P99
PRE-PERITONEAL TUNNELLED PLACEMENT OF PERITONEAL DIALYSIS
CATHETER WITH LAPAROSCOPIC GUIDANCE: A TECHNIQUE TO IMPROVE
PERITONEAL DIALYSIS CATHETER PATENCY
Jones, S, Chandrasekar, R
Wirral University Hospitals NHS Foundation Trust, Wirral
INTRODUCTION: Renal replacement therapy by Peritoneal Dialysis (PD) retains
independence and reduces the restrictions on daily life of approximately 34,000 patients in the
UK. Common causes of failure are infection and obstruction usually due to omental wrapping.
Laparoscopic placement of the PD catheter is thought to be associated with better outcome
than open or percutaneous placement. However rates of obstruction have been recorded as high
as 36.8%. The purpose of this study was to assess patency following pre-peritoneal tunnelled
placement of PD catheter with laparoscopic guidance in our unit.
SURGICAL TECHNIQUE: A 10 mm laparoscope is inserted in the left upper quadrant. A
small infraumbilical incision is made. Under laparoscopic guidance the PD catheter is
tunnelled in the pre-peritoneal plane, extending from just below the umbilicus to just above the
dome of the bladder. It is then exited into the pelvis and the tip of the PD catheter is positioned
to lie just behind the bladder. The other end is tunnelled subcutaneously to exit at the marked
site on the skin. This technique helps to maintain placement of the PD catheter in the pelvis
without the use of sutures. In addition the length that lies freely in the peritoneal cavity is
reduced, thus reducing the risk of migration superiorly, and thereby omental wrapping leading
to obstruction and failure.
METHOD: A retrospective analysis was conducted of consecutive patients undergoing PD
catheter insertion from January 2009 to July 2011. Patients were identified by operative
records and outcomes determined from a detailed database maintained prospectively.
RESULTS: A total of 66 patients had PD catheters placed by the described technique during
the 31 month period. Total patency = 60.6% (n=40) with a median follow up of 21 months
(range 2-32). Primary patency was achieved in 34 patients and assisted patency in 6 patients.
Secondary procedures performed to achieve assisted patency include 2 laparoscopic
omentectomies and 4 laparoscopic repositioning of PD catheter. 26 PD catheters (39.3%) were
removed, including 11 for infection, 4 for complications, and 3 for peritoneal failure. Only 6
(9%) were removed for catheter obstruction.
CONCLUSION: The observed rate of PD catheter obstruction in our series is lower than that
reported historically for the open surgical technique or for the simple non-tunnelled
laparoscopic placement in a recent prospective study. The pre-peritoneal tunnelled placement
of PD catheter reduces the need for secondary intervention and should therefore delay
conversion to haemodialysis with its associated costs, impact on health, and lifestyle
restrictions. It has the potential to maintain the independence and quality of life of many
patients requiring renal replacement therapy.