Perit Dial Int
29(4):
394-406
2009
© 2009 International Society for Peritoneal Dialysis
THE USE OF THE LAPAROSCOPE FOR DIALYSIS CATHETER IMPLANTATION: VALUABLE CARRY-ON OR EXCESS BAGGAGE?
John H. Crabtree
Department of Surgery, Southern California Permanente Medical Group,
Kaiser Permanente Bellflower Medical Center, Bellflower, California, USA
Correspondence to: J.H. Crabtree, Department of Surgery, Module 4400, Southern
California Permanente Medical Group, Kaiser Permanente Bellflower Medical
Center, 9400 East Rosecrans Avenue, Bellflower, CA 90706 USA.
John.H.Crabtree{at}kp.org
The use of the laparoscope to guide peritoneal dialysis (PD) catheter
implantation antedates the modern surgical laparoscopic era by almost a
decade. In 1981, Ash et al.
(1) reported the use of a
laparoscopic system to insert PD catheters under local anesthesia in a non
operating-room environment. Using a hand bulb to insufflate the abdomen with
room air and a peer-through-the-eyepiece laparoscope equipped with an
overlying plastic sleeve, a clear space in the peritoneal cavity was
identified. The scope was withdrawn, leaving the valveless sleeve in place to
serve as a conduit for blind passage of the dialysis catheter toward the
identified area.
The advent of laparoscopic cholecystectomy in 1989 ushered in the age of
contemporary surgical laparoscopy. Laparoscopic camera images projected onto
video monitors, automatic gas insufflators, and pneumatically competent port
devices through which instruments could be introduced provided unprecedented
vision and ability to perform complex procedures. Development of a
laparoscopic version of nearly every conventional open abdominal operation
followed. Similarly, there was an explosion of interest in applying the
laparoscope to PD access. Since 1989, laparoscopic catheter insertion has
dominated the medical literature compared to other conventional methods of
catheter placement (Figure 1)
(1–159).
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Figure 1 — Bar graph shows the number of English-language journal reports
describing catheter placement techniques and/or comparative experiences of
catheter insertion methods for chronic peritoneal dialysis according to the
decade of publication. Abstracts, reviews, papers focusing on catheter design,
and books were excluded. Comparative experiences were classified based upon
the methodology supported by the authors' conclusions.
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There are no reliable data to indicate what proportion of catheter
insertions are currently performed by laparoscopy. In 2007 the Current
Procedural Terminology Editorial Panel of the American Medical Association
implemented a new procedure code specific for laparoscopic dialysis catheter
implantation. Due to the approximately 9-month lag in the public availability
of data from the Centers for Medicare and Medicaid Services for each preceding
year, the 2007 figures for what proportion of peritoneal access claims used
this code were unavailable at this writing.
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Figure 2 — Distribution of 85 laparoscopic journal articles according to the
number of laparoscopic catheter placement procedures reported.
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As with any new application of a modality, laparoscopy for catheter
insertion is still undergoing procedure-specific adaptation. The number of
catheter placements performed by individual surgeons is usually small; thus it
takes longer to accrue experience and expertise than for more common
laparoscopic procedures. Surgeons are often unfamiliar with best-demonstrated
practices in catheter implantation and, born of necessity, it is not uncommon
for surgeons to modify the use of available in-house equipment to enable the
laparoscopic procedure. The inevitable consequence of these practice traits is
that there are almost as many laparoscopic techniques for placing catheters as
there are surgeons performing them. Moreover, these conditions of performance
explain the wide variability in reported outcomes, giving substance to the
question of worthiness of the laparoscope as a standard tool for catheter
placement.
 |
LAPAROSCOPY LIMITED TO POSITIONING THE CATHETER
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Simply using the laparoscope to help position the catheter during insertion
has failed to show clear benefit over conventional open placement methods.
Only two randomized clinical trials compare the two modalities used in this
fashion. In 1999, Wright et al.
