The American Journal of Surgery (2009) 197, 8 –13
Clinical Surgery-International
Laparoscopic peritoneal dialysis catheter implantation using a Tenckhoff trocar under local anesthesia with nitrous oxide gas insufflation Amir Keshvari, M.D.a,*, Iraj Najafi, M.D.b, Mihan Jafari-Javid, M.D.c, Masud Yunesian, M.D.d, Reza Chaman, M.D.e, Mohammadkazem Nouri Taromlou, M.D.a a
Department of Surgery, Imam Khomeini Hospital, Tehran, Iran; bDepartment of Nephrology, Shariati Hospital, Tehran, Iran; cDepartment of Anesthesiology, Imam Khomeini Hospital, Tehran, Iran; dDepartment of Environmental Health, Faculty of Public Health, Tehran, Iran; eDepartment of Epidemiology and Biostatics, Faculty of Public Health, Tehran University of Medical Sciences, Tehran, Iran KEYWORDS: Laparoscopy; Local anesthesia; Nitrous oxide insufflation; Peritoneal dialysis catheter; Survival; Tenckhoff trocar
Abstract 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. © 2009 Elsevier Inc. All rights reserved.
Peritoneal dialysis (PD) is an established form of therapy in the management of patients with end-stage renal disease. The key to successful PD is functional long-term access to the peritoneal cavity. Laparoscopy is increasingly being ⴱ
Corresponding author. Tel.: ⫹1-00982166937185; fax: ⫹100982166937185. E-mail address:
[email protected] Manuscript received August 15, 2007; revised manuscript October 10, 2007
0002-9610/$ - see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.10.022
used as a modality for establishing peritoneal access, and various laparoscopic techniques have been described for catheter placement.1–18 The conventional use of carbon dioxide (CO2) gas for peritoneal insufflation during laparoscopy necessitates the administration of a general anesthetic because the gas produces peritoneal pain.19 In addition, CO2 gas absorption from the peritoneum may produce acidosis, especially in patients with marginal physiologic compensatory mechanisms.20 Renal failure patients commonly have severe coexisting medical conditions that make them high
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Catheter implantation using a Tenckhoff trocar
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risk for both general anesthesia and CO2 gas insufflation. Crabtree et al6 and Crabtree and Fishman10 described a laparoscopic approach with the patient under local anesthesia using alternative insufflation of nitrous oxide (N2O) and helium gasses. In this report, we introduce our modification of the Crabtree laparoscopic catheter implantation procedure with N2O pneumoperitoneum with the patient under local anesthesia and describe our outcomes.
Materials and Methods Preparation The patient is instructed to empty his or her bladder before going to the operating room. A single prophylactic dose of cephalosporin is administered for staphylococcal prophylaxis. Vancomycin is reserved for cephalosporin allergy or for patients at risk for infection from methicillinresistant Staphylococcus aureus. All procedures are performed in the operating room with an anesthesiologist in attendance. Electrocardiogram and pulse oximetry are continuously monitored, and periodic determinations of blood pressure are made. Intravenous sedation is used if needed for patient comfort or to relieve fear and anxiety. It is important that the patient is kept sufficiently alert to control his or respiratory pattern and to cooperate with requests to tense the abdominal musculature when required. Trocar insertion is facilitated when the patient is awake enough to push out and tense the abdominal wall. Local anesthesia is achieved by infiltrating the soft tissue and peritoneum with lidocaine HCL 1%. Peritoneal insufflation of N2O is performed, with pressure limits set at 8 mm Hg and increased up to 12 mm Hg as needed. As a precaution, electrocautery is not used because of concerns that N2O does not suppress combustion in the event that an accidental hole is created in the bowel, with subsequent leakage of hydrogen or methane gas. The catheter implantation procedure involves the placement of two laparoscopic ports (Fig. 1). A 5-mm disposable trocar is used to permit insertion of the laparoscopic camera. The second port is a traditional Tenckhoff trocar device (TR-400, Medionics International, Ontario, Canada) that serves as the conduit for insertion of the PD catheter. This reusable stainless steel trocar consists of a tubular trocar body, bivalved trocar tips with attached finger handles, and internal obturator with a pointed tip. The larger diameter of the trocar body overlaps the smaller diameter bivalved trocar tips to keep them in approximation. After insertion of the assembled trocar device through the abdominal wall, the obturator is removed, and the catheter–stylet assembly is advanced through the trocar. The Dacron cuffs of commercially available PD catheters will pass freely through the trocar body and bivalved tip. The trocar body is withdrawn over the catheter, allowing the bivalved trocar tips to be removed separately from around the catheter.
