Novel microlaparoscopic technique for peritoneal dialysis catheter placement

Preperitoneal Local Anesthesia Technique in Laparoscopic Peritoneal Dialysis Catheter Placement

Background and Objectives:

Peritoneal dialysis is an excellent treatment for end-stage renal disease. Peritoneal dialysis is more advantageous if the catheter is positioned laparoscopically with omentopexy. General anesthesia is required for laparoscopic peritoneal dialysis catheter placement. General anesthesia is associated with increased postoperative morbidity and mortality in high-risk patients. In this retrospective study, the results of laparoscopic placement of peritoneal dialysis catheter under preperitoneal local anesthesia technique and sedation are presented for end-stage renal disease patients not fit for general anesthesia.

Methods:

We recruited 13 patients for laparoscopic placement of peritoneal dialysis catheter out of 99 end-stage renal disease patients who presented at a local tertiary hospital. The selection criteria were based on the American Society of Anesthesiologists classification III or above and patients unfit for general anesthesia.

Results:

Laparoscopic placement of peritoneal dialysis catheter was performed on 99 patients, and 13 patients were unfit for general anesthesia. Laparoscopic placement of peritoneal dialysis catheter and omentopexy were performed on these 13 patients together with capnoperitoneum, under preperitoneal local anesthesia technique and sedation. Three catheters were removed due to exit-site infection. One patient died after 2 years due to cardiac disease. The remaining patients continued with peritoneal dialysis. No omental entrapment, catheter migration, or other complications were encountered.

Conclusion:

Laparoscopic placement of peritoneal dialysis catheter under preperitoneal local anesthesia technique and sedation was successful for high-risk patients unfit for general anesthesia. This technique can be expanded for healthy patients to avoid general anesthesia complications, reduce costs, and speed recovery.

Peritoneal Catheters and Exit-Site Practices toward Optimum Peritoneal Access: A Review of Current Developments

Objective

This review updates the 1998 International Society for Peritoneal Dialysis (ISPD) recommendations for peritoneal dialysis catheters and exit-site practices (Gokal R, et al. Peritoneal catheters and exit-site practices toward optimum peritoneal access: 1998 update. Perit Dial Int 1998; 18:11–33.)

Design

Data Sources: The Ovid and PubMed search engines were used to review the Medline databases of January 1980 through June 2003. Searches were restricted to human data; primary key word searches included dialysis, peritoneal dialysis, and continuous ambulatory peritoneal dialysis cross referenced with access, catheter, dialysis catheter, peritoneal dialysis catheter, and Tenckhoff catheter. Related searches were provided via the PubMed related articles link. Study Selection: Reports were selected if they provided identifiable information on catheter design, catheter placement technique, and survival or placement complications. Reports without such data were excluded from review. Each study was then categorized by its characteristics: single-center or multicenter; retrospective or prospective; controlled trial, with or without random patient assignment; or review article.

Main Results

There are few randomized controlled evaluations testing how catheter design and/or placement influence long-term survival and function, and these are typically conducted at a single center. The majority of reports represent retrospective single-center experiences, and these are supplemented by occasional multicenter data registries.

Conclusions

There is substantial variability in catheter outcomes between centers, and this variability is more closely correlated with operator and center characteristics than with catheter design. Some catheter designs appear to impact long-term catheter success, and, in some cases, specific patient characteristics and dialysis formats combine with specific catheter designs to influence catheter survival. Most reporters prefer two-cuff designs and placement of the deep cuff at an intramuscular location. Intramuscular cuff placement results in fewer pericatheter leaks and hernias, but makes catheter removal more difficult. High-risk patients (those with previous pelvic surgery) benefit from visual inspection of the peritoneum during catheter placement, and in randomized controlled trials, catheters with pre-shaped arcuate subcutaneous segments (“swan neck” designs) reduce the risk of early drainage failure via “migration.”

