Use and applications of catheters.
This class of catheters is mostly used for continuous ambulatory peritoneal dialysis, but its use can lead to complications.
Technique to be used
Under general anesthesia, the insertion of a double-ended, gooseneck Tenckhoff catheter begins with the placement of two 3-mm ports on the contralateral side of the abdomen after induction of the pneumoperitoneum with a Veress needle.
Oomentopexy is done with an abdominal suture pin in the ipsilateral upper quadrant. The catheter is inserted through a 1 cm incision in the skin and rectus sheath.
The catheter is obliquely below the posterior rectus sheath with the help of an 8 mm VersaStep ™ trocar. Under direct vision, the tip of the catheter is directed towards the retrovesical area with extreme care to avoid damage to the inferior epigastric arteries.
Insertion of the Tenckhoff catheter in peritoneal dialysis
Peritoneal dialysis was used for the first time for the treatment of end-stage renal disease in 1959. In 1968, Henry Tenckhoff developed the permanent peritoneal catheter, which was placed using an open surgical technique.
Subsequently, percutaneous and laparoscopic techniques have been used for their placement.
Peritoneal dialysis has several advantages over hemodialysis, including quality of life due to its ability to provide better patient mobility and independence, simplicity of use, as well as the clinical benefits of maintaining residual renal function and lower mortality in the first years after starting peritoneal dialysis.
A disadvantage of peritoneal dialysis is poor control of blood pressure due to fluid overload, as well as the risk of peritonitis.
Chronic peritoneal dialysis is an option for many patients with end-stage renal disease. Indications for peritoneal dialysis include the following:
- Failure of vascular access.
- Intolerance to hemodialysis.
- Congestive heart failure.
- Valve prosthetic disease.
- Major risk in children from 0 to 5 years old.
- Patient preferences.
- Distance from a hemodialysis center.
- Poor cardiac function
- Peripheral vascular disease.
Peritoneal dialysis is preferred in patients with the following conditions:
- Bleeding diathesis
- Multiple myeloma.
- Diabetes mellitus labial.
- Chronic infections
- Possibility of kidney transplant in the near future.
- Ages between 6 and 16 years old.
- Anxiety towards the needles.
- Active lifestyle
Peritoneal dialysis has been used infrequently for non-renal indications with variable benefit in other conditions such as the following:
- Refractory congestive heart failure.
- Hepatic failure
- Ascites associated with dialysis.
- Poisoning by drugs.
- Hereditary enzymatic deficiencies.
The intraperitoneal administration has been used for blood transfusions, chemotherapy, insulin and nutrition.
Contraindications for peritoneal dialysis include the following:
- Documented insufficiency of type II ultrafiltration.
- Severe intestinal inflammatory disease.
- Active acute diverticulitis.
- Abdominal abscess
- Active ischemic disease of the intestine.
- Serious active psychotic disorder.
- Intellectual disability marked.
- Women who begin the third trimester of pregnancy.
Contraindications related to peritoneal dialysis include the following:
- Severe malnutrition
- Multiple abdominal adhesions.
- Proteinuria> 10 g / day.
- Amputation of upper limbs.
- Poor personal hygiene
Peritoneal dialysis is not preferable, but it is possible in certain circumstances:
- Multiple hernias
- Severe back pain
- Multiple abdominal surgeries
- Reduced manual dexterity
- Bad situation in the home.
Tenckhoff peritoneal dialysis catheters can be placed percutaneously, laparoscopically or by an open surgical procedure. The anesthetic used will vary with the selected method.
Percutaneous placement can be performed under local anesthesia, while laparoscopic or open surgery requires general anesthesia.
Peritoneal dialysis catheters come in various forms (straight, spiral, swan neck), lengths and number of Dacron cuffs.
The peritoneal dialysis catheter is composed of a flexible silicone tube with an open end hole and several side holes to provide optimal drainage and dialysate absorption.
The extraperitoneal component of the catheter has one or two Dacron cuffs. Dacron cuffs are for optimal fixation.
In adults, a double-cuff catheter is typically used. With the double cuff peritoneal dialysis catheter, the proximal cuff is placed in the preperitoneal space and the distal cuff in the subcutaneous tissue.
The placement of the Tenckhoff peritoneal dialysis catheter requires that the patient be placed in the supine position.
Peritoneal dialysis catheters can be placed through a percutaneous, laparoscopic or open surgical approach. Open surgical and laparoscopic techniques are preferred because of their safety and good initial results.
Although placement of the peritoneal dialysis catheter is less invasive, the percutaneous procedure has risks of unsatisfactory placement and intestinal injury.
Open surgical technique.
The patient is placed in the supine position. General anesthesia is used and intravenous antibiotics are administered.
An infraumbilical incision is made in the midline. The subcutaneous layer is dissected to the rectus abdominis sheath. The anterior rectus sheath opens and the muscle fibers are dissected.
Also, the posterior sheath is incised and the abdominal cavity is opened after dissecting the peritoneum. The abdomen is inspected for adhesions, and if there is any near the abdominal wall, they are dissected.
The patient is then placed in a Trendelenburg position, and the catheter is placed on a stylet and inserted into the peritoneal cavity.
The intraperitoneal portion slides out of the stylet, and the cuff is placed in the preperitoneal space.
The peritoneum and the posterior and anterior rectus sheaths are closed with absorbable sutures, taking care to avoid catheter obstruction and dialysate leakage.
A tunnel is then created to the exit site, which is generally lateral and caudal to the entrance site. The distal cuff is placed subcutaneously, 2 cm from the exit site.
The incision is closed and the catheter is tested by filling the abdomen with 100 ml of sterile saline while checking the entry site for leaks.
The saline solution is drained and inspected to ensure that there is no intraperitoneal bleeding or fecal contamination.
The laparoscopic approach to Tenckhoff catheter placement in peritoneal dialysis is increasingly popular due to its advantage of being able to perform a partial omentectomy or lysis of adhesions if necessary during the initial placement of the catheter.
The patient is placed in the supine position and general anesthesia and intravenous antibiotics are administered.
The pneumoperitoneum is typically established by an open technique with a 5 mm access port in a subumbilical position of the midline.
Diagnostic laparoscopy is performed with a 5-mm 0-degree lens.
An additional 5 mm trocar is placed under direct vision at the site of the intended position of the exit site of the peritoneal dialysis catheter. This is usually left or right paraumbilical 2-3 cm below the navel.
The trocar is advanced through the anterior and posterior rectus sheaths, but not through the peritoneum. Under direct vision, the trocar is directed toward the preperitoneal space, 2-4 cm down and towards the midline of the abdomen.
If there are adhesions, the trocar is placed in the abdominal cavity and the adhesions are lysed. Next, a peritoneal dialysis catheter tipped with a double tip is placed through the paraumbilical orifice.
If there are no adhesions, the second trocar is left in the preperitoneal space. Next, a rigid stylet is used to introduce the peritoneal dialysis catheter into the peritoneal cavity.
The distal catheter of the peritoneal dialysis catheter remains outside the peritoneal cavity and is placed in the preperitoneal space or between the rectal sheaths.
The paraumbilical trocar is removed and the catheter is directed to its exit site. A subcutaneous tunnel is created, and the catheter is carried through the tunnel with the proximal sleeve placed inside the tunnel.
The catheter is tested and the abdomen is deflated. The trocar is removed and the rectal sheaths are closed, ending the surgical procedure.