Figure 1 Primary placement sites of laparoscope and dialysis catheter port cannulas are shown.
Catheter insertion A 5-mm skin incision is made at a point 2 cm below the left costal margin at the anterior axillary line (Palmer’s point).21 The pneumoperitoneum is established after inserting a 5-mm port in closed fashion at this site (Fig. 2A). The patient is requested to push out and tense the abdominal wall as the port is pushed through the abdominal wall and peritoneum. The abdomen is insufflated with N2O, and a 5-mm laparoscope is inserted for general exploration. The patient is placed in the Trendelenburg position to enable the small intestine to fall out of the pelvis. Attention is directed toward placement of the catheter port (Fig. 2B). In general, a 1-cm transverse skin incision for this port is made 2 cm lateral to the umbilicus in a paramedian location. The location of the incision is kept toward the medial aspect of the rectus sheath to avoid the epigastric vessels. The Tenckhoff trocar is placed through the paramedian incision and advanced gently and directly downward through the rectus muscle to the level of the posterior rectus sheath. The tip of trocar is easily seen through the laparoscope as it tents down the posterior sheath and peritoneum. The trocar is then angled toward the pelvis and advanced approximately 4 cm lower than the skin incision before it is pushed through the peritoneal membrane into the abdominal cavity (Fig. 3). The catheter is prepared by rinsing it in saline solution and loading it onto a stylet. Under laparoscopic control, and after extraction of the Tenckhoff trocar obturator, the catheter–stylet assembly is advanced through the catheter port to a temporary position in the pelvis. The stylet is partially withdrawn as the catheter is inserted until provisional placement is achieved. The stylet is then completely removed from the catheter. All parts of the trocar are disassembled from around the catheter. The stylet is then reinserted into the catheter. Together, the catheter–stylet assembly is advanced so that the deep cuff is visible above the peritoneal membrane. This maneuver is important to make certain that
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The American Journal of Surgery, Vol 197, No 1, January 2009
Figure 2 Steps of the implantation procedure of dialysis catheter: (A) Insertion of 5-mm trocar in closed fashion for initial gas insufflation. (B) Tenckhoff trocar is angled toward the pelvis. (C and D) Two-step maneuver for creating subcutaneous arcuate tunnel and skin exit site.
the deep cuff is implanted within the rectus sheath. When the catheter is positioned in the desired pelvic location, the stylet is removed.
The catheter is tunneled subcutaneously in an arcuate configuration to produce a downward skin exit site. The arcuate configuration is facilitated by making a small incision at the apex of the arc is approximately 3 cm cephalad and 2 cm lateral of the insertion incision (Figs. 2C and D). From the apex of the arc, the catheter is tunneled to the exit site. The design of the subcutaneous tunnel should place the superficial cuff 2 to 3 cm from the exit wound to prevent cuff extrusion. A pliable stainless steel tunneling stylet (PS-423; Medionics) that does not exceed the diameter of the catheter is useful to direct the catheter through the subcutaneous tunnel and exit site, thus producing the smallest hole possible that leaves the skin snug around the tubing. Catheter function is tested using a 0.5-L bag of normal saline to demonstrate rapid inflow and outflow. Removal of the laparoscopic port is delayed until a satisfactory irrigation test of the catheter has been achieved. In this series of patients, no purse-string sutures were used around the catheter at the external fascia. The fascia of the 5-mm port site is not ordinarily repaired. Skin wounds are closed with nonabsorbable suture material. Peritoneal dialysis is generally delayed for a minimum of 2 weeks to permit complete wound healing. Catheter irrigation with 1 L heparinized saline is performed within 24 hours after surgery and weekly thereafter until PD is instituted.
Statistical methods
Figure 3 Tenckhoff trocar is advanced approximately 4 cm lower than the skin incision.
