| Abstract|| |
Continuous ambulatory peritoneal dialysis (CAPD) is a well established modality for treating patients with end-stage renal disease (ESRD). The placement of a peritoneal dialysis catheter (PDC) is carried out either by the open method or by laparoscopy. The laparoscopic technique offers the major advantage of direct vision aiding placement of the catheter in the proper place and the additional performance of diagnostic laparoscopy. The traditional laparoscopic placement of PDC requires three ports. In this study, a two port technique for laparoscopic placement of PDC is described in nine patients. This prospective study was carried out at The Armed Forces Hospital, Khamis Mushayt, Saudi Arabia. Nine patients with ESRD underwent laparoscopic placement of the PDC between January 2001 and May 2002. There were seven females and two males, with a mean age of 52 years (range 38-75 years). The mean operating time was 41 minutes (range 30 -75 min). The mean post-operative hospital stay was 4.5 days (range 2-15 days). Two patients (22.2%) developed leakage of dialysate from the 5 mm-port and one patient (11.1%) had migration of the PDC. Our study suggests that this new modified technique appears to be safe and simple and is associated with rapid post-operative recovery.
Keywords: CAPD, Peritoneal dialysis catheter, Laparoscopy, Two-port placement.
|How to cite this article:|
Al-Hashemy AM, Seleem MI, Al-Ahmary AM, Bin-Mahfooz AA. A Two-Port Laparoscopic Placement of Peritoneal Dialysis Catheter: A Preliminary Report. Saudi J Kidney Dis Transpl 2004;15:144-8
|How to cite this URL:|
Al-Hashemy AM, Seleem MI, Al-Ahmary AM, Bin-Mahfooz AA. A Two-Port Laparoscopic Placement of Peritoneal Dialysis Catheter: A Preliminary Report. Saudi J Kidney Dis Transpl [serial online] 2004 [cited 2021 Apr 14];15:144-8. Available from: https://www.sjkdt.org/text.asp?2004/15/2/144/32896
| Introduction|| |
Continuous ambulatory peritoneal dialysis (CAPD) has been shown to be a comparable alternative to hemodialysis, at least during the first years of treatment, for patients with end-stage renal disease (ESRD).  Although it is an effective modality of renal replacement therapy, CAPD accounts for less than 3% of dialysis carried out in Saudi Arabia. 
The classic placement technique of the peritoneal dialysis catheter (PDC) requires a small infra-umbilical incision through which the catheter is inserted blindly, and directed towards the pouch of Douglas. Laparoscopic placement has gained wide acceptance as it has the lowest incidence of catheter complications as well as the longest duration of catheter survival in comparison to all other methods.  In order to further simplify the laparoscopic method of PDC placement, we have adapted a two-port technique instead of the conventional three-port method.
The aim of this report is to present our preliminary results of using the two-port technique of laparoscopic PDC placement in nine consecutive patients.
| Material and Methods|| |
Between January 2001 and May 2002, nine patients (2 males and 7 females) with ESRD on hemodialysis underwent laparoscopic placement of the PDC using the two-port technique at The Armed Forces Hospital, Southern Region, Khamis Mushayt, Saudi Arabia. All these patients had serious vascular access problems which necessitated the change over to CAPD. The mean age of the patients was 52 years (range 38-75 years). The time required for catheter placement, interval to initiation of peritoneal dialysis, post-operative analgesic requirement, resumption of oral feeds, hospital stay and postoperative complications were recorded. The clinical details of the patients are shown in [Table - 1].
Technique of Catheter Placement
The procedure was carried out using aseptic precautions and under general anesthesia with the patient in the supine position. A 1 to 1.5 cm supra-umbilical incision was made and pneumo-peritoneum created using a Veress needle and insufflation of carbon-di-oxide at pressure of 12-14 mm Hg. A 10 mm port was then inserted, a laparoscopic camera introduced and exploration was carried out. A 5 mm port was then placed through an incision in the mid-clavicular line at the level of the umbilicus and passed towards a point 2 cm lateral to the midline, midway between the umbilicus and the symphysis pubis, subcutaneously, to create a tunnel [Figure - 1]. The patient was then placed in a 30 o Trendelenburg position [Figure - 2]. The Tenckhoff PDC was then passed in to the abdominal cavity through the supra-umbilical 10 mm port after removal of the camera. The pigtail tip of the catheter was directed into the pouch of Douglas in females and the rectovesical pouch in male patients assisted by a Maryland forceps placed through the 5 mm port. The external end of the catheter was grasped and brought out through the 5 mm port up to the inner Teflon cuff; this step was done under laparoscopic guidance. The 10 mm port site was closed with a pursestring suture using non-absorbable material such as single zero nylon. The catheter was then secured in the proper place with a double zero nylon stitch. The PDC was tested on the operating table using normal saline.
| Results|| |
All the patients were started on oral feeds on the day of surgery after full recovery from general anesthesia. None required injectable post-operative analgesics and the pain was controlled easily with paracetamol tablets. The mean catheter-placement time was 41 minutes (range 30-75 mins). The mean post operative hospital stay was 4.5 days (range 215 days). Six of the patients were discharged on the second post-operative day, two patients after one week due to dialysate leak, and one patient stayed for two weeks post-operatively because of malpositioning of the PDC. This patient required insertion of a new PDC.
