Monika A Krezalek, MD, Jose M Velasco, MD, Ervin W Denham, MD, John G Linn, MD, Michael B Ujiki, Louisa T Ho, Joann Carbray, BS, Stephen P Haggerty, MD. NorthShore University Health System
Introduction: Benefits of peritoneal dialysis (PD) over hemodialysis (HD) have been widely established and include greater patient autonomy and quality of life, preservation of residual renal function, and slight survival advantage. Catheter dysfunction is a common reason for transfer to HD and occurs up to 38% and 14% of the time after open and laparoscopic insertion respectively. Common causes are: compartmentalization from adhesions, omental entrapment, and catheter tip migration. In an attempt to improve catheter function and decrease complication rates, advanced laparoscopic techniques such as adhesiolysis, rectus sheath tunnel, and omentopexy have been recommended. Our group began incorporating these techniques based on surgeon preference over the last four years. The aim of this study is to investigate the rates of PD catheter dysfunction and peri-operative complications after advanced laparoscopic insertion at our institution.
Methods and procedures: We retrospectively collected and analyzed data on 100 consecutive laparoscopic PD catheter placements at NorthShore University Health Systems between 6/3/2010 and 2/24/2014. We included data from five high volume minimally invasive surgeons. Demographics, Perioperative and long term follow-up data were collected. Primary end points included catheter dysfunction and complications.
Results: Sixty four percent of patients had a history of prior abdominal operations, while 23% required adhesiolysis. Rectus sheath tunneling was performed in 58% of cases, and omentopexy was performed in 64%. Average operation length was 38.9 minutes (28.5 minutes without additional procedures). After a mean follow up of 19 months, we noted a 5% outflow obstruction rate due to adhesions (2), omental wrapping (1), fibrin plug (1), and entrapment under bowel in deep pelvic location (1). We also noted a 2% catheter migration rate, both occurring when rectus sheath tunneling was not performed. Early post-operative complications included urinary retention (2%), ileus (1%), and early peritonitis (2%). There were no cases of bleeding, bowel perforation or PD fluid leak. We noted a 3% rate of umbilical port-site hernia requiring repair (two were recurrent, initially repaired primarily at the time of PD catheter placement). Additionally, post-operative length of stay was 0.6 days for elective and 5.5 days for emergent operations.
Conclusions: Advanced laparoscopic insertion techniques using adhesiolysis, rectus sheath tunnel and selective omentopexy are effective at minimizing PD catheter dysfunction and add very minimal time and risk to the operation. A randomized controlled trial is needed to confirm that this approach is superior to basic laparoscopic, percutaneous and open insertion techniques.