(93) reported no significant
difference in outcomes in a prospective randomized comparison of catheters
placed by laparoscopic and conventional approaches. No laparoscopic
interventions were described by Wright beyond confirmation of catheter
position in the pelvis. Although Wright's study is often cited by the
antagonists of laparoscopy, the probability for type II error is great in that
subject numbers were small (21
laparoscopic and 24 conventional catheters) and average follow-up was short
(12.6 and 15 months respectively). Prevalence of prior surgery, indicating
risk of adhesions, was higher in the laparoscopic group (52% vs 21%). The
authors indicated that this demographic difference was insignificant (Yate's
continuity corrected chi-square test, p = 0.058) but a more
appropriately applied Fisher's exact test confirms this disparity in his study
groups to be statistically meaningful (p = 0.035). A history of
abdominal surgery is recognized to significantly increase the risk for
mechanical catheter complications
(143,160).
The absence of mechanical dysfunction in either of his subject groups is
atypical for studies of this sort and compels caution in assessing the value
of laparoscopy by these results.
Also in 1999, Gadallah et al.
(83) reported the results of
their prospectively randomized comparison of laparoscopic (n = 76)
and open surgical (n = 72) placement of catheters. Gadallah used the
laparoscopic approach originally described by Ash et al.
(1) that identifies a clear
space within the peritoneal cavity to which a catheter is directed. The
prevalence of previous abdominal surgery was 49% and 45.8% for the
laparoscopic and open surgical groups respectively. The incidence of
mechanical malfunction leading to catheter loss was not statistically
different for the two groups (7.9% for laparoscopic and 11.1% for open
surgical). Average duration of follow-up was not mentioned. If it were not for
inexplicably excessive pericatheter leakage and peritonitis rates in the open
surgical group, Gadallah would not have been able to show improved survival
benefit for his laparoscopically placed catheters.
Two additional studies reported comparative analyses between laparoscopy
(limited to catheter positioning) and conventional open catheter insertion,
but in a nonrandomized prospective case series design. In 1998, Eklund et
al. (74) compared Ash's
laparoscopic technique (n = 65) to open surgical placement
(n = 43) over a short-term follow-up period averaging only 8.4 and
9.1 months respectively. As in the Gadallah study, Eklund reported
inexplicably excessive pericatheter leakage and peritonitis rates, but in the
laparoscopic group instead. Without this aberration, Eklund would not have
been able to show a difference in catheter survival between the two
groups.
In 2005, our institution reported a nonrandomized prospective case series
comparing laparoscopic and conventional open catheter placement procedures
(134). The study included a
group designated as "basic laparoscopy" in which the use of the
laparoscope was essentially limited to confirming catheter position. The
prevalence of prior surgery was significantly higher in the basic laparoscopic
group than the open surgery group (55.1% vs 30%). Mean follow-up was 26.9 and
23.3 months for the basic laparoscopic (n = 78) and open placement
groups (n = 63) respectively. Limited use of the laparoscope did not
produce a statistically significant difference in the occurrence of catheter
flow obstruction (12.8% for basic laparoscopy and 17.5% for open surgery). The
probability of type II error existed from differences between the groups for
prior surgical history and small patient numbers; nevertheless, as noted in
the above studies, simply using the laparoscope to position the catheter did
not appear to significantly diminish the risk of mechanical catheter
dysfunction.
Two comparative analyses employing laparoscopy as described by Ash are not
included in this discussion due to incomplete demographic characterization of
study groups and failure to report or segregate data on catheter flow
dysfunction
(40,42).
Moreover, the surgical groups either had significant history of prior surgery
or insertion techniques prone to produce the measured adverse events were
employed. While Ash's laparoscopic approach was favored by both studies, the
huge bias against the conventional surgical groups precludes meaningful
comparison.
