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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2001  |  Volume : 12  |  Issue : 2  |  Page : 175-178
Simplified Surgical Placement of Tenckhoff Catheter under Local Anesthesia: The Dammam Central Hospital Experience


1 Department of Nephrology, Dammam Central Hospital, Dammam, Saudi Arabia
2 Department of Surgery, Dammam Central Hospital, Dammam, Saudi Arabia

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   Abstract 

Many methods are used for the placement of Tenckhoff catheters. Eighteen consecutive Tenckhoff catheters were placed under local anesthesia through a mini laparotomy with a reduced operating team. There were only three total catheter failures. Complications were infrequent and operating time was less than one hour on average. This simple procedure should be a part of the training program of all junior surgeons and nephrologists.

Keywords: Continuous ambulatory peritoneal dialysis, Tenckhoff catheter.

How to cite this article:
Youmbissi T J, Al Amir A, Malik Q T, Al Joaeb A S, Al Khursany I, Ghacha R, Kumar S A, Rafi A, Al Ahmed F, Abdul Rahman M R, Karkar A. Simplified Surgical Placement of Tenckhoff Catheter under Local Anesthesia: The Dammam Central Hospital Experience. Saudi J Kidney Dis Transpl 2001;12:175-8

How to cite this URL:
Youmbissi T J, Al Amir A, Malik Q T, Al Joaeb A S, Al Khursany I, Ghacha R, Kumar S A, Rafi A, Al Ahmed F, Abdul Rahman M R, Karkar A. Simplified Surgical Placement of Tenckhoff Catheter under Local Anesthesia: The Dammam Central Hospital Experience. Saudi J Kidney Dis Transpl [serial online] 2001 [cited 2019 Nov 22];12:175-8. Available from: http://www.sjkdt.org/text.asp?2001/12/2/175/33808

   Introduction Top


Access to blood circulation is vital to either form of dialysis, hemodialysis (HD) or peritoneal dialysis (PD). In the latter form, access to blood is gained by placing a catheter in the peritoneal cavity. [1] Dialysis access procedures and complications represent a major cause of morbidity, hospitalization and cost. [2] In Saudi Arabia, continuous ambulatory peritoneal dialysis (CAPD) is not yet widespread and as such CAPD catheter placement is not part of the routine duties of surgeons or physicians dealing with dialysis access. This procedure is generally an elective one, usually carried out under general anesthesia (GA) and does not receive the priority it deserves from the consultants, surgeons and anesthetists. [3] Confronted with this problem at the start of our CAPD program, and in order to avoid slowing down, for logistic reasons, of an already not yet popular system, we set up a new policy for a simplified Tenckhoff catheter placement. The present study describes the technique and presents its preliminary results.


   Methods Top


In the new policy, Tenckhoff catheter placement was simplified. The procedure was conducted in a smaller operating room (OR) and under local anesthesia (LA), led by a nephrologist (with a background experience in Tenckhoff catheter placement) and a surgical resident (senior, or at times junior). Patients were usually hospitalized just before the procedure. All anticlotting and antiplatelet medications were discon­tinued 48 hours prior to admission. Patients on hemodialysis were dialyzed at least 12 hours prior to the procedure. Pre-operatively, the coagulation profile was checked and all patients were given laxatives to keep the colon empty. The abdominal wall, particularly the umbilicus, was carefully cleaned and aseptically wrapped in the medical ward. Patients were usually pre­medicated with diazepam 30 minutes prior to entering the OR. Standard rules for a mini laparotomy were followed.

In the OR, the abdominal wall and the umbilicus were carefully cleaned again. After administering LA, access to the peritoneum was gained through a midline incision. A double cuff straight Tenckhoff catheter was inserted and directed caudally towards the pelvis but its tip was not fixated. The first cuff was secured to the peritoneum by two purse strings with 00 chromic catgut biting slightly on the cuff, an anti-leakage technique originally described by Odor et al. [4] Thereafter, the inflow­outflow was checked (by the CAPD nurse in attendance particularly if the Andy system is used). If the flow was satisfactory, the tunnel segment was created. The abdominal cavity was then drained and the wound closed in the standard manner. The catheter was tunneled in a curved manner so that the exit was directed downwards.

Subsequent to the procedure, a break-in period of 2 to 4 weeks was observed.


   Results Top


Eighteen consecutive Tenckhoff catheters were placed with the new policy over the past few years. Average procedure time was 45 ± 12 minutes. All patients were stable during the operation and none required the intervention of an anesthetist. The anesthesia team was represented in the theatre by only a technician. After the procedure, the patients were wheeled back directly to the renal unit without transiting through the recovery room.

The complications noted during the first week (short-term) comprised bleeding (2 cases; 11%), leakages (4 cases; 22%), outflow obstruction (3 cases; 16.6%) and catheter tip migration (2 cases; 11%). There were two early total catheter failures (11%): one from catheter tip migration and the second from outflow obstruction with omental wrapping. There were no cases of reflex ileus, visceral perforation, catheter dislodgment, early exit/tunnel infection or peri-catheter hernia. Late catheter related complications were not frequent except for peritonitis (0.62 per patient year), exit site/tunnel infection (6 cases; 33%) and external cuff erosion (2 cases; 11%). There was only one late catheter failure caused by omental wrapping (5.5%). All cases of catheter failure were corrected surgically by the same team.

No correlation was found between catheter complications and factors such as age, body weight, sex or presence of diabetes mellitus.


