Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

C H A P T E R 91

INSERTION OF TENCKHOFF

CATHETER

Kristene K. Gugliuzza

STEP 1: SURGICAL ANATOMY

Place the uppermost trocar or the incision in a paramedian position. This allows for burial of the cuff of the catheter under the muscle and decreases the incidence of cuff erosion through the incision. Make the optimal placement by placing the catheter on the abdomen in a position where the end of the catheter or the bottom of the cuff is situated on the symphysis pubis and the first cuff lies over the rectus muscle. Place the incision where the first cuff lays on the abdomen. The exit site is usually lateral to the first trocar. Use this site for the second trocar (Figure 91-1).

Achieve the optimal placement of the exit site with the aid of a home dialysis nurse. This provider can meet with the patient preoperatively to design the exit site that is most functional for the patient. Functionality is predicated by the handedness of the patient (usually more comfortable when the catheter is placed on the same side as the dominant hand) and body habitus (different placement for a patient with a large panniculus versus a thin patient; patient comfort in having the catheter below the belt line or above).

Site for incision or trocar

Site for exit of catheter or trocar

Catheter on skin before incision

MC

FIGURE 91–1

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1 0 1 0 S E C T I O N X I I • VA S C U L A R

STEP 2: PREOPERATIVE CONSIDERATIONS

Twenty million Americans, one in nine adults, have chronic kidney disease (CKD), and 20 million more are at increased risk. The peritoneal dialysis (PD) catheter is one of the

three options for treatment of stage 5 CKD (glomerular filtration rate [GFR] 15 ml/min). The other options are hemodialysis and transplantation. Fifteen percent of the population dependent on dialysis chooses the option of PD.

There are four methods to place a PD catheter. One is an emergent, temporary catheter at the bedside. Use this method only in a patient who requires immediate dialysis and cannot be moved from the intensive care unit (ICU). The second method is an open placement usually performed in the operating room with the patient under local or general anesthesia. The third and fourth methods are placed laparoscopically, either as an assist to open surgery or as the primary technique for placement of the catheter.

Use the emergent and the laparoscopic-only procedures when there is no fear of adhesions that increase the risk of perforation of bowel through the blind insertion of the trocar or needle.

The emergent placement of a PD catheter is similar to the procedure of diagnostic peritoneal lavage (DPL). The Seldinger technique (using a blunt-tipped flexible guidewire inside a finder needle to introduce a sheath or a catheter into the peritoneal space) is a safe method to place the catheter. You can accomplish this technique with an incision through the skin down to the peritoneum or as a puncture through the skin.

It is helpful if the patient’s bowel is deflated. Encourage the patient to ingest only liquids the day before the procedure.

STEP 3: OPERATIVE STEPS—OPEN PROCEDURE

Patient positioning

Place the patient supine.

The surgical preparation should include the skin from the nipples to the symphysis pubis and laterally from the mid-anterior axillary line to the anterior axillary line.

1. INCISION

To estimate the correct position of the incision for the first cuff of the catheter, lay the catheter on the abdomen with the bottom of the curl placed on the symphysis pubis. The first cuff will lay lateral to the umbilicus on the side of the exit site mark that has been placed preoperatively by the dialysis nurse. Make the incision approximately 1 cm above and below the area of the cuff (see Figure 91-1).

1 0 1 2 S E C T I O N X I I • VA S C U L A R

2. DISSECTION

Place the catheter over a long metal guide or stylet that has been lubricated with watersoluble gel. Take care to look at the catheter because some have a white line that you must keep in the anterior or “up” position. With care, place the catheter and the guide through the hole into the peritoneal cavity. Guide the catheter along the posterior surface of the abdominal wall toward the iliac crest. Once there, aim the catheter toward the symphysis pubis. This allows for placement of the tip or bottom of the curl in the pelvis area close to the abdominal wall (Figure 91-4). After removing the stylet, test the function of the catheter by instilling a dilute heparinized saline through the end of the catheter. You should be able to instill, aspirate, and siphon the fluid easily through the catheter without force or interruption of flow. Usually, placing the patient in a reverse Trendelenburg position and administering approximately 100 mL of fluid aids in this maneuver.

If there is difficulty in any of these three maneuvers, reposition the catheter.