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PROGRESSIVE LAPAROSCOPIC PRACTICES
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The potential strength of laparoscopy is that it allows an opportunity to
proactively address problems that adversely affect catheter outcome,
specifically, catheter tip migration, peritoneal adhesions, omental or other
tissue entrapment, and diagnosis of previously unsuspected abdominal wall
hernias. Preemptively identifying and attending to these problems at the time
of the implantation procedure are the likely advantages of surgical
laparoscopy over other catheter insertion techniques.
Catheter Tip Migration: Various laparoscopic techniques have been
derived to promote pelvic orientation of the catheter tip and to prevent
migration. Many of these methods represent more effective and less invasive
versions of previously described open surgical procedures that tacked the
catheter to the abdominal wall
(6,7,11,26,63,147)
or created obliquely angled tissue tunnels to encourage catheter direction
toward the pelvis
(8,12,37,45,48,60–62).
The most direct laparoscopic approach was to place a catheter anchoring stitch
to the bladder, uterus, or pelvic sidewall to keep the catheter tip at home in
the pelvis
(68,86,92,100,103,120,136,
137,139,158).
The problems with this technique were that it required extra laparoscopic
ports to place the stitch and the suture sometimes failed by pulling out of
the tissues, but, at other times, its secure hold complicated catheter
removal. A modification of this approach was to fashion a suture sling
(87,141)
or to construct a tissue sling by suturing a fold of peritoneum over the
tubing (71) at a site caudal
to the catheter insertion point, which fixed a segment of the catheter to the
back of the anterior abdominal wall in a craniocaudal alignment toward the
pelvis.
A more attractive and effective method of minimizing catheter tip migration
takes advantage of the natural toughness and craniocaudal direction of the
rectus sheath fascial envelope. Laparoscopy is utilized to guide implantation
of the catheter through a long rectus sheath tunnel in its passage to the
peritoneal cavity. Craniocaudal immobilization of the catheter in the rectus
muscle and sheath not only promotes a pelvic course for the catheter but also
reduces the risk of pericatheter leakage and eliminates the possibility of
pericatheter hernias (134).
While several techniques have been described to accomplish this laparoscopic
maneuver, all employ modifications of existing laparoscopic ports
(84,96,98,103,112,113,124,125,134,136,156),
stylets
(133,135,140),
trocars (155), and other
devices
(72,154)
that depart from their intended use. Clearly, this is an area where catheter
implantation science could benefit from the development of a dedicated
apparatus specifically designed to insert peritoneal catheters through a long
rectus sheath tunnel in a simple, safe, accurate, and reproducible fashion
while maintaining pneumatic competence and visibility during laparoscopy.
Peritoneal Adhesions: Laparoscopy is the only practical way to
reliably investigate the suitability of the abdominal cavity for PD in
patients with adhesions from prior surgery and peritonitis. In contrast, very
little can be seen or felt through the limited exposure provided by the
peritoneotomy of conventional open catheter placement approaches. Extension of
the open procedure to a formal laparotomy and adhesiolysis has been described
but it was accompanied by prolonged hospitalization and the necessity of more
vigorous postoperative irrigation to clear bloody drainage
(6).
The pneumoperitoneum of laparoscopy allows minimally invasive inspection of
the peritoneal cavity in a setting that simulates the dialysate filled
abdomen. The site of catheter insertion can be modified to avoid adhesions and
the catheter may be directed through or around adhesive scar tissues into a
location of good drainage function. Alternatively, adhesions that interfere
with catheter placement or produce compartmentalization that might impede
dialysate drainage can be divided by laparoscopic adhesiolysis using
ultrasonic shears or electrosurgical devices that minimize bleeding. The use
of adhesiolysis as an adjunctive tool during catheter placement was described
by 37 of the 85 (43.5%) laparoscopic reports cited herein.
Omental Entrapment: Catheter blockage and dislocation by the
greater omentum is a common mechanical complication. In an attempt to avoid
this problem, omentectomy was recommended at the time of the catheter
insertion procedure in 14 of 49 (28.6%) conventional open surgery reports
cited in this review. During open placement, as much omentum as possible was
resected by delivering it through the peritoneotomy incision or through a
separate midline incision. In 1985, as a substitute for omentectomy, McIntosh
et al. (23) described
suturing the omentum to the upper abdominal wall region (omentopexy) during
open catheter insertion. There is no indication that omentopexy gained any
favor during the conventional catheter placement era.