Wang's Forceps-Assisted Percutaneous Insertion and Fixation of Peritoneal Dialysis Catheter

Percutaneous insertion of peritoneal dialysis catheters is theoretically most preferred by nephrologists because of the advantages of bedside performing, surgery independence, and minimal injury over other procedures of catheter placement such as open surgical dissection or laparoscopic operation. However, blindly placing catheters in the percutaneous procedure brings the risk of catheter malposition or bowel perforation; this largely retarded it's implementation. We had previously developed a novel technique termed "Wang's forceps-assisted catheter insertion and fixation," which had been successfully applied in the open surgical catheter insertion and displaced catheter reposition in our center. In this study, we further explored the possibility of applying the Wang's forceps in the procedure of percutaneous catheter insertion both in porcine model and patients with end stage renal disease (ESRD). A total of three miniature pigs successfully received percutaneous catheter insertion using Seldinger's technique with Wang's forceps assistance. The catheters were all placed in the right position and functioning well in dialysate drainage. This novel method of percutaneous catheter insertion was then performed on 20 ESRD patients. The procedure showed effective time-saving with the average operating time of 29.2 ± 3.53 min and was well tolerated by patients with minimal pain and injury. During a follow-up time of 6 months, no complications of catheter displacement, leakage, or blockade occurred. Our preliminary observation demonstrates that utilization of Wang's forceps in a percutaneous procedure conferred benefits of accurately placing and fixing catheters while preserving the merits of minimal invasion and simple performance.

Identification of the appropriate fixation site to avoid peritoneal catheter migration based on a mechanical analysis

Aim: To conduct mechanical analysis on the relationship between abdominal wall fixation point and the displacement of catheter top, and establish the finite element model for the complex forces and conditions that the catheter wears in human abdominal cavity, in order to provide the scientific basis for optimizing the catheter position in abdominal wall fixation method.

Methods: Using the PIPE59 finite elements to divide units, and taking the lower part of catheter, that is, below interior polyester cuff to simulate and compute the displacement formula.

Results: The whole model includes a total of 1701 units. Periodic load was used to simulate the dynamic pressure that peritoneal dialysis catheter gets in abdominal cavity. The load direction was perpendicular to the catheter axis. We used pressure amplitude, duration and frequency as the boundary conditions, and adjusted the fixation point of the catheter lower part at the same time, thus calculating the extreme displacement value of the catheter top end with changing parameter conditions. We also did fitted regression on the results and obtained the displacement formula: y = 0.2 × 0.87^x (y: the end displacement of peritoneal dialysis catheter, x: the distance between fixation point and the interior polyester cuff), R²: .982. Simulation the catheter maximal displacement on flat surface demonstrated that additional catheter fixation at the site of 9 cm or more below the internal cuff significantly restricted the catheter migration.

Conclusions: The optimal position of fixation point in peritoneal dialysis is about 9 cm away from the interior polyester cuff.

Long-Term Outcomes of Single-Port Laparoscopic Placement of Peritoneal Dialysis Catheter

INTRODUCTION

Laparoscopic insertion of peritoneal dialysis (PD) catheter has become a preferred method compared to the traditional open technique for PD catheter insertion. We retrospectively report the outcome of 1-port laparoscopic placement PD catheters in our institution.

METHODS

A total of 263 patients with end-stage renal disease who underwent single-trocar laparoscopic PD catheter insertion during a recent 6-year period were reviewed. Laparoscopic technique involves introducing a PD catheter over a stiff guidewire into the abdominal cavity through a 10-mm laparoscopic port. Pertinent clinical variables, procedural complications, and follow-up outcome were analyzed.

RESULTS

There were 182 men and 81 women. The mean age was 56 years. Technical success was 95.8%. Catheter occlusion was the most common early complications (<6 months) that occurred in 4 (1.5%) patients. Late complications (> 6 months) including catheter occlusion, cuff extrusion, catheter leakage, catheter migration, infection, and hernia occurred in 5 patients (1.9%), 2 patients (0.8%), 3 patients (1.1%), 3 patients (1.1%), 6 patients (2.3%), and 4 patients (1.5), respectively. Mean follow-up time was 39 ± 18 months. Catheter survival rate at 1, 2, 3, 4, and 5 years was 96%, 94%, 90%, 85%, and 82%, respectively.

CONCLUSION

Laparoscopic PD catheter implantation via a single-trocar utilizing a stiff guidewire technique is feasible and safe. This method can result in low complication and high catheter survival rate.

Flexible endoscopic single-incision extraperitoneal implant and fixation of peritoneal dialysis catheter: proof of concept in the porcine model

BACKGROUND

Peritoneal dialysis (PD) catheters placed in the pelvic space without anchoring present a high rate of migration. We aimed to assess the feasibility of a single-incision approach, using a flexible endoscopic preperitoneal tunneling for catheter implantation and fixation.

