Laparoscopic Peritoneal Dialysis Access Surgery
Publication Date: June 1, 2014
Last Updated: March 14, 2022
Recommendations
PATIENT SELECTION
Contraindications for laparoscopic PD catheter placement include active abdominal infection and uncorrectable mechanical defects of the abdominal wall. (Moderate, Strong)
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History of prior abdominal surgery, regardless of how many, is not a contraindication to laparoscopic PD catheter insertion. It is appropriate for surgeons with experience in advanced laparoscopy to attempt lysis of adhesions and catheter placement in these patients. (Low, Strong)
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Patients with abdominal wall hernias should be diagnosed and repaired before or at the same time as PD catheter insertion. A repair should be chosen that minimizes peritoneal dissection and does not place mesh intraperitoneally. (Low, Weak)
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Peritoneal dialysis may be initiated in patients with intraabdominal foreign bodies such as after open abdominal aortic aneurysm graft repair, but a four month waiting period is recommended. Very limited data exists regarding peritoneal dialysis in the presence of an adjustable gastric band. (Low, Weak)
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Peritoneal dialysis may be safely initiated in patients with ventriculoperitoneal shunts. (Low, Weak)
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Gastrostomy tubes can be used in pediatric patients on peritoneal dialysis, though placement by blind percutaneous endoscopic technique (PEG) appears to be associated with higher infection rates compared to open insertion. (Low, Weak)
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Laparoscopic PD catheter insertion with carbon dioxide pneumoperitoneum requires general anesthesia. Patients who are high risk to undergo general anesthesia should be considered for a technique of catheter insertion that only requires local anesthesia and sedation, such as open insertion or fluoroscopically guided percutaneous insertion. Laparoscopic insertion using nitrous oxide pneumoperitoneum and local anesthesia is also an option where available. (Low, Weak)
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INSERTION OPTIONS
For peritoneal access, blind percutaneous, open surgical, peritoneoscopic, fluoroscopically guided percutaneous, and laparoscopic insertion procedures, when performed by experienced operators, are feasible and safe with acceptable outcomes. (Moderate, Strong)
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ADVANCED LAPAROSCOPIC TECHNIQUES TO AVOID CATHETER DYSFUNCTION
Laparoscopic lysis of adhesions should be incorporated to reduce catheter dysfunction. (Moderate, Strong)
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Laparoscopic suture fixation of the PD catheter may reduce catheter dysfunction but additional evidence is needed. (Low, Weak)
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Rectus sheath tunneling helps prevent migration and may be superior to suture fixation since it does not require added ports and instruments. (Low, Weak)
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Omentopexy in adults is a safe adjunct to laparoscopic PD catheter insertion and should be incorporated either routinely or selectively to reduce catheter dysfunction. (Moderate, Weak)
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Omentectomy should be considered in pediatric patients undergoing peritoneal dialysis catheter placement. (Low, Weak)
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The combination of lysis of adhesions, rectus sheath tunneling and omentopexy in combination offers the lowest rate of postoperative PD catheter dysfunction and should be a preferred technique in adults. (Moderate, Strong)
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PERIOPERATIVE CONSIDERATIONS
Presurgical assessment should include thorough examination for hernias, and the catheter exit site should be marked before surgery. (Very Low, Weak)
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A need for preoperative bowel preparation has not been conclusively demonstrated and further evidence is needed before a recommendation can be provided. (, )
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Prophylactic antibiotics should be used prior to laparoscopic insertion of PD catheter. Vancomycin may be superior to first generation cephalosporins in minimizing early peritonitis after PD insertion. However its routine should only be considered based on local resistance patterns and outcomes. (Moderate, Strong)
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SURGICAL TECHNIQUE
Peritoneal access during lap PD insertion should be obtained away from previous scars; surgeons should use the technique they are most comfortable and experienced with. (Low, Weak)
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The surgeon should minimize the size and number of ports used and place them in a manner that optimizes visualization of the catheter peritoneal insertion point and the pelvis. (Low, Weak)
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When inserting the PD catheter through the abdominal wall, the deep cuff should be placed inside the rectus sheath. (Low, Strong)
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The superficial PD catheter cuff should be 2 cm from the skin exit site in children and at least 2 cm in adults to prevent future cuff extrusion. (Very Low, Weak)
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POSTOPERATIVE PROTOCOL
Minimizing dressing changes and handling may be beneficial in the first two postop weeks. (Very Low, Weak)
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Adequate time should be given after surgery for healing before PD is initiated and the current standard is two weeks. A more urgent start should be considered when the benefits outweigh the risks. (Low, Weak)
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OUTCOMES BY SURGICAL PROCEDURE