Even with laparoscopic approaches to catheter implantation, many surgeons
still tease the omentum out through the laparoscopic port site and perform an
open partial omentectomy
(87,102,106,152,158,159).
Laparoscopic omental resection has been performed; however, it adds
significant procedure time and is rarely carried out
(149). Since 1994 our
institution has employed laparoscopic omentopexy during catheter rescue
procedures to prevent recurrence of omental obstruction
(161). In 1997, Heithold
et al. (71) first
described the use of laparoscopic omentopexy during the catheter implantation
procedure to prevent omental entrapment. Reports followed with recommendations
to perform omentopexy during all catheter placement procedures
(88,104,121,135)
or to selectively apply the omental tack-up procedure only when redundant
omentum was observed to extend to the pelvis
(96,113,134,149).
Recently, Goh (162)
recommended an alternative method of laparoscopic omentopexy for catheter
rescue consisting of folding the omentum upon itself and suturing it into this
position, a procedure that can be equally exploited during catheter
insertion.
Other Tissue Attachment: Excessively long epiploic appendices of
the rectosigmoid colon, a redundant floppy sigmoid colon, and uterine tubes
are infrequent causes of catheter blockage
(163). Laparoscopic resection
of the epiploic appendices and tacking up of redundant colon along the left
lateral abdominal wall (colopexy) has been performed during the catheter
placement procedure (71).
Salpingectomy and ovariopexy to prevent obstruction by the Fallopian tubes
during laparoscopic catheter insertion have been described
(73,158).
Abdominal Wall Hernias: The reported incidence of abdominal wall
hernias in PD patients ranges from 9% to 31%
(164). Peritoneography has
been used during conventional catheter placement in the pediatric population
to detect asymptomatic hernias
(2,60).
Laparoscopy permits a unique opportunity to perform an internal abdominal wall
examination to look for previously unsuspected hernias. All identified hernias
should be repaired at the time of the catheter placement procedure
(102,109,121,159).
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EFFECTIVE USE OF LAPAROSCOPY
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Many of the clinical studies extolling the merits of laparoscopy for
peritoneal access consist of too few subjects with an insufficient period of
observation. Almost half the published reports were comprised of 15 or fewer
laparoscopic catheter insertion procedures
(Figure 2) and, in over three
fourths of these studies, the average duration of postoperative follow-up was
less than 12 months or not stated (Figure
3). These limited clinical experiences are unlikely to deliver a
convincing argument about the value of laparoscopy.
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Figure 3 — Distribution of 85 laparoscopic journal articles according to mean
postoperative catheter follow-up in months. For the intent of this
illustration, reported values for median follow-up were assumed to approximate
mean follow-up.
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Moreover, few studies involve one or more of the progressive laparoscopic
practices discussed above or appreciate the synergism of combining these
techniques. Maintaining pelvic orientation of the catheter is important to
keep it out of reach of the omentum; therefore, catheter immobilization
techniques alone produce better outcomes than when they are not used
(100,158).
Even so, a significant number of patients have redundant omentum that extends
to the pelvis and that can still produce blockage despite correct catheter
position
(147,155,156).
Treating the omentum alone produces a better outcome than when it is not done
(21,41,121,
158); however, an unsecured
catheter tip can migrate to a position of poor drainage function or become
ensnared in an omental remnant
(23,54,149).
Combining the progressive laparoscopic practices of immobilization of the
catheter toward the pelvis and omental treatment (omentectomy or omentopexy)
produces an outcome that is better than when the procedures are performed
individually (Table 1).
