Benefits of laparoscopy in the management of malfunctioning peritoneal dialysis catheters: 3 clinical cases

Laparoscopic techniques for placement of peritoneal dialysis catheters are becoming increasingly popular. There may be several problems related to the functioning of peritoneal dialysis catheters. This is a report of three cases illustrating the diagnostic and often therapeutic interest of laparoscopy in patients presenting with peritoneal dialysis catheter malfunction. Case one shows laparoscopic treatment for pleural leakage, case two catheter malposition due to inflammatory and hemorrhagic adhesions with the omentum and case three a total encapsulation of the dialysis catheter by fibrin.

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Benefits of laparoscopy in the management of malfunctioning peritoneal dialysis catheters: 3 clinical cases

Authors

D Mutter, F Costantino, J D'Agostino, J Marescaux

Abstract

Laparoscopic techniques for placement of peritoneal dialysis catheters are becoming increasingly popular. There may be several problems related to the functioning of peritoneal dialysis catheters. This is a report of three cases illustrating the diagnostic and often therapeutic interest of laparoscopy in patients presenting with peritoneal dialysis catheter malfunction. Case one shows laparoscopic treatment for pleural leakage, case two catheter malposition due to inflammatory and hemorrhagic adhesions with the omentum and case three a total encapsulation of the dialysis catheter by fibrin.

Classification

clinical cases

Keywords

Benefits of laparoscopy, management of malfunctioning peritoneal dialysis catheters

Media type

Surgical video

Duration

06'10''

Publication

2009-04

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E-publication

WeBSurg.com, Apr 2009;9(04).
URL: http://www.websurg.com/doi-vd01en2510.htm

Benefits of laparoscopy in the management of malfunctioning peritoneal dialysis catheters: 3 clinical cases

1. Introduction 00'07''

There may be several problems related to the functioning of peritoneal dialysis catheters. Laparoscopy may be used to solve some of them.

2. First case 00'17''

The first typical case is one of pleural leakage of the dialysis solution, which necessitates the termination of the peritoneal dialysis. In most cases, the leakage source of the dialysis solution towards the chest can be identified under laparoscopic control. It is commonly caused by a peritoneal lesion in the fibrotic portion of the diaphragm situated in the supra-hepatic region. The right side is more prone to lesions than the left side.

3. Identification of the diaphragmatic lesion 00'53''

The magnified view offered by laparoscopy allows to identify peritoneal lesions in this fibrotic part. The objective of this study is to close these orifices in order to recover a normal peritoneal dialysis. Suturing these lesions is not an efficient solution due to the diaphragm’s fragility and to the hyperpressure caused by many litres of dialysis solution in the abdomen. We opted for an original technique requiring that a polypropylene mesh be placed between the parietal reflection along the liver and the diaphragm, thus originating in a very dense fibrosis. The size of the prosthesis is measured thanks to the introduction of a tape measure, and the mesh is re-trimmed according to the measures. The prosthesis is usually around 15cm long and is from 5 to 7cm wide.

4. Mesh placement and fixation 02'01''

It is placed at the level of the peritoneal reflection, between the posterior attachments of the liver’s triangular ligament and the diaphragm. It must imperatively be placed at the level of this peritoneal reflection line so that it is entirely covered by the liver after exsufflation. Indeed, contact between the mesh and the bowel loops may cause significant adhesions. In some cases, it needs to be slightly re-trimmed so that it can be placed correctly at the level of the triangular ligament’s reflection. During the initial scarring process, it is attached by a few Protack® staplers. During the exsufflation at the end of the operation, the liver covers the mesh completely. The peritoneal dialysis can be re-started the next postoperative day. The success rate of this procedure is of around 80%.

5. Second case 03'50''

In specific cases, a peritoneal catheter malfunction with possible infusion although with a difficult retrieval of the dialysis solution may be observed. A catheter malposition is often observed when conventional X-rays are performed. A laparoscopic exploration performed under insufflation via the dialysis catheter along with placement of three 5mm trocars allowing to minimize the parietal opening and ensuring a rapid resumption of the dialysis, often contributes to understand the cause of such a malposition.

6. Identification of adhesions and catheter cleaning 04'31''

In the present case, there are inflammatory and hemorrhagic adhesions between the catheter and the omentum; these caused the catheter’s encapsulation, but it can be freed easily laparoscopically. A quick “flush” of the catheter helps to clean it by eliminating the deposit of fibrin inside the catheter. In the absence of infection, dialysis is resumed rapidly with success.

7. Third case 05'12''

This case illustrates a total encapsulation of the dialysis catheter by fibrin lying in contact with the peritoneum. In the present case, the dialysis solution could neither be infused nor retrieved.

8. Catheter encapsulation 05'30''

The laparoscopic exploration confirms that the dialysis catheter is totally encapsulated within the anterior abdominal wall in such a way that it is coated with thick fibrin. There was no additional over infection and the exploration could give no explanation as to the origin of this encapsulation.

9. Catheter repositioning 06'00''

Despite the repositioning and cleansing of the catheter, the dialysis could not be resumed effectively in this patient. These three cases illustrate the diagnostic and often therapeutic interest of laparoscopy in patients presenting with peritoneal dialysis catheter malfunction.