Minilaparoscopic extraperitoneal tunneling with omentopexy: a new technique for CAPD catheter placement.

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-related problems. To overcome these problems, different laparoscopic techniques have been presented, being preferable to the open and percutaneous methods. OBJECTIVE: To introduce and evaluate the efficiency of laparoscopic omental fixation and extraperitoneal placement of the cuff-coil part (the straight portion) of the catheter to prevent catheter tip migration, pericatheter leakage, severe abdominal pain, and the obstruction caused by omental wrapping. SETTING: The study was carried out in the General Surgery Department, Akdeniz University Medical School, in Turkey. PATIENTS AND METHODS: Between November 2001 and March 2005, the technique was applied in 44 consecutive patients (mean age 51.6 years, range 18 - 67 years) with end-stage renal disease. During this laparoscopic technique, the omentum was first fixed onto the parietal peritoneum, and then the catheter was introduced through the subumbilical trocar site into the posterior rectus compartment and advanced toward the symphysis pubis. The catheter was then inserted into the abdominal cavity, passing the peritoneal opening, which was prepared before catheter insertion. The straight portion of the catheter was located into the extraperitoneal area of the anterior abdominal wall. The curled end, which contains the side-holes of the catheter, was placed into the true pelvis. Catheter position and patency were verified under direct vision using a 2 mm telescope. RESULTS: All procedures were completed laparoscopically. Operating time ranged between 40 and 100 minutes (median 52 minutes). There was no intraoperative complication or surgical mortality. Peritoneal dialysis was initiated within 15 - 24 hours after catheter implantation. After a median follow-up period of 17.4 months (range 1 - 38 months), early exit-site infection occurred in 1 of 44 patients. All catheters functioned well postoperatively. There was no pain during CAPD. CONCLUSION: This new laparoscopic technique using an extraperitoneal approach with omentopexy for PD catheter placement could prove extremely useful for preventing catheter malfunction caused by catheter tip migration, pericatheter leakage, omental wrapping, and periodic catheter movement that causes abdominal pain in CAPD.