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TABLE 1 Literature Survey Demonstrating the Synergism of Combining Progressive
Laparoscopic Practices of Catheter Immobilization and Omental
Treatmenta
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There are no prospective randomized studies comparing laparoscopic catheter
placement techniques employing the previously discussed progressive practices
to either laparoscopic approaches not using them or other conventional
catheter insertion methods. Since the effective use of laparoscopic techniques
clearly produces better outcomes, it may be ethically difficult to justify
performing a randomized controlled comparison with conventional catheter
placement procedures. However, two previous case series studies are available
that compare the combined use of progressive laparoscopic practices with
control groups. Ogunc (135)
performed laparoscopic catheter implantation in 44 subjects in whom there was
a 20.5% prevalence rate of previous abdominal surgery. All patients underwent
rectus sheath catheter tunneling and omentopexy. Adhesiolysis was required in
11.4% of patients to facilitate catheter placement. During a median follow-up
of 17.4 months, there were no occurrences of catheter flow dysfunction. In a
group of 35 open implantation procedures performed during the preceding 5-year
period, 22.8% were complicated by omental entrapment.
In the study from our institution previously introduced under the section
on laparoscopy limited to catheter positioning, there was a third group
designated as "advanced laparoscopy"
(134). In this group of 200
catheter procedures with a 53% prevalence rate of prior surgery, rectus sheath
tunneling was performed in all cases, omentopexy was selectively applied in
14.5% of procedures when omentum was found in the pelvis, and adhesiolysis was
required on 7% of occasions. With a mean follow-up of 21 months, the incidence
of flow obstruction was only 0.5%, compared to 12.8% and 17.5% for basic
laparoscopy and open dissection groups respectively (p <
0.0001).
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LAPAROSCOPY AND PRACTICE GUIDELINES TOWARD OPTIMAL PERITONEAL ACCESS
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In 1998, the International Society for Peritoneal Dialysis published a
comprehensive report describing best-demonstrated practices toward optimal
peritoneal access (165). The
guidelines and principles detailed in this report are applicable regardless of
the catheter insertion method employed. Each laparoscopist should critically
evaluate their catheter placement technique against these guidelines and
either amend their approach or seek to validate their variance by scientific
study. Undoubtedly, new laparoscopic-related guidelines and principles will be
added as laparoscopic catheter implantation methodology evolves. A brief
review of techniques that depart from accepted practice will be presented.
Corroborating the wisdom of the philosopher George Santayana, "Those
who cannot remember the past are condemned to repeat it," many
laparoscopic surgeons have perpetuated the error of using the midline for
catheter placement. Seventeen of 85 (20%) laparoscopic reports described
midline catheter insertion. Historically, midline implantation of dialysis
catheters was preferred because less dissection was required to reach the
peritoneal cavity and the risk of bleeding was lower. However, the relative
thinness of the fascia and peritoneum in the midline infraumbilical region
makes it difficult to achieve a good seal around the catheter, resulting in an
unacceptable rate of pericatheter leaks. Due to the limited fascial
attachments and compromised tissue ingrowth of the deep catheter cuff, there
is a higher incidence of external displacement of the transmural segment of
the catheter tubing, resulting in late pericatheter leaks, hernias, and
extrusion of the superficial cuff through the exit wound
(14,22,25,29,38,63,78).
Instead, the catheter should be inserted at a paramedian site through the body
of the rectus muscle, with the deep cuff positioned within the muscle.
Subcutaneous tunneling of the catheter from the insertion incision to the
skin exit site with a hemostat clamp or using the laparoscopic port wound for
the catheter exit site creates a patulous tissue tract and skin hole that
predisposes the patient to exit-site and tunnel tract infection
(166). These inferior
practices were used in 22 of the 85 (25.9%) reviewed laparoscopic reports. A
5-mm laparoscopic port does not provide a satisfactory skin hole for 5-mm
catheter tubing. The 5-mm designation of the port refers to the diameter of
the instruments that can be passed through it, not the outside diameter of the
port conduit, which typically measures 6.6 mm to 8.1 mm, depending on the
vendor. In addition, wrenching the port around during the course of the
procedure stretches and contuses the skin edges, further making it an
unsatisfactory exit wound. Instead, the catheter should be exited through the
skin with a tunneling guide that does not exceed the diameter of the catheter
tubing and that can be passed in the direction from the paramedian insertion
incision to the exit site. The exit wound should be the smallest hole possible
that leaves the skin snug around the catheter. The Faller stylet (Faller
tunneling stylet; Covidien AG, Mansfield, MA, USA) is specifically constructed
for this purpose and can be advanced through the exit-site skin without making
a prior incision.