MATERIALS AND METHODS

Eight pigs were involved in this experimental study. A 2/0 Vicryl loop was sutured at the tip of a PD catheter. In 4 pigs, a 1.5 cm incision was made on the left paramedian line and the parietal peritoneal layer was identified by splitting rectal muscles. A gastroscope was inserted in the incision and advanced in the extraperitoneal space. An exit hole was made in the peritoneum over the low pelvic cavity. A guidewire was left in the abdominal cavity, and the PD catheter was inserted over the guidewire. The endoscope was inserted in the tunnel again, and endoscopic clips were deployed over the Vicryl loop to fix the catheter. In 4 pigs, the PD catheter was inserted laparoscopically using a two-port approach. The catheter's tip was fixed with laparoscopic clips on the Vicryl loop. A strain test to assess the force required to detach clips was performed using a digital dynamometer.

RESULTS

Operative time for flexible endoscopic tunneling was longer when compared to the laparoscopic implant (29.5 ± 4.43 vs. 22.7 ± 2.51 min). Mean force to displace the catheter was similar after flexible endoscopic fixation when compared to laparoscopic clip fixation (5.57 N ± 2.76 vs. 4.15 N ± 1.76).

CONCLUSIONS

Flexible endoscopic extraperitoneal tunneling allows for minimally invasive single-incision PD catheter placement and fixation.

A new simplified one-port laparoscopic technique for peritoneal dialysis catheter placement

BACKGROUND

Various techniques for laparoscopic insertion of a peritoneal dialysis catheter have been described. Usually 2 - 3 ports are required, and complications related to the port sites (such as abdominal wall hernia, leakage, and hemorrhage) cannot be avoided. To minimize the potential complications, we designed a simplified 1-port laparoscopic technique for peritoneal dialysis catheter placement. ♢

METHODS

We conducted a retrospective data review of 44 patients who underwent 1-port laparoscopic insertion of a Tenckhoff catheter from June 2009 to February 2011. All patient data, including postoperative complications, were analyzed. ♢

RESULTS

The mean follow-up period was 11.52 months. All catheters were working properly, except in 1 patient who developed peritonitis 3 months after catheter placement. (The catheter was removed.) No postoperative abdominal wall hemorrhage, early leaks, hernias, or catheter migration occurred. No exit-site or tunnel infections were observed. ♢

CONCLUSIONS

Our 1-port laparoscopic technique provides excellent catheter fixation, avoids excessive port sites, and yields good cosmesis. The low complication rate and the simplicity of the method justify its standard use for Tenckhoff catheter placement.

Dual-incision laparoscopic surgery for peritoneal dialysis catheter implantation and fixation: a novel, simple, and safe procedure

BACKGROUND

Peritoneal dialysis (PD) is an alternative modality to hemodialysis and is usually used to treat patients with end-stage renal disease. Dual-incision laparoscopic surgery (DILS) had been reported in several surgical fields; however, no report was proposed about DILS in PD catheter implantation (DILS-PD). In this study, we present DILS with a novel, simple, and safe procedure for PD catheter implantation with fixation and describe the long-term outcome.

SUBJECTS AND METHODS

We conducted a prospective data collection and retrospective review of all PD patients from April 2010 until June 2012. During this study period, we performed open surgery for PD catheter implantation (OS-PD) and DILS-PD concurrently. Demographic data, medical, operative, and postoperative findings, and information regarding complications were compared between these two groups.

RESULTS

Forty-eight patients had DILS-PD, and 70 patients had OS-PD. There was no difference between the two groups in age, gender, American Society of Anesthesiologists grade, creatinine level, body mass index, and previous abdominal surgery. There was no surgical mortality in either group. The follow-up period ranged from 6 to 24 months, with a mean of 22.4±16.5 months. There was no tube migration in the DILS-PD group, but 25.7% of the patients in the OS-PD group had tube migration (P<.001). A significantly decreased exit-site/tunnel infection rate was found in the DILS-PD group (4.2%) compared with the OS-PD group (17.1%) (P=.032). However, there was no obvious difference in peritonitis occurrence between groups. A significantly decreased catheter failure rate was found in the DILS-PD group (4.2%) compared with the OS-PD group (22.9%) (P=.006). DILS-PD group patients had a favorable survival rate for catheter implantation compared with OS-PD group patients.

CONCLUSIONS

Our DILS-PD with fixation technique is a simple and safe procedure. This procedure minimized or even eliminated the possibility of migration without additional cost. Our DILS-PD fixatation technique should be recommended for use routinely.

Laparoscopic internal fixation is a viable alternative option for continuous ambulatory peritoneal dialysis catheter insertion

Purpose

One of the major drawbacks of peritoneal dialysis (PD) is catheter migration and dysfunction. Preventing catheter migration is one of the main concerns. We compared laparoscopic internal fixation method with open surgical method for catheter migration rates.

