was performed in the eight cases with adhesions. In the five cases with malpositioning but no adhesions, the catheters were repositioned in the pelvic cavity. Two catheters had to be withdrawn because of infection. In one case with tunnel infection, the catheters were exchanged simultaneously. There was only one perioperative complication, consisting of temporary dialysate leakage. There were no mechanical or infection problems. The overall success rate of catheter function (>30 days after laparoscopy) was 100%, except for two cases in which the catheters had to be removed. CONCLUSION: Laparoscopy is a highly effective and successful method for the evaluation and management of peritoneal dialysis catheter dysfunction.     

Laparoscopic management of Tenchkoff catheters in continuous ambulatory peritoneal dialysis

We describe a one-port laparoscopic technique for assisting in Tenchkoff catheter placement and salvaging obstructed ones in patients requiring continuous ambulatory peritoneal dialysis (CAPD). This unique technique enables diagnostic laparoscopy, adhesiolysis, repositioning of catheters, and omentectomy to be performed without laparotomy. Six patients were treated. Only one 10-mm port was required, using an operating laparoscope and an instrument introduced through the working channel of the laparoscope. Adhesiolysis was performed under laparoscopic vision; omentectomy and flushing of blocked catheters were carried out extracorporeally. The catheters were then repositioned to the pelvic cavity under laparoscopic vision. All patients were followed up for 6–10 months. No mechanical problem was noticed. Our one-port laparoscopic technique is a simple and effective method for treating patients who have mechanical problems with their peritoneal dialysis catheters. Received: 14 January 1997/Accepted: 14 April 1997     

Laparoscopic observations of adhesions between peritoneal dialysis catheters and intraperitoneal organs: A retrospective,observational study

Laparoscopy provides extensive data for the decannulation of a peritoneal dialysis catheter and is being increasingly used to diagnose encapsulating peritoneal sclerosis. However, there are few reports on the methods of decannulation of peritoneal dialysis catheters. In this study, we examined the laparoscopic findings and postoperative complications of patients undergoing peritoneal dialysis catheter removal. A total of 119 laparoscopic decannulations of peritoneal dialysis catheters were performed between 2003 and 2018 at the Juntendo University Hospital and Juntendo University Nerima Hospital. Laparoscopy was performed during peritoneal dialysis catheter removal by a gastrointestinal surgeon. Patient characteristics such as age, sex, duration of peritoneal dialysis, history of peritonitis and age at the time of peritoneal dialysis termination were assessed. Of these 119 cases, 19 (16.0%) showed adhesion between the peritoneal dialysis catheter and intraperitoneal organs. There were 13 (10.9%) cases involving a tangled omentum, 4 (3.4%) cases involving the small intestine and 2 (1.7%) cases of adhesions extending from the bowels to the abdominal wall. No postoperative complications were associated with the laparoscopic surgery. In these cases, blind decannulation of the peritoneal dialysis catheter may result in injury to the gastrointestinal tract in patients with adhesions. Therefore, we need to pay attention to adhesions between peritoneal dialysis catheters and intraperitoneal organs, and laparoscopy could be a valuable tool in detecting such adhesions and ensuring patient safety.

     

Primary laparoscopic placement of peritoneal dialysis catheters in children and young adults

Background: Primary placement of peritoneal dialysis catheters in children often requires suturing of the catheter into the pelvis. We describe our experience with a gasless laparoscopy technique in children and young adults. Methods: During an 18-month period, 12 patients (mean age, 14 years) underwent primary laparoscopic placement of peritoneal dialysis catheters. A single umbilical port was used for abdominal wall elevation, telescope, and catheter. A needleholder was introduced via an accessory port at the future catheter exit site or through the umbilical port. Omentectomy was performed through the umbilical incision. The catheter was tunneled to the lateral abdominal wall. Follow-up data (≥15 months) included time to initiation of dialysis, hospitalization, and outcome. End points were cure, transplantation, or death. Results: Diet was started on the day of surgery and dialysis on the following day. Four patients had seven complications, including leakage and entanglement of the catheter in tubal fimbriae. Long-term revision-free catheter survival was 67% at 24 months. Conclusions: This minimal access technique for primary placement of peritoneal dialysis catheters includes securing of the catheter tip in a dependent location and omentectomy. It allows nearly immediate use of the catheter, leads to a minimal hospital stay, and has acceptable long-term patency. Received: 24 December 1998/Accepted: 3 March 1999     

