Laparoscopy for PD Catheter Placement: Advantages and Disadvantages versus Peritoneoscopy

541 In this issue of Peritoneal Dialysis International, Ogunc reviews the various methods of placing peritoneal dialysis (PD) catheters and accurately describes the problems associated with surgical (dissection) techniques (1). Although results vary widely, outflow obstruction and pericatheter leaks are frequent complications of PD catheter placement when performed with standard surgical techniques, causing catheter removal in 13% and 9% of catheters respectively (2–4). Infection causes much more frequent catheter loss and, after surgical placement, 45% of PD catheters are lost to infectious complications (2–4). Laparoscopic techniques have been widely accepted in surgical procedures because they minimize trauma and hasten postoperative recovery of patients undergoing a number of procedures. Laparoscopy rarely improves the outcome of surgical procedures; although, in some cases, improved visualization means more accurate surgery. Laparoscopy yields excellent visualization of the peritoneum during procedures and is the only technique apart from laparotomy that can accurately delineate intraperitoneal adhesions. Therefore, it makes sense that placement of PD catheters would be improved by this technique. However, with standard equipment, the results have not been improved. A recent review of laparoscopic/peritoneoscopic placement procedures demonstrated a trend to advantage for these procedures in diminishing all types of catheter complications, versus surgical placement, but not with significant improvement (5). One problem with laparoscopic catheter placement is that the standard laparoscopic equipment is not designed to place PD catheters through a minimum size hole in the peritoneum and to place the deep cuff securely within the rectus muscle. When a 10 mm laparoscope is used for insertion of a catheter, the hole in the muscle layer is much larger than the catheter (especially if a Hassan port is used). When advancing the catheter through the 10 mm cannula, it is difficult to position the catheter so that the cuff rests within the rectus muscle when the cannula is withdrawn. When using a 5 mm port with split-away sheath, advancement of the catheter through the sheath will always leave the cuff on the outside of the rectus muscle, to be positioned then manually. Another problem with laparoscopic catheter placement is that the procedure does not make full use of the tools for intervention and improvement of catheter function. Laparoscopy can be used to direct the catheter into locations free of adhesions but, except for this ability to avoid adhesions during catheter placement, the procedure does not add stability to the catheter position over time or prevent omental attachment to the catheter. Ogunc describes some improvements to laparoscopic placement designed to diminish outflow failure of PD catheters: he creates a preperitoneal tunnel for the straight part of the catheter to fix the coil of the catheter in the lower abdomen and against the parietal peritoneum, and he performs omentopexy or omentectomy to remove the omentum from the area of the catheter. The results are relatively impressive, with no outflow failures and only 1 exit-site infection in 44 patients followed for 17.4 months. Neither musculofascial tunneling of the catheter nor omentopexy are “new” concepts in the field of peritoneal catheter placement or in laparoscopy. Helfrich et al. (6) and Favazza et al. (7) described short rectus sheath tunnels dur ing open dissection implantation. Laparoscopic-directed tunneling of the catheter through the rectus sheath has been described by Nijhuis et al. (8), Draganic et al. (9), Gerhart (10), Poole et al. (11), Cala et al. (12), and Crabtree et al. (13,14). The use of omentopexy during catheter implantation has been previously described by McIntosh et al. (15), Crabtree et al. (13,14), and Ogunc’s earlier work (16,17). Work by Crabtree and others has demonstrated advantages to COMMENTARIES