Overall and revision-free survival rates of catheters were estimated using the Kaplan–Meier method. Catheter failure was defined as the removal of the catheter for mechanical
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Table 1 Mechanical complications of 175 laparoscopically implanted peritoneal dialysis catheters Parameter
N (%)
Catheter tip migration Omental entrapment Intestinal entrapment Uterine tube adhesion Intraluminal fibrin clot Pericatheter leak Superficial cuff extrusion Reoperation for hemorrhage Pericatheter hernia Visceral injury
3 5 2 2 3 13 3 1 0 0
(1.7) (2.9) (1.1) (1.1) (1.7) (7.4) (1.7) (0.6) (0) (0)
complications, such as pericannular leak, flow obstruction, or catheter migration. Catheter loss due to death, transplantation, lost to follow-up, and infection was censored.
Results From March 2004 to June 2007, 176 consecutive laparoscopic procedures resulted in 175 successful catheter implantations in 165 patients using the method described herein. One patient with extensive adhesions could not be implanted. The mean patient age was 51.5 years (range 13 to 84), and 50.9% of patients were female. All operations were performed by one surgeon. All but 16 catheters were two-cuff, swan-neck, coiled-tip Tenckhoff catheters (Medionics). All procedures were successfully completed with the patient under local anesthesia with N2O insufflation. Except for 2 patients who died of myocardial infarction before starting PD, follow-up was between 1 to 36 months (mean follow-up 14.6). The overall 1- and 2-year catheter survival rates were 92.7% and 91.3%, respectively, and 1- and 2-year revision– free survival rates were 90.1% and 87.3%, respectively. The most frequent mechanical complication was pericatheter leak (7.4%). All leaks resolved spontaneously with catheter rest. Catheter tip migration resulting in flow dysfunction was observed after 1.7% of catheter placements and was limited to the initial procedures in our laparoscopic experience. Other causes of flow dysfunction included omental entrapment (2.9%), intestinal entrapment (1.1%), adherent uterine tube (1.1%), and intraluminal fibrin clot (1.7%). Flow dysfunction was successfully remedied by laparoscopic revision in 8 of 15 cases. Occurrences of other mechanical complications were quite low and are listed in Table 1.
Comments This report describes our initial experience with laparoscopic placement of PD catheter with the patient under local
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anesthesia. To date, our series is the largest reported case series of laparoscopic catheter implantations using N2O insufflation. In addition to introducing our technique and reporting our long-term results, we have identified areas to further improve our outcomes. One of the reasons given by surgeons for not using laparoscopic PD catheter implantation is that a general anesthetic is required and that other catheter placement methods can be performed with the patient under local anesthesia. The conventional use of CO2 gas to create pneumoperitoneum is not well tolerated when the patient is under local anesthesia. The insufflated CO2 reacts with the peritoneal surface to produce carbonic acid. The resulting irritation causes pain.19 Heating and warming of the CO2 gas does not prevent pain,22 probably because it does not avert peritoneal acidosis.23 Alternative insufflation gases, ie, N2O and helium, are inert and do not cause peritoneal acidosis,24 offering a plausible explanation for absence of pain and thus enabling laparoscopy with the patient under local anesthesia. Moreover, the use of CO2 can be associated with the development of hypercarbia, respiratory acidosis, and cardiac arrhythmia caused by absorption of CO2 from the peritoneal surface.20 Our successful use of N2O insufflation with the patient under local anesthesia to perform laparoscopic implantation of PD catheters corroborates the experience reported by Crabtree et al.6 The ability to perform these procedures with the patient under local anesthesia allows renal failure patients, who might not ordinarily be considered suitable candidates for general anesthesia, to take advantage of the benefits offered by laparoscopic placement of PD catheters. A theoretic concern related to the use of N2O for insufflation is its inability, compared with CO2 or helium, to suppress combustion. With similar oxidizer properties as room air, N2O is not flammable, but in the presence of a combustible gas, such as hydrogen or methane, neither N2O nor room air will suppress volatile gas combustion should ignition occur.25 Although hydrogen and methane are produced in the colon by the normal bacterial flora, neither of these gases is detectable in pneumoperitoneum during laparoscopy.26 With the use of cautery devices, it is theoretically possible to ignite hydrogen or methane leaking from an accidental hole in the colon. Colon perforations during laparoscopy are rare, and preoperative bowel preparation with agents, such as polyethylene glycol, reduces volatile gas production to negligible levels.25 Even without bowel cleansing, the safe use of electrosurgical devices with N2O pneumoperitoneum has been recently reported for various gastroesophageal procedures and cholecystectomy.25,27 The majority of clinical reports of laparoscopic PD catheter placements have used the traditional periumbilical site for initial gas insufflation and location of the laparoscope.2–5,7–9,11–13,16,18 A periumbilical port is too close to the point of catheter insertion to be a useful site. Performing initial insufflation and insertion of the laparoscope lateral to the rectus sheath at a point remote from