Video-assisted laparoscopic procedures in peritoneal dialysis

Background Although laparoscopy is commonly adopted for the diagnosis and management of various medical or surgical problems, its use for patients with peritoneal dialysis has seldom been addressed. This retrospective study analyzes the indications and clinical effects of this procedure. Methods: A retrospective chart was drawn up and a videotape review performed for 18 laparoscopic procedures involving 198 patients receiving peritoneal dialysis on a long-term basis at our dialysis unit from May 1992 to June 2002. The clinical and demographic parameters in this study included gender, age, underlying renal diseases, duration of peritoneal dialysis before laparoscopy, indications of laparoscopic intervention, laparoscopic findings, time of operation, laparoscopic procedures, postoperative complications, mortality, and catheter results. Results: A total of 18 laparoscopic procedures were performed in 17 uremia patients, with indications including catheter malfunction in five cases, preimplantation evaluation of peritoneal space in three cases, evaluation of the etiology underlying intractable peritonitis in nine cases, and verification of the cause for dialysate leakage in one case. Four (80%) of the five catheter malfunctions were successfully corrected, including one case of catheter migration and three cases of omental wrapping, whereas correction failed in the remaining case because of severe bowel adhesion. New catheter placement after adhesiolysis was successful in all three cases of preimplantation peritoneal evaluation (100%). Of the nine patients whose peritonitis episodes were evaluated, two were found to have secondary peritonitis, two had fungal peritonitis; one had tuberculous peritonitis and four had bacterial peritonitis. In the case of persistent exit-site dialysate leakage, laparoscopy showed a penetrating injury of the abdominal wall, raising a strong suspicion of iatrogenic injury during the tunneling maneuvers in initial catheter placement. Two conversions to laparotomy were performed: one to repair the penetrating injury and the other to save the life of a patient threatened by severe fungal peritonitis with abdominal cocoon formation. The laparoscopic procedures lasted 20 to 150 min (average, 50 min). Despite one instance of postoperative hydrocele, there was no operative mortality. Conclusions: The analytical results of this study demonstrate that the current video-assisted laparoscopic technique is an effective means for managing several problems related to peritoneal dialysis such as catheter malfunction, preimplantation evaluation, location of the source of the dialysate leak, and assessment of the causes for peritonitis. Thus, this technique should always be considered when the these problems arise.     

Ultrasound/fluoroscopy-assisted placement of peritoneal dialysis catheters

Peritoneal dialysis (PD) catheters may be inserted blindly, surgically, and either by laparoscopic, peritoneoscopic, or fluoroscopic approach. A modified fluoroscopic technique by adding ultrasound-assistance was performed in the present study to ensure entry into the abdominal cavity under direct ultrasound visualization. From March 2005 to May 2007, ultrasound-fluoroscopic guided placement of PD catheters was attempted in 32 end-stage renal disease (ESRD) patients. Preoperative evaluation was performed on all patients prior to the procedure. After initial dissection of the subcutaneous tissue anterior to the anterior rectus sheath, the needle was inserted into the abdominal cavity under the guidance of ultrasound. The position of the epigastric artery was also examined using ultrasonography to avoid the risk of arterial injury. PD catheters were successfully placed in 31 of the 32 ESRD patients using this technique. In all of these patients, the needle could be seen entering the abdominal cavity using an ultrasound. In one patient the procedure was abandoned because of bowel puncture by the micro-puncture needle that was inadvertently advanced into a loop of bowel. This patient did not develop acute abdomen nor needed any intervention. One patient died 4 days after placement of the catheter of unrelated causes. One patient was started on acute peritoneal dialysis the same day of catheter placement without any complications. The rest of the patients started peritoneal dialysis within 2-6 weeks of catheter placement. None of the patients had bleeding related to arterial injury as ultrasound was able to visualize the epigastric artery. Our experience shows that ultrasound-fluoroscopic technique is minimally invasive and allows for accurate assessment of the entry into the abdominal cavity. This technique can avoid the risk of vascular injury altogether.