Methods

From January 2008 to August 2009, PD catheters were inserted by laparoscopic fixation (LF) method in 22 patients and by open surgery (OS) in 32 patients. Clinical data were reviewed retrospectively. The frequency of migration, peritonitis, and other complications were compared. Catheter and patient survival rates were also compared.

Results

The mean age and sex ratio were not different between groups. Mean follow-up duration was 29.1 months in LF group and 26.1 months in OS group. More patients in LF group (27.3%) had history of laparotomy than in OS group (3.1%) (P = 0.01). The mean operation time was significantly longer in LF group (101.6 ± 30.4 minutes) than in OS group (72.4 ± 26.03 minutes) (P = 0.00). The cumulative incidence of catheter migration was 65.6% in OS group and 13.6% in LF group (P = 0.00). Migration-free catheter survival was higher in LF group (P = 0.001). There were no differences in complication rates between groups. Overall catheter survival was similar (P = 0.93). Patient survival rate at 2 years was not different (P = 0.13).

Conclusion

Laparoscopic internal fixation of continuous ambulatory peritoneal dialysis catheter significantly reduces migration rates without any addition of complications. Also, laparoscopic technique did not incur patient morbidity or mortality despite the requirement for general endotracheal anesthesia and longer operation time. Therefore, internal fixation can be afforded safely in patients with previous abdominal surgery as either a salvage or preventive measure in patients with repeated catheter migration.

Our long-term results of Tenckhoff peritoneal dialysis catheters placement via laparoscopic preperitoneal tunneling technique

Previously we described the technique to lessen complications of continuous ambulatory peritoneal dialysis (CAPD) and to achieve immediate use of the catheter. In this study we evaluated our long-term results of the technique. A total of 61 procedures were carried out in 58 patients from September 2003 to February 2009. All patients were followed in our hospital CAPD clinic. Demographic, medical, operative, postoperative, and other information regarding complications and continued patient management was obtained retrospectively from the patients' medical records and entered into a computerized database. There were 33 men and 25 women. The mean age was 58 years. In 29 of the 58 patients indication of catheter placement was end stage renal failure combined with diabetes mellitus. Mean follow-up time was 33.31 ± 20.11 months. Catheter related complications were outflow obstruction (n=3, 5.2%) and peritonitis (n=2, 3.4%). Etiologies of catheter removal were out flow obstruction (n=2), recovery from renal disease (n=2), peritonitis (n=1), and pregnancy (n=1). The mean catheter survival time was found 5.57 ± 0.17 years. Our long-term results showed that the method ensured accurate placement, preperitoneal fixation, and immediate use of the catheter for routine peritoneal dialysis. Preperitoneal fixation of the catheter decreased outflow obstruction over long-term follow-up.

[Experiences with Tenckhoff peritoneal dialysis catheter]

Peritoneal dialysis is a generally accepted method for the treatment of patients with end-stage renal disease. Two main techniques for the insertion of the peritoneal catheter are known: open surgery and the laparoscopic-assisted technique.

AIM

To describe our surgical procedure and implantation technique and to determine the outcome of our patients who underwent the conventional and the laparoscopic assisted placement of a catheter.

METHODS

Between September 2001 and June 2009, 124 patients underwent either conventional or laparoscopic peritoneal dialysis catheter insertion procedure.

RESULTS

52 male, and 70 female patients were studied (mean age: 62 years), 110 conventional and 14 laparoscopic assisted operation were done.

CONCLUSIONS

The traditional method for placement of peritoneal dialysis catheters is by "blind" insertion of the catheter through a small lower abdominal incision. The laparoscopic placement is a new but well-established technique and offers some advantages, such as a safer and accurate placement of the catheter under direct vision, less postoperative pain and complications, and a longer functional survival, compared to the conventional open technique. The functional outcome of the catheters was satisfactory in the majority of patients in this study. The conventional technique is simple, safe and has low costs, and in our opinion, it should be used for the most times, and the laparoscopic technique should be considered as the method of special choice in patients with end-stage chronic renal failure.

Prospective randomized study for comparison of open surgery with laparoscopic-assisted placement of Tenckhoff peritoneal dialysis catheter--a single center experience and literature review

BACKGROUND

The ideal method for catheter placement in patients undergoing peritoneal dialysis remains debatable. This prospective study intends to clarify whether laparoscopic assisted percutaneous puncture is superior to open surgery.