12 the catheter insertion site provides a wider field of vision and avoids port conflict.1,10,14,15,17 We preferentially used Palmer’s point in the left upper quadrant. In addition to providing an excellent field of vision without port conflict, it is a safe initial access for patients with a history of lower abdominal surgery.21 Visibility from Palmer’s point is equally well for left or right paramedian catheter placement, providing flexibility in choice of insertion sites in the event of unexpected intraperitoneal adhesions. With the patient awake and able to push out and tense the abdominal wall, we routinely insert a 5-mm trocar in closed fashion for initial gas insufflation. There is increasing recognition that rectus sheath tunneling is an important adjunctive technique to keep the catheter positioned in the pelvis and to prevent catheter tip migration.1,10,11,15–17 The use of laparoscopy to guide musculofascial tunneling is the only practical method of performing this maneuver. Currently, there is no procedure specific tool to accomplish rectus sheath tunneling for PD catheters. Crabtree and Fishman10,15 used a nonbladed trocar system that employed a radially expandable sleeve that fit snugly over a Veress-type needle to perform tunneling. After placement, the needle was removed, and the sleeve served as a conduit for port cannula insertion. The length of the tunnel was limited by the tendency of the sleeve to kink in the musculofascial track when the needle was removed. In addition, the port is not universally available. We used the Tenckhoff trocar device to perform rectus sheath tunneling. The device is reusable and therefore cost-effective. Our three cases of catheter migration (1.7%) occurred during the early period of our reported experience. As we developed expertise in performing the tunneling maneuver with the Tenckhoff trocar, we had no further occurrences of catheter migration. Other methods of musculofascial tunneling of the catheter have been described but require placement of a third port.11,16,17 The requirement of additional ports without providing further benefit defeats the concept of minimal invasiveness and increases procedure cost. Laparoscopic fixation of the catheter to the lower abdomen or pelvis with a tacking suture has been described as another method of preventing catheter tip migration.2,4,7–9,12,13 Suturing techniques also require extra ports, and it is not uncommon for tacking stitches to eventually fail by pulling out with consequent catheter migration.9,13 Our pericatheter leak rate of 7.4% is within the range reported by others.1–5,7–18 All of our cases represented lowvolume leaks that spontaneously stopped a few days after surgery. Modification of our technique to include a pursestring suture around the catheter at the level of the anterior fascia should significantly decrease this occurrence. Omental entrapment occurred in 2.9% of our patients. This low incidence may be best explained by pelvic immobilization of the catheter in a rectus sheath tunnel beyond the reach of the omentum. Most of the time, the omentum does not extend to the true pelvis. Crabtree28 noted that the
The American Journal of Surgery, Vol 197, No 1, January 2009 omentum reached the deep pelvis in 15% of patients. Ogunc16 and Crabtree28 prevented omental entrapment by performing laparoscopic omentopexy. Ogunc performed omentopexy in all patients, whereas Crabtree used a selective approach, performing the omental tack-up procedure only when the omentum was observed to extend to the pelvis. Adopting selective prophylactic omentopexy will be a useful adjunct to further improve our catheter outcome. In summary, laparoscopic implantation of PD catheters has many advantages over conventional catheter placement methods. Laparoscopically guided rectus sheath tunneling decreases the incidence of catheter tip migration and omental entrapment. Other adjunctive procedures, such as omentopexy and adhesiolysis, are made possible by a laparoscopic approach. The patient benefits from a minimally invasive technique with the assurance of obtaining successful long-term catheter function. The use of N2O as insufflation gas enables safe and comfortable performance of the laparoscopic procedure with the patient under local anesthesia, thereby eliminating the concern for using laparoscopy for catheter placement in high-risk patients.
Acknowledgments The authors express their thanks and appreciation for the grant provided for this study by Sina Trauma and Surgery Research Center.
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