Laparoscopic-assisted peritoneal dialysis catheter placement: a microinvasive technique

Background Peritoneal dialysis is an alternate form of dialysis for patients with end-stage renal disease (ESRD). Although not as widely used as hemodialysis, peritoneal dialysis (PD) has clear advantages, especially those related to patient satisfaction and simplicity. The purpose of our study was to describe and look at the results of a microinvasive technique for placement of peritoneal dialysis catheters under laparoscopy. Methods From August 2003 to January 2006, 12 patients with ESRD underwent laparoscopic-assisted peritoneal dialysis (LAPD) catheter placement with the microinvasive technique at our institution. Data collected included age, gender, underlying renal disease, and length of operation. Followup was completed for all patients (at least 6 months) and catheter-related morbidity and mortality were also analyzed. Results There were 13 procedures performed (one patient had LAPD catheter placement twice). The average age was 45 years and the most common cause of ESRD was uncontrolled arterial hypertension. Procedural time averaged 33.6 min (range = 24–50 min). Peritoneal dialysis was introduced two weeks after the procedure and no dialysate leaks were observed. There were two catheter-related morbidities; both were catheter exit-site abscesses, one managed surgically with removal of the PD catheter and the other managed conservately with culture-sensitive antimicrobials. Patient satisfaction was beyond acceptable in 92% of the patients (12 of 13). Average longevity of the catheter was 61 weeks (427 days). There were no mortalities. Conclusion LAPD catheter placement is an easy technique with acceptable catheter longevity and minimal morbidity. The microinvasive technique leads to better patient satisfaction and cosmetic outcome without affecting its function. Therefore, we believe that by promoting microinvasive LAPD catheter placement, PD will gain more acceptance among doctors and patients.     

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.     

大网膜部分切除在腹腔镜腹膜透析管置入术的应用价值

目的探讨大网膜部分切除术在慢性肾脏病5期患者腹膜透析管置入术中的应用价值。方法选择郑州大学第一附属医院腹腔镜外科于2017-01—2019-08间收治的268例慢性肾脏病5期患者,其中190例行常规腹腔镜下腹膜透析管植入术(常规腹腔镜组)、78例行腹腔镜下腹膜透析管置入并大网膜部分切除术(大网膜切除组)。对2组患者的临床资料进行比较分析。结果2组患者的年龄、性别、术前血红蛋白、术前肌酐值等一般资料差异无统计学意义(P>0.05)。268例手术均获成功,大网膜切除组手术时间长于常规腹腔镜组,手术费用多于常规腹腔镜组;常规腹腔镜组堵管10例,大网膜切除组无堵管病例。差异均有统计学意义(P<0.05)。结论腹腔镜下腹膜透析管置入并大网膜部分切除术,对预防术后大网膜包裹腹膜透析管效果良好,具有临床应用价值。     

Mini-laparoscopic placement of a peritoneal dialysis catheter

Background: The laparoscopic placement of continuous ambulatory peritoneal dialysis (CAPD) catheters is now an accepted technique. We evaluated a new technique for CAPD catheter placement that requires only a single 2-mm port. Methods: A pilot study was conducted at an academic minimally invasive surgery center. Seven consecutive patients in whom a CAPD catheter was required underwent placement of a 2-mm Veress port and a laparoscope. A carbon dioxide pneumoperitoneum was induced up to 14 mmHg. Under direct visualization with a 2-mm scope, a CAPD catheter was advanced over the right lower quadrant toward the pelvis using a modified Seldinger technique. Results: Seven patients (four women and three men) with end-stage renal disease underwent mini-laparoscopic placement of a CAPD catheter. Mean patient age was 35.3 ± 11.3 years (range, 17–50). Mean operative time was 20.7 ± 5.0 min (range, 14–29). Patients were dialyzed in the immediate postoperative period. No leaks were identified, and there were no intraoperative or postoperative complications. Conclusion: A mini-laparoscopic technique using a single 2-mm port and a modified Seldinger technique is feasible, safe, and effective for peritoneal dialysis catheter placements.     

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.     

Two-port laparoscopic placement of a peritoneal dialysis catheter with abdominal wall fixation

We devised a new laparoscopic technique for peritoneal dialysis catheter (PDC) placement to overcome the common problem of malfunction or migration of the catheter. Between March 2005 and August 2006, 38 patients underwent laparoscopic catheter placement with lower abdominal wall fixation. Using an abdominal scout film, we checked for catheter tip migration regularly. There was no leak in the immediate postoperative period. After follow-up of 21.5 months (range 6–34), all catheters were working properly, although tip migrations were found in the iliac fossa in three patients and in the right upper quadrant in one patient. A port site hernia developed in one patient and peritonitis developed in two patients. Only one remote migration (2.6%) occurred during the study period. Thus, our method of laparoscopic catheter insertion might be a feasible option.     