All the patients had initiation of peritoneal dialysis test, using one liter of dialyzing solution on the day of surgery followed by full successful peritoneal dialysis on the second postoperative day. Two patients (22.2%) developed leak of dialysate from the 5 mm-port and one patient (11.1%) had migration of the PDC.
The follow-up ranged between 3 and 15 months.
| Discussion|| |
CAPD has become an accepted mode of renal replacement therapy and is a popular option especially in children with ESRD.  In contrast to in-center hemodialysis, CAPD allows patients the independence to undergo chronic dialysis at home in a very cost effective manner. , With CAPD, there are no painful punctures into venous accesses, no need for anti-coagulation and there is decreased transfusion requirements. Patients on CAPD are reported to survive significantly longer than those on hemodialysis.  Despite these advantages, the use of CAPD in Saudi Arabia very small (< 3%). 
The available methods of PDC placement include percutaneous insertion which does not allow the surgeon to secure or place the catheter accurately in the pelvis. The open method requires a painful incision followed by blind insertion and carries a high potential for adhesions, incisional hernia and delay in instituting full volume peritoneal dialysis.  The laparoscopic placement, which is in popular use now, has the lowest incidence of catheter-related complications, low incidence of post-operative adhesions in addition to the longest duration of catheter survival. 
Catheter migration, resulting in poor return of dialysate, is a common complication associated with all techniques of catheter placement.  In the present series, one patient required laparoscopic insertion of a new catheter due to migration. Dialysate leak remains a problem with catheter placement for CAPD. The leakage rate following placement of the PDC through an abdominal incision has been reported to be between 13-27%, especially with institution of early peritoneal dialysis. ,, For laparoscopic placement of the PDC, the reported leakage rate is 16%.  Two of the patients in this series had leakage (22.2%). Another study is presently ongoing at our center to evaluate a new laparoscopic technique for placement of the PDC to minimize the leakage problem.
| Conclusion|| |
Our study, albeit on a very small number of patients, suggests that the two-port laparoscopic technique of placement of PDC is safe and simple, allows for accurate positioning of the catheter tip in the pelvis and rapid postoperative recovery. However, the observed complications of catheter migration, infection and dialysate leak, point to a need for further studies and possible further refinement of the technique of insertion of the PDC.
| References|| |
|1.||Vonesh EF, Moran J. Mortality in end-stage renal disease: a reassessment of differences between patients treated with hemodialysis and peritoneal dialysis. J Am Soc Nephrol 1999;10:354-65. [PUBMED] [FULLTEXT]|
|2.||Abu-Aisha H, Paul TT. CAPD: is it a viable mode of renal replacement therapy in Saudi Arabia? Saudi J Kidney Dis Transplant 1994;5(2):145-56. |
|3.||Ash SR. Bedside peritoneoscopic peritoneal catheter placement of Tenckhoff and newer peritoneal catheters. Adv Perit Dial 1998; 14:75-9. [PUBMED] |
|4.||Oreopaulos DG, Robson M, Izatt S, Clayton S, de Veber GA. A simple and soft technique for continuous ambulatory peritoneal dialysis (CAPD). Trans Am Soc Artif Intern Organs 1978;24:484-9. |
|5.||Brem AS, Brem FS, McGrath M. Psychosocial characteristics and coping skills in children maintained on chronic dialysis. Pediatr Nephrol 1988;2:460-5. |
|6.||Brem AS, Toscano AM. Continuous cycling peritoneal dialysis for children: an alternative to haemodialysis treatment. Pediatrics 1984;74:254-8. [PUBMED] |
|7.||Kim YS, Yang CW, Jin DL et al. Comparison of peritoneal catheter survival with fistula survival in hemodialysis. Perit Dial Int 1995;15:147-151. |
|8.||Spence PA, Mathews RE, Khanna R, Oreopoulos DG. Improved results with a paramedian technique for the insertion of peritoneal dialysis catheters. Surg Gynecol Obstet 1985;161:585-7. [PUBMED] |
|9.||Hwang TL, Chen MF, Leu ML. Comparison for four techniques of catheters insertion in patients undergoing continuous ambulatory peritoneal dialysis. Eur J Surg 1995;161:401-4. |
|10.||Nahman NS Jr, Middendorf DF, Bay WH et al. Modification of the percutaneous approach to peritoneal dialysis catheter placement under peritoneoscopic visualization: clinical results in 78 patients. J Am Soc Nephrol 1992;3:103-7. |
|11.||Stone MM, Fankalsrud EW, Salusky IB, Takiff H, Hall T, Fine RN. Surgical management of peritoneal dialysis catheters in children: five year experience with 1800 patient - month follow up. J. Pediatr Surg 1986;21:1177-81. |
|12.||Lessin MS, Luks FI, Brem AS, Wesselhoeft CW Jr. Primary laparoscopic placement of peritoneal dialysis catheters in children and young adults. Surg Endosc 1999;13:1165-67. |
Mohamed I Seleem
Department of Surgery, Armed Forces Hospital, Southern Region, P.O. Box 101, Khamis Mushayt
[Figure - 1], [Figure - 2]
[Table - 1]