PD: Access

Best practices

• Bowel program to prevent perioperative constipation

• Empty bladder before procedure; otherwise, Foley catheter should be inserted

• Single preoperative dose of IV antibiotic to provide antistaphylococcal coverage 

• Paramedian insertion of PD catheter through the body of the rectus muscle with deep duff within or below the muscle fibers

• Pelvic position of the catheter tip

  • Upper part of the true pelvic bowl

  • Majority of dialysate pools in the pelvic region

• Purse string suture to prevent leaks

  • If using 

• Subcutaneous tunneling instrument does not exceed diameter of the catheter

• Flow test to confirm function

• Exit site ≥2 cm beyond superficial cuff

  • Minimize risk of extrusion

  • Minimize risk of involvement of the cuff if there is an exit site infection

• No catheter anchoring sutures

  • Predisposes to early exit site and tunnel infection

  • If noted to be present after surgery, they should be removed

• Non-occlusive dressing

  • Occlusive dressing can macerate exit site or insertion incision

Selecting an insertion technique 

• Advanced laparoscopic

• Open dissection

Principles of catheter insertion

• Create an oblique, watertight subcutaneous tunnel through the abdominal wall

  • Oblique (rather than straight) path through the abdominal wall reduces the risk of hernia and leak

• Positional the tip in the pelvis

• Do an omentectomy when possible to help reduce the risk of early catheter failure [Cribbs et al., 2010]

  • Relatively simple for both open and laparoscopic technique

• Laparoscopy preferred over open

  • Data is becoming more convincing that laparoscopic is generally superior to open technique [Crabtree & Burchette, 2009]

    • Better flow

      • Easier to achieve optimal catheter position

    • Longer catheter life

      • May be because of lower rate of adhesion formation with laparoscopic technique

    • Ability to perform additional surgeries (e.g., hernia repair)

• Deep cuff secured in the muscle between anterior and posterior sheaths of the abdominal rectus

• Regardless of whether laparoscopic or open technique is used, the subcutaneous tissue should be smaller than the catheter

  • Do not use a hemostat to push the catheter through; hemostats have a wide triangular shape that will widen the tunnel when pushed through

  • Use Steinmann pin or can use peel-away sheath  with guidewire (Seldinger technique)

• Tiny exit site should be small

  • Can use skin punch biopsy to make the incision (round hole for round catheter helps minimize the hole size)

Open dissection insertion of PD catheter

• [***]

Percutaneous PD catheter placement

• Can be done with or without image guidance, but whenever possible image guidance is standard practice

• Preoperative ultrasound:

  • identification (by ultrasound with color doppler) to evaluate course of epigastric vessels

  • Visceral slide test to evaluate for adhesions and identify optimal site for placement

  • Identification of bladder to avoid bladder injury

• If skin thickness >5.5 cm, percutaneous approach may be technically difficult

• Procedure:

  • Ultrasound guided local anesthesia

  • Skin incision, with blunt dissection down to the fascia

    • Make incision large enough that there is plain vision of the anterior rectus sheath

  • Needle (e.g., Hawkins, Veress micropuncture set) insertion under ultrasound guidance

  • Ultrasound guided advancement of the needle down to the peritoneum and through the peritoneal membrane, creating a tunnel 

  • Peritoneal placement of Hawkins needle confirmed with contrast injection under fluoroscopy

  • Guidewire advances through Hawkins needle into the peritoneum

  • Peel-away sheath threaded over guidewire after removing the needle

  • Peel-away sheath advanced [***] into the peritoneal cavity 

  • Contrast confirmation of ***

  • PD catheter tunneled to the exit site

  • ***

Basic Laparoscopy

• Laparoscope used only to verify the position of the catheter tip

  • In lieu of fluoroscopy

• No additional procedures performed in order to limit the risk of complications

Advanced Laparoscopy

• In addition to catheter insertion, adjunctive procedures performed to reduce the risk of mechanical complications:

  • Rectus sheath tunneling

    • Prevents catheter migration

  • Omentopexy

    • For redundant omentum when it rests within juxtaposition of the catheter tip

  • Adhesiolysis

  • Epiploectomy

    • Epiploic appendices: fat filled tabs, or pendants, of peritoneum that project from the serous coat of the colon

      • Can lead to obstruction or siphon into (and occlude) the catheter

      • Resection of epiploic appendices

  • Salpingectomy 

    • Redundant uterine tubes can siphon into the catheter

  • Colopexy

  • Diagnosis of unsuspected hernias (e.g., inguinal, umbilical, spigelian)

    • Repair at the time of the catheter implantation procedure

  • [***]

• Outcomes

  • Percutaneous insertion vs basic laparoscopy: no difference in regards to flow dysfunction [Voss et al., Maher et al.]

  • Advanced laparoscopy vs open dissection: advanced laparoscopy provides better outcome with flow dysfunction 

  • Advanced vs basic laparoscopy: advanced laparoscopy provides better outcome with flow dysfunction 

Training programs are available for surgeons from the International Society for Peritoneal Dialysis and University of South Florida: www.pdusurgeons.com