腹腔镜引导下腹膜透析管置放术

目的　探讨腹腔镜引导下放置腹膜透析管的方法。　方法　选择 9例慢性肾功能衰竭患者 ,在腹腔镜引导将Tenckhoff腹膜透析管置入腹腔并经皮下隧道引出。　结果　所有病例腹膜透析管均放置成功。手术时间 10min～ 2 0min。均成功的进行了腹膜透析。患者术后 2～ 7天出院。　结论　腹腔镜引导放置腹膜透析管技术具有透析管定位准确 ,手术切口小 ,术后疼痛轻。优于常规开腹技术     

Laparoscopic omental fixation technique versus open surgical placement of peritoneal dialysis catheters

Background: Continuous ambulatory peritoneal dialysis (CAPD) is an effective form of treatment for patients with end-stage renal disease. Open insertion of peritoneal dialysis (PD) catheters is the standard surgical technique, but it is associated with a relatively high incidence of catheter outflow obstruction and dialysis leak. Omental wrapping is the most common cause of mechanical problems. The purpose of this study was to determine the efficacy of the laparoscopic omental fixation technique to prevent the obstruction caused by omental wrapping and also to compare this laparoscopic technique with open peritoneal dialysis catheter insertion with respect to postoperative discomfort, complication rates, and catheter survival. Methods: Between March 1998 and October 2001, 42 double-cuff, curled-end CAPD catheters were placed in 42 patients. The outcomes of the 21 patients in whom the PD catheters were placed laparoscopically with omental fixation technique were compared with those of the 21 patients in whom the catheters were placed with open surgical technique. Recorded data included patient demographics, catheter implantation method, early and late complications, catheter survival, and catheter outcome. Results: Early peritonitis episodes occurred in 8 of 21 patients (38.0%) in the open surgical group (OSG) versus 2 of 21 patients (9.5%) in the laparoscopic omental fixation group (LOFG) (p < 0.05); late peritonitis episodes occurred in 3 of 21 patients (14.2%) in the OSG versus 1 of 21 patients (4.7%) in the LOFG (p < 0.05). Early exit site infection occurred in 8 of 21 patients (38.0%) in the OSG versus 4 of 21 patients (19.0%) in the LOFG (p < 0.05), with many catheter-related problems in the conventional surgical group. There was no outflow obstruction in the LOFG. The conventional procedure was faster than the laparoscopic omental fixation technique. Analgesic requirements and hospital stay were less in the laparoscopic group. Laparoscopic surgery also enabled diagnosis of intraabdominal pathologies and treatment of the accompanying surgical problems during the same operation. Occult inguinal hernia was diagnosed in 2 patients, inguinal hernioplasty was performed in 4 patients, adhesiolysis was performed in 8 patients who had previous abdominal surgery, and liver biopsy was taken in 2 patients. Ovarian cystectomy was performed in another patient during laparoscopic CAPD catheter placement. Conclusion: The laparoscopic omental fixation technique (described by Öünç and published in 1999) is a highly effective and successful method for preventing obstruction due to omental wrapping with a better catheter survival. Laparoscopic surgery also allows the diagnosis and treatment of the accompanying surgical pathologies during the same operation.     

Laparoscopic versus open peritoneal dialysis catheter insertion cost analysis

Background

Peritoneal dialysis (PD) is a cost-effective alternative to hemodialysis (HD). PD catheters have traditionally been inserted through a small open incision, but insertion using laparoscopic visualization has become increasingly popular and is associated with less catheter malfunction. The aim of this study was to compare costs of laparoscopic and open insertion strategies while taking into account postoperative complications and future salvage procedures.

Methods

A decision analysis model was constructed to simulate 1 y outcomes after PD catheter insertion by either the open or laparoscopic approach. Possible outcomes after PD catheter placement included functional catheter, infection, and catheter malfunction. Ultimately, patients continued with successful PD or switched to HD. Baseline probabilities, costs, and ranges were determined from a critical review of the literature. Sensitivity analyses were performed to determine the model strength over a range of clinically relevant probabilities.

Results

The total annual costs, including postoperative management and dialysis treatment, were $69,491 for laparoscopic insertion and $69,960 for open insertion. In case of a catheter malfunction, an initial attempt at salvage by fluoroscopy-guided wire manipulation cost less than a first attempt by laparoscopic repositioning.