   Discussion Top


Prior to the new policy, Tenckhoff catheter placement was carried out under the full responsibility of surgeons and anesthetists, and general anesthesia (GA) was used. Thus, the prevailing constraints regarding the time, place and circumstances of the procedure resulted in long delays. Contraindications to GA also used to prevent a number of patients from being on CAPD, particularly the elderly, diabetics, obese patients etc. Our results show that surgical Tenckhoff catheter placement can be minimally and safely carried out under LA by a combined team of nephrologist­junior surgeon, thus empowering the CAPD team, the ultimate users of the catheter, of the full control of the procedure.

There are many variations concerning the approach to the peritoneum. The midline approach advocated by Tenckhoff is meant to avoid excessive bleeding. [5] The paramedian approach may preempt peri-catheter leakage. [6] In our series, we used an anti-leakage suture technique, [4] in spite of which peri-catheter leakage was our commonest complication and later predisposed the patients to peritonitis. Our failure rate was within acceptable limits, [3],[4] and even better than in some earlier series of CAPD. [4],[7] However, the number of patients in our study is small for proper statistical comparison. The other complications were less prevalent.

Historically, Tenckhoff placement started through the trocar technique [5] and was carried out by nephrologists, usually using peritoneoscopy in many units. [7] Later on, with improvement in catheter design [8] and the widespread acceptance of CAPD, much attention was paid to the surgical aspects of the technique. [9],[10]

In countries where CAPD is frequently used, CAPD catheter placement and care is an important exercise in the training of surgical residents. [4] The placement of the Tenckhoff catheter has gone through many changes. Subcutaneous techniques to access the peritoneum even predates [11] the development of the Tenckhoff catheter. Later on, the technique was researched and improved by many groups [12],[13] and today, in many centers in countries with a large CAPD recruitment, the insertion is carried out percutaneously with minimal surgery in the out-patient department, with the patient sent home on the same day after the first 2-4 exchanges. Training of patients and relatives are carried out prior to surgery. Catheters are inserted only when patients and relatives have mastered the technique. [6] In countries such as Saudi Arabia, placement of Tenckhoff catheters is still considered in some hospitals as a major surgical procedure, and may be time-consuming. The efficacy and safety of our simplified procedure under LA show that Tenckhoff catheter placement should not be a major impediment to the practice of CAPD, even in secondary care or small general/district hospitals. This procedure, which in some countries is the first laparotomy of the junior surgical residents, should become part of the training of our general surgery residents.


   Acknowledgment Top


We wish to thank Sisters Sophie George, Betty Manding and Mary Varghese for their contribution to this work.

 
   References Top

1.Tenckhoff H, Schechter H. A bacteriolo-gically safer peritoneal access device. Trans Am Soc Intern Organs 1968;2:181-7.  Back to cited text no. 1    
2.Hakim R, Himmelfarb J. Hemodialysis access failure: a call for action. Kidney Int 1998;54:1029-40.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Olcott C 4th, Feldman CA, Coplon NS, Oppenheimer ML, Mehigan JT. Con­tinuous ambulatory peritoneal dialysis. Technique of catheter insertion and management of associated surgical complications. Am J Surg 1983;146:98-102.  Back to cited text no. 3    
4.Odor A, Allesio-Robles LA, Leuchter IJ, et al. Experience with 150 consecutive permanent peritoneal catheters in patients on CAPD. Perit Dial Bull 1985;S226-9.  Back to cited text no. 4    
5.Tenckhoff H. Chronic peritoneal dialysis manual. Chapter 8 University of Washington School of Medicine. Seatle1976;23-33.  Back to cited text no. 5    
6.Helfrich GB, Pechar BW, Alijam MR, Bernard WF, Rakowskita, Winchester JF. Reduction of catheter complications with lateral placement. Perit Dial Bull Suppl 1983;3:52-4.  Back to cited text no. 6    
7.Henao J, Mejia G, Arbelaez M, et al. A new approach for catheter placement and care in CAPD. Perit Dial Bull 1985;S223-5.  Back to cited text no. 7    
8.El Shahat YI, Cruz C. The impact of catheter designs on preventing CAPD complications. Saudi J Kidney Dis Transplant 1995;3:275-9.  Back to cited text no. 8    
9.Robison RJ, Leapman SB, Wetherington GM, et al. Surgical Consi­derations of continuous ambulatory peritoneal dialysis. Surgery 1984;96:723-30.  Back to cited text no. 9  [PUBMED]  
10.Francis DM, Donnelly PK, Veitch PS, et al. Surgical aspects of continuous ambulatory peritoneal dialysis--3 years experience. Br J Surg 1984;71:225-9.  Back to cited text no. 10  [PUBMED]  
11.Malette WG, McPhaul JJ, Bledsoe F, McIntosh DA, Koegel E. A clinically successful subcutaneous peritoneal access button for repeated peritoneal dialysis. Trans Am Soc Artif Intern Organs 1964; 10:396-9.  Back to cited text no. 11  [PUBMED]  
12.Helfrich GB, Winchester JF. What is the preferable technique for the peritoneal catheter implantation? Perit Dial Bull 1983;2:132-3.  Back to cited text no. 12    
13.Lovinggood JP. Peritoneal catheter im-plantation for CAPD. Perit Dial Bull 1984;4:S106-9.  Back to cited text no. 13    

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Correspondence Address:
T J Youmbissi
Consultant Nephrologist, Dammam Central Hospital, P.O. Box 10388, Dammam 31443
Saudi Arabia
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PMID: 18209370

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    Abstract
    Introduction
    Methods
    Results
    Discussion
    Acknowledgment
    References
 

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