Despite the stern warning against the use of catheter anchoring stitches by
Tenckhoff himself in 1968
(167), this bad habit has
managed to survive into the laparoscopic era
(55,70,84,123–125).
A suture should never be used to anchor the catheter. Sutures left in for
several weeks commonly produce stitch pustules or abscesses that risk early
exit-site and tunnel tract infection. It is appropriate to immobilize the
catheter to prevent motion at the exit wound and accidental displacement
during the first several weeks following implantation until sufficient time
has been allowed for exit-site healing and catheter cuff fixation by tissue
ingrowth. This is best accomplished by securing the catheter to the skin
adjacent to the exit wound with medical adhesive tincture and sterile adhesive
strips
(8,134).
Further immobilization of the catheter is obtained with a dressing that covers
the entire device. The surgeon can help avert catheter dislodgement accidents
by making postoperative dressing changes the exclusive purview of the PD
nursing staff.
Many laparoscopic surgeons remain married to the umbilicus and appear
hopelessly unable to divorce themselves from this cicatricial birthmark for
Veress needle and laparoscope placement. Thirty-five of 85 (41.2%) laparoscopy
papers employed this approach. Just as in the case of midline catheter
placement, midline port sites are prone to leaks and hernias
(92,120,136,139,
149,154).
The elevated hydrostatic pressure associated with PD plays no small part in
the development of port site hernias. Moreover, the conventional periumbilical
region for laparoscope placement is too close to the catheter insertion site
to be practical. This close proximity results in port conflict, poor
visibility, and frustration with the procedure. For optimal visualization and
ergometric use of laparoscopic instruments, the laparoscope and accessory
ports should be placed 16 – 18 cm from the target area
(168). Thirteen of the 85
(15.3%) reviewed laparoscopic experiences found that lateral insertion of the
Veress needle and laparoscopic ports provided excellent safety and
visualization for catheter implantation procedures, especially in patients
with prior lower abdominal surgery. In the remainder, 18 (21.2%) used a
paramedian puncture for Ash's one-port laparoscopic approach, 12 (14.1%)
performed a paramedian entry with secondary insertion of lateral accessory
ports, and 7 (8.2%) entered at a non periumbilical midline location.
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COST OF LAPAROSCOPY
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A familiar argument against the routine use of laparoscopy for implantation
of PD catheters is the high cost of endoscopic equipment. To address this
concern, a brief study of endoscopic costs is necessary. For this analysis, a
complete modern-day endoscopic platform will be taken to include the following
equipment: flat panel primary and secondary viewing monitors, high flow gas
insufflator, camera control unit, camera head, laparoscope with accompanying
sterilization tray, light source, digital capture device with printer, cart
for primary video tower, roll stand for secondary monitor, and all necessary
hardware and cables for equipment operation. While the price tag for such
equipment is high, one of several view-points for correctly considering this
expense is the cost per use. A fair analysis of cost must also include
opportunity costs of capital to acquire the equipment, usable lifetime, and
costs of operation and maintenance.
With the above considerations in mind, the annual economic cost of
equipment is calculated by amortizing the initial investment expense over the
lifetime of the equipment
(169). A 5-year lifetime of
the endoscopic equipment is assumed and the opportunity cost can be
approximated by the real market interest rate using a conservative value of
5%. Annual operating and maintenance costs are estimated at 10% of purchase
price (170). Applying the
full retail values provided by three vendors that market in the USA, the
average acquisition cost in 2008 for the aforesaid endoscopic platform is
$141,750. Using this purchase price, the estimated annual economic cost is
$32,741, with annual operating and maintenance costs of $14,175. The per
procedure cost is estimated as the sum of the annual economic and operating
and maintenance costs divided by the number of procedures performed per year.