Conclusions

When accounting for a year of postoperative management and treatment, laparoscopic insertion can be less costly than open insertion in the hands of an experienced surgeon. Despite higher initial costs, PD catheter insertion under laparoscopic visualization can have lower total costs due to fewer postoperative complications. With increasing emphasis on cost-effective care, laparoscopic insertion is a valuable tool for initiating PD.     

改良的腹膜透析导管固定方法在腹透置管术中的应用

目的 观察改良的腹膜透析(peritoneal dialysis,PD)导管固定方法在PD置管术中的应用.方法 收集2014年6月至2019年6月在扬州大学医学院附属泰兴市人民医院肾脏内科确诊为终末期肾病并选择PD治疗的大于18岁的患者,随机分为常规手术组与改良腹壁固定组,随访6个月,比较两组患者手术用时,术后导管漂管...     

Laparoscopic versus traditional peritoneal dialysis catheter insertion: a meta analysis

Objective: The objective of this study is to compare the catheter-related complications as well as catheter survival between laparoscopic and traditional surgery in peritoneal dialysis catheter insertion. Results: Five randomized controlled trials and 11 cohort studies were identified. Meta-analysis showed laparoscopic catheter is superior to traditional surgery in terms of controlling catheter migration (OR 0.17, 95% CI 0.08–0.33; p?p?=?0.0001; 2-year survival rate: OR 2. 07, 95% CI 1.29–3.33, p?=?0.0001), but slightly increases the risk of bleeding (OR 2.13, 95% CI 1.07–4.23, p?=?0.03). The two groups were not significantly different in other catheter-related complications. As regards the quality of the analysis, only the migration analysis ranked A-level, while the rest fell into Class B or C. The overall research quality was moderate. Conclusion: Laparoscopic surgery is superior to traditional surgery on reducing catheter migration and prolonging catheter survival rate according to our analysis.     

常用腹膜透析导管类型及导管相关性并发症

腹膜透析导管是腹膜透析的重要环节,导管相关性并发症约占腹膜透析转为血液透析原因的20%。不同类型导管由于结构和形状的不同,导致相关性并发症的发生率不同。双袖套较单袖套导管可更好地预防皮肤出口感染和腹膜炎;鹅颈管在预防隧道及皮肤出口感染上优于Tenckhoff直管;导管腹腔段卷曲型与直型比较,漂管及引流障碍的发生率更低。然而,随着透析技术和护理技术的提高,不同类型导管所致相关并发症的发生率均明显下降,已无明显差异。在重视导管类型选择的同时,更应强调皮肤和导管护理的重要性。     

Laparoscopic peritoneal dialysis catheter insertion using a Quinton percutaneous insertion kit.

OBJECTIVE: We assessed a unique technique of laparoscopic peritoneal dialysis (PD) catheter insertion which can minimize catheter dysfunction. METHODS: We performed a retrospective review of patients undergoing laparoscopic PD catheter placement with a Quinton percutaneous insertion kit between July 2000 and December 2004. RESULTS: Thirty-one catheters were placed laparoscopically. The mean operating time was 52 minutes. Adhesiolysis was required in 9 (29%) and omentectomy or omentopexy in 3 (10%) cases. Late complications included catheter dysfunction in 2 patients (6.5%), debilitating abdominal pain requiring catheter removal in 1 patient, and 1 trocar-site hernia. The mean follow-up was 17 months. CONCLUSIONS: Laparoscopic PD catheter insertion using a Quinton percutaneous insertion kit is safe, reproducible, and effective. It facilitates placement of the catheter tip into the pelvis and allows adhesiolysis, omentectomy, or omentopexy when necessary. Utilization of this technique results in a low rate of PD catheter dysfunction.     

腹腔镜在腹膜透析管复位中的临床应用

目的：评价应用腹腔镜手术方法行腹膜透析管复位的治疗效果,并总结相关治疗经验。方法收集2010年3月至2014年5月我院腹透中心收治的33例经常规保守治疗后,腹透液进出仍然不通畅,并确诊为导管持续性移位,须行手术复位腹膜透析导管患者的临床资料,进行回顾性分析,评价腹腔镜下腹透导管复位术的效果。结果33例导管持续性移位的患者均采用全麻下腹腔镜手术复位。术中所见多为单纯导管移位（21/33,63.6%）,腹腔镜直视下将腹膜透析管直接放至膀胱直肠陷窝或子宫直肠陷窝,并加用不可吸收线将导管固定于邻近腹壁,以减少再次移位的可能性;其次为大网膜包裹（12/33,36.4%）,腹腔镜直视下钝性分离包裹于导管上的大网膜,后续操作步骤同单纯导管移位者。全部33例患者均用上述技术成功复位,手术时间维持在30~45 min,平均出血量约5~10 ml;术中患者生命体征平稳,未见明显并发症;术后行腹膜透析,伤口处无渗液、漏液,伤口愈合良好;术后随访3~50个月,33例患者均可正常进行腹膜透析,未再出现导管移位。结论腹腔镜下腹膜透析管复位定位准确,切口小,易于愈合,合理运用可显著提高腹膜透析技术成功率。     