Blind percutaneous PD catheter insertion has acceptable malfunction and leak rates compared with open insertion in patients who have never had prior abdominal surgery. The technique may be especially useful in high-risk patients for general anesthesia as it can be performed at the bedside, under local anesthesia by trained nephrologists. However, bowel perforation and bleeding risk should be considered. (Moderate, Weak)
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Open surgical insertion continues to be a standard to which others are compared. It is safe (low perforation rate) and effective and can be performed under local anesthesia and sedation. It appears to have higher leak and dysfunction rates compared to image guided percutaneous and advanced laparoscopic insertion. (Moderate, Weak)
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Peritoneoscopic insertion is a technique used worldwide, mostly by “interventional” nephrologists. It has been studied in patients who have had prior surgery, but there is at least a 1% perforation rate. It appears to be comparable to open surgical insertion in experienced hands, but has not been compared to laparoscopic and fluoroscopic guided percutaneous insertion. (Low, Weak)
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In patients without prior abdominal surgery, percutaneous fluoroscopic PD catheter insertion results in similar or better complication rates and dysfunction rates compared to open or basic laparoscopic insertion, and avoids general anesthesia. (Moderate, Weak)
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Basic laparoscopic insertion without using techniques to minimize catheter dysfunction results in similar dysfunction rates as open insertion. (Moderate, Strong)
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Advanced laparoscopic PD catheter insertion using lysis of adhesions, catheter fixation preferably with rectus sheath tunnel, and omentopexy performed in combination has the lowest reported rate of catheter dysfunction in adults, even in patients with prior abdominal surgery. (Moderate, Strong)
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EARLY POSTOP COMPLICATIONS
Bleeding after PD catheter insertion may occur from inferior epigastric artery injury or lysis of adhesions and should be managed according to standard surgical principals. The insertion point should be at the medial border of the rectus sheath to avoid arterial injury. Coagulation parameters should be assessed and corrected pre-operatively. (Very Low, Weak)
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Dialysate leaks after PD catheter placement may be amenable to treatment, and potentially prevention, with the use of fibrin glue, particularly in the pediatric population. (Low, Weak)
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Exit site infection is managed by oral antibiotics. Chronic exit site and cuff infections may managed by catheter salvage consisting of unroofing the track, shaving the superficial cuff and using a new exit site. (Low, Weak)
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Pain during PD is a rare complication that is usually amenable to medical management but occasionally requires repositioning or removal of the catheter. (Low, Weak)
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PD CATHETER MALFUNCTION
Malfunctioning peritoneal dialysis catheters should be evaluated by physical examination and plain radiographs to rule out constipation. If negative, further studies such as catheterography or CT peritoneography, followed by diagnostic laparoscopy are indicated. (Low, Weak)
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Non-operative treatments of malfunctioning PD catheters which have been proven effective include flushing, thrombolytics and fluoroscopic wire manipulation. (Low, Weak)
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Patients with malfunctioning peritoneal dialysis catheters not amenable to nonoperative measures should undergo laparoscopy with catheter repositioning, adhesiolysis, omentectomy or omentopexy. Patency should be assured by stripping and flushing. Suture fixation of the catheter to the pelvis or polypropylene sling may be utilized to reduce catheter migration. Surgical techniques for catheter salvage require individualization based upon operative findings. (Moderate, Strong)
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Recommendation Grading
Overview
Title
Laparoscopic Peritoneal Dialysis Access Surgery
Authoring Organization
Society of American Gastrointestinal and Endoscopic Surgeons
Publication Month/Year
June 1, 2014
Last Updated Month/Year
May 30, 2023
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
The use of peritoneal dialysis (PD) as a primary mode of renal replacement therapy has been increasing around the world. The surgeon’s role in caring for these patients is to provide access to the peritoneal cavity via a PD catheter and to diagnose and treat catheter complications. Since the early 1990s laparoscopy has been applied by many adult and pediatric surgeons for insertion of PD catheters as well as for salvage of malfunctioning catheters. This document is an evidence based guideline based on a review of current literature and the opinions of experts in the field. It provides specific recommendations to assist surgeons who take care of adult and pediatric peritoneal dialysis patients.
Target Patient Population
Peritoneal dialysis patients
Inclusion Criteria
Female, Male, Adolescent, Adult, Child, Older adult
Health Care Settings
Ambulatory, Hospital, Operating and recovery room, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Management, Treatment
Diseases/Conditions (MeSH)
D010530 - Peritoneal Dialysis, D010531 - Peritoneal Dialysis, Continuous Ambulatory, D003956 - Dialysis
Keywords
Kidney Dialysis, dialysis, peritoneal dialysis
Source Citation
Methodology
Number of Source Documents
234
Literature Search Start Date
May 1, 2010
Literature Search End Date
January 1, 2013