In the modern era of surgery, the endoscopic platform is used by most surgical
specialties (general surgery, pediatric surgery, cardiothoracic, vascular,
orthopedics, gynecology, urology, neurosurgery, plastics, and head and neck)
to perform a wide variety of procedures. Metropolitan centers have an expected
annual volume of 400 – 500 cases per endoscopic platform. Using this
range of procedures, the estimated cost of the endoscopic platform per use
varies from $94 to $117.
The above estimated per procedure cost was based upon state-of-the-art
equipment at full retail value when, in fact, vendors routinely apply deep
discounts to the list price. Performing the above calculations using my
institution's purchase price for the above equipment in 2008 and average case
volume per endoscopic platform for the preceding 12 months, the per procedure
cost is $43. Add to this cost per use of endoscopic equipment another $130 for
a disposable Veress needle and two laparoscopic ports, and $38 for the
economic cost (estimated using 3-year lifetime for surgical instruments),
operating and maintenance outlay, and reprocessing expenses of a reusable
laparoscopic instrument tray. At any rate, the total cost attributable to the
laparoscopic component of the peritoneal access procedure is still less than
some of the popular peritoneal catheter devices being implanted
(e.g., the $155 – $179 cost of a coiled tip, 2-cuff, preformed
arc bend catheter with a $141 – $151 titanium catheter adapter as
supplied by two major USA vendors).
The expense of laparoscopy must also be considered from the standpoint of
cost-effectiveness. Facilitated by techniques not available to other catheter
placement methods, laparoscopy produces a lower incidence of complications
that are expensive to fix or result in costly transfer to hemodialysis
(171). Since laparoscopy
provides an effective way of dealing with adhesions, more patients that
ordinarily might not be considered PD candidates because of prior abdominal
surgery or peritonitis are offered this effective and lower cost modality of
renal replacement therapy
(160). As a side note for
those that are critical of laparoscopy because of the necessity of general
anesthesia, this increase in the PD candidate pool of patients provided by
laparoscopy more than offsets the small fraction of high-risk individuals
excluded from a general anesthetic by reason of hemodynamic instability.
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VALUABLE CARRY-ON OR EXCESS BAGGAGE?
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As the focus of the modern surgical era shifts toward minimal invasiveness,
a growing number of surgical specialties have embraced the value of endoscopy.
In the field of PD, the transition from conventional catheter placement
methods to laparoscopic implantation is inevitable. When applied effectively,
the laparoscopic modality can both prevent and resolve many of the common
mechanical problems that complicate insertion of PD catheters. Simply using
the laparoscope as glitzy gadgetry to only witness the position of the
catheter is blatant underutilization of this modality and represents
unacceptable practice. If the laparoscope is brought along for the ride,
genuine use ought to be made of it; otherwise, it is nothing more than excess
baggage. The carry-on values that laparoscopy brings to the catheter
implantation procedure that minimize the risk of catheter migration,
pericatheter leak and hernia, omental entrapment, and flow obstruction include
the progressive practices of rectus sheath tunneling, omentopexy,
adhesiolysis, epiploectomy, salpingectomy, and colopexy. Enabled by these
techniques not available to other catheter placement methods, laparoscopy
provides the highest probability of achieving successful long-term peritoneal
access.
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DISCLOSURE
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The author has no conflict of interest to declare.
Received 29 August 2008;
accepted 30 October 2008.
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This article has been cited by other articles:
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J. H. Crabtree
WHO SHOULD PLACE PERITONEAL DIALYSIS CATHETERS?
Perit. Dial. Int.,
March 1, 2010;
30(2):
142 - 150.
[Abstract]
[Full Text]
[PDF]
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