腹膜透析管出口感染的菌种和预后分析

目的 了解腹透管出口感染的菌种和预后。方法 定期随访规律性腹膜透析(腹透)患者的腹透管出口，将出口分为良好出口、可疑出口、感染出口(ESI)和隧道感染(TI)，并统计ESI的发生率、细菌种类、治疗效果和预后。结果 在18个月随访期间定期检查69例腹透患者的出口，共发生ESI 21例次，病原菌中以金黄色葡萄球菌(47．6％)和绿脓杆菌(28．6％)为主。经治疗，17例次治愈，4例次末愈(2例次为金葡菌，2例次为绿脓杆菌)并导致隧道感染(TI)。临床诊断TI发生率为0．012次／病人年，超声显像诊断TI发生率为0．036次／病人年。其中1例cuff剥离后出口愈合良好。3例拔管。结论 感染的细菌种类影响预后。隧道感染发生于出口感染末愈的病例中，超声显像检查能提高诊断阳性率。     

超声引导下腰方肌阻滞在腹膜透析置管术中的应用效果

目的观察超声引导下腰方肌阻滞在腹膜透析置管术中应用的有效性及安全性。方法选择择期行腹膜透析置管术终末期肾病患者90例,男49例,女41例,年龄45～65岁,ASAⅢ或Ⅳ级,随机分为三组,每组30例:A组采用局麻,B组采用0.5%罗哌卡因25 ml行超声引导下腹横肌平面阻滞,C组采用0.5%罗哌卡因25 ml行超声引导下腰方肌阻滞。记录麻醉前(T_0)、阻滞完成后30 min(T_1)、切皮时(T_2)、置管时(T_3)、打隧道穿刺出皮肤时(T_4)和缝合切口时(T_5)的MAP和HR;记录舒芬太尼追加例数,记录T_2—T_5时VAS评分和围术期不良反应的发生情况。结果 T_3—T_4时C组MAP明显低于A组和B组,HR明显慢于A组和B组(P0.05),B组MAP明显低于A组,HR明显慢于A组(P0.05)。T_3—T_4时C组VAS评分明显低于A组和B组(P0.05),B组VAS评分明显低于A组(P0.05)。C组舒芬太尼追加例数明显少于A组和B组(P0.05),A组舒芬太尼追加例数明显多于B组(P0.05)。三组下肢乏力发生率差异无统计学意义,三组均无一例其他不良反应。三组围术期均未发生明显的穿刺并发症。结论超声引导下腰方肌阻滞麻醉应用于终末期肾病患者腹膜透析置管术中效果确切,可减少麻醉性镇痛药的使用,不增加不良反应。     

Laparoscopic introduction of a continuous ambulatory peritoneal dialysis (capd) catheter by a two-puncture technique

We describe a laparoscopic two-puncture technique for the placement of a continuous ambulatory peritoneal dialysis catheter. With a mean follow-up period of 8 months the short-term results of the first 19 laparoscopic catheter insertions are evaluated and discussed. It appears to be a simple, safe, and viable procedure with a low morbidity and very good results in the short term. The same technique can also be used in catheter salvage in case of outflow obstruction or cathether migration, thus increasing catheter longevity.     

Comparison of open and laparoscopic secure placement of peritoneal dialysis catheters

Background A major and frustrating complication of peritoneal dialysis catheter placement is mechanical outflow obstruction, which may be caused by catheter tip migration. Therefore, a secure and correct positioning of the catheter is important to minimize this risk. This technique is easily accomplished by a laparoscopic approach.Methods The outcomes of 50 patients in whom peritoneal dialysis catheters were inserted laparoscopically with a secure catheter placement technique were compared with those of 52 patients who underwent an open surgical technique using a stiff wire as guidance for the catheter. The data were prospectively collected but not randomized. All the patients had virgin abdomens, and all the procedures were undertaken or supervised by one surgeon.Results Catheter migration occurred in six patients (12%) in the open group, as compared with none in the laparoscopic group (p = 0.027). There were no significant differences in catheter survival between the two groups.Conclusions The laparoscopic technique with secure placement of the catheter lowered the incidence of catheter migration, but did not increase the catheter survival.     