Upper incision

PD catheter

Exit site

FIGURE 91–4

C H A P T E R 91 • Insertion of Tenckhoff Catheter 1015

1. INCISION

When laparoscopic assistance or laparoscopic placement only is being used, the methods are similar to the open procedure. Place the 5-mm trocar in the most cephalad position blindly or open as described previously (see Figure 91-7, 1). If placed open, the trocar can be easily placed through the hole in the posterior fascia and the purse-string tightened around the trocar (Figure 91-7). Secure the string with a rubber-shod clamp. Insufflate

the abdominal cavity with CO2 to proper pressures (12 to 18 cm H2O pressure). Place the 5-mm camera through this trocar. An exploration of the cavity will reveal adhesions to the abdominal wall that can be taken down with the placement of two trocars (5 mm). These can be placed under direct vision. Place the trocars tangentially to separate the outer and the inner holes, which allows for less leakage if the catheter is to be used quickly. One trocar is placed at the marked exit site (see Figure 91-7, 2) and the other in the midline or contralateral aspect of the abdomen (see Figure 91-7, 3).

(1) Incision and camera site

(3) Third trocar site

(2)Marked area for exit site and second trocar site

FIGURE 91–7

C H A P T E R 91 • Insertion of Tenckhoff Catheter 1017

STEP 4: POSTOPERATIVE CARE

Make sure that the patients are under the care of a home dialysis program. The standard of care is for the patient to see the dialysis nurses within 2 to 3 days. At that time, the nurses begin to set up the schedule for the home dialysis training. Each dialysis center individualizes the dressings for the exit site. The nurses have protocols that are followed rigorously.

Tell the patient not to swim or take baths. Taking a shower is the primary option for bathing.

Give instructions to the patients regarding signs of infection and contact numbers in case any redness, tenderness, swelling with pain, or discharge occurs at the sites of the incisions or exit site.

Use of the dialysis catheter is also individualized. If the cuff is secured to the posterior fascia, the catheter can be used immediately with low volumes, increasing the volumes slowly over several days to the therapeutic levels. Usually, the wait is 2 weeks for healing of the incision sites and scarring of the outer cuff in the tunnel.

STEP 5: PEARLS AND PITFALLS

Use the home dialysis nurses to help with the placement of the exit site. The patients have greater satisfaction when the exit site is in a convenient spot.

If the catheter cuff is secured to the posterior fascia and the 5-mm trocars are placed tangentially through the abdominal wall, the likelihood of leaking is less and the catheter may be used sooner (if not immediately).

The use of the laparoscope allows the surgeon to perform other procedures, if needed (e.g., lysis of adhesions, hernia repair, cholecystectomy, partial omentectomy).

Securing the catheter to the anterior abdominal wall may prevent catheter migration and enhance return of dialysate.

Take care not to puncture the catheter outside of the abdominal cavity, because it will not heal and you will have to place another one.

Do not suture the catheter at the exit site. Place a clear, air-permeable dressing over the site and catheter. Then call your home dialysis nurses to come re-dress the site while the patient is in the postanesthesia care unit or the day surgery unit. The dialysis nurses are part of the team and they are diligent about reducing the risk of infection.

SELECTED REFERENCE

1. Tsimoyiannis EC, Siakas P, Glantzounis G, et al: Laparoscopic placement of the Tenckhoff catheter for peritoneal dialysis. Surg Laparosc Endosc Percutan Tech 2000;10:218-221.

C H A P T E R 92

INSERTION OF PERITONEAL

VENOUS SHUNTS

Kristene K. Gugliuzza

STEP 1: SURGICAL ANATOMY

The target of the venous portion of the procedure is the internal jugular vein. The vein sits in the minor supraclavicular fossa between the sternal and clavicular heads of the sternocleidomastoid muscle and the clavicle and under the platysma muscle. It is encased in the fibrous carotid sheath, independent of and anterior lateral to the carotid artery. The phrenic nerve is posterior lateral; the ansa cervicalis crosses lateral to medial at the level of the carotid artery bifurcation and above the omohyoid muscle; and the vagus nerve is posterior medial. On the left, under the clavicle is the thoracic duct, which crosses from medial to lateral and enters the subclavian vein (Figure 92-1).

The target of the peritoneal portion of the procedure is the peritoneum, or the confluence of the posterior fascia of the abdominal musculature with the peritoneum.

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