Laparoscopic Peritoneal Dialysis Catheter Insertion using 3-cuff Technique.

Majid T Aized, MD2, Erina Kansakar, MD1, John Webber, MD, FACS2. 1McLaren Port Huron Hospital, 2Detroit Medical Center, Wayne State University

Faulty surgical technique and mechanical complications diminish the life of peritoneal catheter. A single cuffed catheter provides a solo anchorage point and results in catheter tip displacement, leak at catheter exit site, cuff protrusion and infectious complications . We extend the single cuff catheter using an additional inverted V shaped catheter with two cuffs. These three cuffs fix the catheter in the subcutaneous tunnel.

The following describes the technique used in 60 consecutive patients who had PD catheter placed between July 2012 and June 2013.

All patients had the catheter exit site marked prior to surgery (above the umbilicus,away from the belt line and usually left abdomen). The peritoneal cavity is accessed via 5mm incison in left upper quadtrant using the optiview technique and pneumoperitoneum is established. A 5 mm trocar is placed in the right lower quadrant for catheter positioning. A 10mm non-bladed trocar is placed below the umbilicus directing towards the pubis at approximately 45 degrees angle to create a peritoneal tunnel. A pigtail catheter with a single cuff is introduced via the 10mm port. The catheter sits deep in the pelvis while the cuff is positioned right above the peritoneum at the entry point (acts a first fixation point). A second inverted V shaped catheter with a cuff on each arm is used for extension. A 2 cm incision is made in the skin and subcutaneous tissue three fingerbreaths below the left costal margin. A small stab incision is made at the premarked catheter exit site and a subcutaneous tunnel is created directed towards the left subcostal incision. The lateral limb of the inverted V catheter is brought out through the premarked catheter exit site .The medial limb of the inverted V shaped catheter is tunneled through the subcutaneous tissue to exit at the infraumbical 10 mm port site. The two catheters are connected with a titanium connector. The two additional cuffs provide additional fixation points. The catheter is connected to a titanium luer lock. Inflow and outflow of dialysate fluid is tested and 150-200 ml of fluid is left in the pelvis. Dialysis is initiated in 7-10 days. All umbilical hernias identified during the procedure and primarily repaired with transfascial prolene sutures using Carter Thomason device.

We have not identified any cuff protrusion or exit site leak in 60 cases performed .Two needed catheter revision . These male patients had failed transplanted kidney which further narrowed the male pelvis. A straight tip catheter was used to prevent displacement of the catheter tip out of the pelvis. One patient had catheter removed for extensive intraperitoneal adhesions.

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