Laparoscopic versus open peritoneal dialysis catheter placement

Background

Laparoscopy revolutionized many General Surgery procedures by decreasing hospital stay, minimizing recovery time, and reducing wound infection rates. This study evaluates the potential benefits of laparoscopic approach to peritoneal dialysis catheter (PDC) placement.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for laparoscopic and open PDC placement. We evaluated patient demographics, comorbidities, operative time, length of stay (LOS), and postoperative outcomes. Univariate comparison and multivariate logistic regression analysis (MVA) adjusting for confounding factors including age, body mass index (BMI), comorbidities, and preoperative conditions were performed.

Results

A total of 3134 patients undergoing PDC placement were recorded in the NSQIP database between 2005 and 2012, including 2412 laparoscopic cases (LPDC) (77 %) and 722 open (OPDC). Overall, the majority of cases were performed by General Surgeons (81 %) with most of the remainder completed by Vascular Surgeons (16.8 %). Patients undergoing LPDC versus OPDC demonstrated no significant difference in gender (54 vs. 56 % males, p = 0.4), smoking history (8.5 ± 18.3 vs. 7.2 ± 16.9 pack years, p = 0.06), diabetes (42 vs. 40 %, p = 0.4), COPD (4.6 vs. 5 %, p = 0.63), or preoperative dialysis requirement (72 vs. 73 %, p = 0.6), but they were younger (57.2 ± 14.8 vs. 60.5 ± 15.9 years, p = 0.05) and had a higher BMI (29.3 vs. 29 kg/m², p = 0.04). In univariate analysis of LPDC versus OPDC, overall wound complications (1.6 vs. 2.9 %, p = 0.02), deep surgical site infections (0.12 vs. 0.83 %, p < 0.006), minor complications (3.8 vs. 6.5 %, p < 0.05), major complications (4.3 vs. 6.9 %, p < 0.05), and LOS (1.8 ± 11.9 vs. 4.4 ± 10 days, p < 0.0001) favored the LPDC approach, but only operative time (57.6 ± 4.6 vs. 71.8 ± 5.3, p < 0.001) remained significant in MVA after controlling for confounding factors. Both LPDC and OPDC had equivalently low rates of catheter failure (0.21 vs. 0.14 %, p = 0.7).

Conclusion

Using univariate analysis, there appears to be a benefit from LPDC placement. However, after controlling for confounding variables, the techniques appear to have equal outcomes. Surgeons should perform a LPDC or OPDC according to the approach with which they are most familiar. However, continued adoption, dispersal, and refinement of the laparoscopic approach may further optimize patient outcomes.

     

The role of laparoscopic surgery in the management of a malfunctioning peritoneal catheter

IntroductionPeritoneal catheter malfunction is a common complication of peritoneal dialysis (PD). It has a high failure rate with conservative management. Catheter replacement was historically the standard surgical treatment of choice. Nowadays, laparoscopy has been introduced as an alternative surgical modality to rescue the malfunctioning peritoneal catheter and also offers the possibility of replacement if indicated. The aim of this study was to compare the outcomes of these two surgical modalities.MethodsThe medical records of consecutive patients who underwent surgical treatment for malfunctioning PD catheters (between January 2010 and April 2013) were analysed. The primary outcome included successful return to adequate PD. The secondary endpoint was length of catheter patency and the cause of catheter failure.ResultsA total of 32 cases were identified, of which 8 had open catheter replacement and 24 had a laparoscopic intervention. The overall median follow-up duration was 12.5 months. The success rate for laparoscopic surgery in terms of functioning catheter at 12 months was 62.5% but only 37.5% for open surgery. The mean length of catheter patency after laparoscopic intervention was 31.6 months compared with only 13.6 months for the open surgery group. The most common cause of catheter failure diagnosed during laparoscopic intervention was catheter migration (33.0%), followed by omental wrap and catheter blockage by fibrin/blood plug (25.0% each). Open surgery did not have any diagnostic potential.ConclusionsLaparoscopy is the treatment of choice for malfunctioning PD. Its proven benefit includes simultaneous identification of the aetiological cause of malfunction together with direct correction of this problem, thereby maximising outcome. It also allows for rapid recommencement of PD and avoidance of haemodialysis, saving cost and resources.