MATERIALS AND METHODS

From 2002 to 2006, 77 patients receiving first catheter placement were enrolled and randomized to either an open group of 40 patients or a laparoscopic group of 37 patients. Patient characteristics, operation-related data, procedural complications, and clinical outcome were compared by using the statistical software SPSS ver. 11.5 (SPSS, Chicago, IL).

RESULTS

Laparoscopy had a longer operative time (68.32+/-31.90 versus 46.68+/-15.99 min; P<0.001), shorter wound length (1.69+/-0.46 versus 2.34+/-0.84 cm; P<0.001), and higher costs (P<0.001) compared with open surgery. Laparoscopy tended to have a higher incidence of pericannular bleeding (21.6% versus 7.5%) and a lower rate of early catheter migration (2.7% versus 15.0%), but its early/late/overall complication rate did not statistically differ. No surgical mortality occurred. Rate and cause of overall mortality or catheter dropout did not statistically differ. Catheter longevity was equivalent in both groups.

CONCLUSIONS

Laparoscopic assisted percutaneous puncture exhibited no superiority to open surgery. As a matter of fact, open surgery's shorter operative time and reduced equipment requirement can increase cost-effectiveness. Therefore, conventional open surgery is recommended for most patients with primary catheter placement.

Laparoscopic peritoneal dialysis catheter implantation using a Tenckhoff trocar under local anesthesia with nitrous oxide gas insufflation

BACKGROUND

Laparoscopic implantation of peritoneal dialysis catheters has many advantages over conventional methods. The ability to perform laparoscopy with the patient under local anesthesia allows renal failure patients, who ordinarily might not be considered candidates for general anesthesia, an opportunity to undergo this procedure.

METHODS

Using local anesthesia and nitrous oxide pneumoperitoneum, 175 catheters were implanted in long musculofascial tunnels under laparoscopic guidance to minimize the risk of catheter migration and flow dysfunction.

RESULTS

Nitrous oxide pneumoperitoneum was well tolerated, allowing all procedures to be safely completed with the patients under local anesthesia. The overall 1- and 2-year catheter survival rates were 92.7% and 91.3%, respectively. The incidence of catheter tip migration and omental entrapment was 1.7% and 2.9%, respectively. Temporary pericatheter leak occurred in 7.4% of cases.

CONCLUSIONS

Nitrous oxide insufflation enables safe performance of laparoscopic surgery with the patient under local anesthesia. Patients benefit from a minimally invasive technique with the assurance of obtaining successful long-term catheter function.

Laparoscopic-assisted placement of peritoneal dialysis catheters: implantation technique and results

BACKGROUND

Peritoneal dialysis is a generally accepted method for the treatment of patients with end-stage renal failure. The laparoscopic placement of peritoneal dialysis catheters is a well-established technique and offers some advantages, such as a safer placement of the catheter, less post-operative complications, and a longer functional survival, compared to the conventional open technique. The aim of this study was to describe our implantation technique and to determine the results of our approach.

PATIENTS AND METHODS

Between January 2000 and February 2006, 47 patients with end-stage chronic renal failure underwent a laparoscopic peritoneal dialysis catheter insertion procedure. Perioperative and follow-up data were collected prospectively.

RESULTS

The mean operating time was 35 minutes (range, 16-100). There was no perioperative morbidity. Nine (19.1%) patients experienced 10 mechanical complications: fluid leakage in 6 (12.8%) patients, acute hydrothorax in 1 (2.1%), catheter tip migration in 2 (4.3%), and catheter obstruction in 1 (2.1%) patient. Episodes of peritonitis were observed in 5 (10.6%) patients. One (2.1%) patient developed a catheter infection. In 3 (6.4%) patients, a port site hernia occurred that required surgical repair, 5 (10.6%) patients underwent laparoscopic revisions owing to mechanical complications, 9 (19.1%) patients underwent renal transplantation, and 6 (12.8%) patients died during the later follow-up. After a mean follow-up time of 17 months (range, 2-76), 30 (63.8%) catheters are still in use for dialysis.

CONCLUSIONS

The functional outcome of the dialysis catheters was satisfactory in the majority of patients in this study. The described technique for catheter implantation is simple and safe, and in our opinion, the laparoscopic technique should be considered as the method of choice in patients with end-stage chronic renal failure.

Laparoscopic-Assisted Peritoneal Dialysis Catheter Implantation in Pediatric Patients

OBJECTIVES

To assess the feasibility and complications of laparoscopic-assisted placement of peritoneal dialysis catheters (PDCs) in pediatric patients.

METHODS

A total of 15 patients undergoing laparoscopic-assisted PDC insertion were studied. A single 10-mm epigastric port was used, unless concomitant diseases were present. A double-cuffed straight Tenckhoff catheter was implanted, with the deep cuff placed within a preperitoneal tunnel underneath the left rectus muscle. The catheter tip was positioned in the left iliac fossa by stylet wire manipulation under laparoscopic control, with the exit site oriented laterally or downward. Subtotal omentectomy was performed by way of the epigastric port site. The findings were compared with those of a group of patients undergoing open PDC insertion.

RESULTS

The median operating time was not different in the two groups. In the laparoscopic group, a single port was used in 9 cases, and adhesiolysis was performed in 2. The median time to PD initiation was not different in the two groups, nor were any significant differences found in the infectious complications, leak or obstruction rates, or need for secondary surgical revisions between the two groups. Surgical revision was necessary because of peritonitis in 1, persistent leak in 1, and dislodgement in 2 in the open group and because of blockages in 3 in the laparoscopic group. Laparoscopy allowed for the rescue of two such catheters.

CONCLUSIONS

The results of our study have shown that laparoscopy allows for careful assessment of the abdominal cavity, recognition and treatment of intraabdominal diseases, and precise placement of PDCs. However, it does not seem to reduce the early catheter-related complication rate. Mechanical obstruction remains a common cause of early catheter malfunction. However, laparoscopy can allow for the rescue of blocked catheters.

The comparison in terms of early complications of a new technique and percutaneous method for the placement of CAPD catheters

BACKGROUND

Starting continuous ambulatory peritoneal dialysis (CAPD) immediately after insertion of a peritoneal dialysis catheter is essential in end-stage renal disease (ESRD). In relation to the insertion methods, various mechanical and infectious complications may arise. In this study, we aimed to compare early complications of the laparoscopic tunneling method of CAPD placement that we developed recently in order to minimize the complications, with those of the conventional percutaneous method.

SUBJECTS AND METHOD

Included in this study were 12 consecutive patients with ESRD to whom we introduced catheters for CAPD by way of laparoscopic tunneling between April 2003 and July 2003 and followed up for at least 6 months, and 30 patients to whom the catheters were placed percutaneously in the same time period with the same follow-up time. The complications seen during the first 6 months after catheter placement with these two different methods were compared.

RESULTS

In all of the subjects, dialysis was started soon after catheter placement. No peroperative morbidity was seen in any of the patients. While with laparoscopic tunneling method no mechanical problem was seen, the percutaneous method resulted in early leakage in 10%, pericatheter bleeding in 3.3%, and hernia in 3.3% of the patients. As infectious complications, peritonitis occurred as one episode/36 patient-months in laparoscopic tunneling and one episode/22.5 patient-months in percutaneous method; catheter insertion site infection was seen in none in the laparoscopic method, while one episode/90patient-months was seen with the percutaneous method. Tunnel infection did not arise in any of the subjects.

CONCLUSION

The authors of this study think that the peritoneal tunneling method for introducing CAPD, which has been recently developed and began to be routinely used by them, is rather safe in terms of early complications.

A new laparoscopic technique for the placement of a permanent peritoneal dialysis catheter: the preperitoneal tunneling method

BACKGROUND

Mechanical outflow obstruction and leakage from the exit site of the catheter are two common complications of continuous ambulatory peritoneal dialysis. To lessen these complications and to achieve immediate use of the catheter, we developed a new laparoscopic technique for catheter placement.

METHODS

A total of 12 consecutive patients with end-stage renal failure were included in this study between April 2003 and July 2003. The average age of the patients was 42.4 years (range, 37-72). Patients were excluded only if a serious risk for general anesthesia was found. Using two 5-mm ports and a 3.3-mm mini-laparoscope, a peritoneal dialysis catheter was passed through a preperitoneal tunnel before the tip of the catheter was introduced into the pelvis. Routine peritoneal dialysis was started immediately after the operation while the patients were still in the operating room.

RESULTS

The mean operating time was 18.6 min (range, 12-37). There was no operative morbidity. The mean follow-up period was 4.3 months (range, 3-7). No leakage of the dialysate liquid or outflow obstruction was observed during this period.

CONCLUSION

The advantages of this method include accurate placement, preperitoneal fixation, and immediate use of the catheter for routine peritoneal dialysis. We also believe that because of the preperitoneal fixation of the catheter, this technique will decrease outflow obstruction, which usually occurs due to omental wrapping or displacement of the catheter tip.