Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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CHAPTER 91 • Insertion of Tenckhoff Catheter 1011

◆ If you are performing an open procedure without the aid of the laparoscope, carry the inci-

sion down through the skin and subcutaneous tissues to the muscle (Figure 91-2). Incise

the fascia of the muscle and split it down to the posterior fascia. Place a purse-string suture

in the fascia with the diameter approximately the size of a dime and then make an incision

in the middle of the circle (Figure 91-3).

Incision for

cuff placement

Exit site

FIGURE 91 –2

Peritoneum and

posterior rectus fascia

Anterior rectus fascia

Rectus abdominis muscle split

Peritoneal portion of

Missouri swan-neck

catheter

J Smith

Purse-string suture

Ball under

peritoneum

FIGURE 91 –3

1012 Section XII • Vascular

2. DISSECTION

◆ Place the catheter over a long metal guide or stylet that has been lubricated with water-

soluble 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 cathe-

ter by instilling a dilute heparinized saline through the end of the catheter. You should be

able to instill, aspirate, and siphon the ﬂ uid easily through the catheter without force or

interruption of ﬂ ow. Usually, placing the patient in a reverse Trendelenburg position and

administering approximately 100 mL of ﬂ uid aids in this maneuver.

◆ If there is difﬁ culty in any of these three maneuvers, reposition the catheter.

PD catheter

Upper incision

Exit site

FIGURE 91 –4

CHAPTER 91 • Insertion of Tenckhoff Catheter 1013

◆ After successfully testing the function of the catheter, tighten the purse-string around the

catheter below the cuff (or between the intraperitoneal ball and the ﬂ at disc of the Missouri

swan-neck catheter) and suture the cuff or disc to the posterior peritoneum in a whipstitch

fashion. You must avoid puncturing the catheter with the needle (Figure 91-5).

◆ Tunnel the end of the catheter through the rectus muscle and subcutaneous tissue to the

exit site that was previously marked by the home dialysis nurse. The use of a sharp curved

trocar is best to decrease the dead space around the catheter. To decrease the incidence of

infection caused by an extruded cuff, make sure to have the second cuff of the catheter

remain in the subcutaneous space and at least 1 cm from the exit site.

3. CLOSING

◆ Close the incisions in one or two layers, as per the tradition of the institution. Do not close

the exit or place a suture around the catheter. Apply a simple clear air-permeable dressing

over the exit site and the catheter to lessen the movement of the catheter.

Exit site

Catheter in pelvis

Suture

first trocar site

Catheter in pelvis

Disc

Cuff

Skin

Ball

Fat

rectus fascia

Peritoneum

Posterior

rectus fascia

Rectus muscle

FIGURE 91 –5

1014 Section XII • Vascular

STEP 3: OPERATIVE STEPS—LAPAROSCOPIC OPTION

◆ When using the laparoscopic techniques, the surgeon must arrange the patient and the

equipment in the most useful positions. Place the patient supine. Place the monitor at the

foot of the bed, because the pelvis is the primary area of interest and is where the tip or

the base of the curled catheter is going to lay (Figure 91-6).

Monitor

FIGURE 91–6

CHAPTER 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. Insufﬂ ate

the abdominal cavity with CO

to proper pressures (12 to 18 cm H

O 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 tro-

car 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).

(3) Third trocar site

(1) Incision and camera site

(2) Marked area for exit site

and second trocar site

FIGURE 91 –7

1016 Section XII • Vascular

◆ When the pelvis and lower aspect of the peritoneal cavity is free from adhesions, move the

camera to one of the other trocars. Remove the upper trocar and advance the catheter over

the stylet through the purse-string into the cavity. To decrease the loss of intra-abdominal

pressure, hold the purse-string tight around the catheter as it is advanced. Once the cuff is

at the posterior fascia, hold the suture in place with a rubber-shod clamp.

2. DISSECTION

◆ Using the camera and a grasping instrument through the remaining trocar, place the end of

the catheter (or the curl) in the pelvis above the bowel and omentum. Securing the catheter

to the posterior abdominal wall is an advantage because it prevents catheter migration and

enhances return of dialysate. Make a small incision in the skin in the midline and above the

symphysis pubis. Using a laparoscopic suture passer, pass an absorbable suture (2-0 or

larger) into the abdominal cavity under direct vision. Then guide the suture around the

catheter, at the start of the curl if using a curled catheter, or at least 5 to 8 cm above the

end of a straight catheter, and retrieve by the suture passer. Bring the suture to the outside

and then tie it down securely.

3. CLOSING

◆ The completion of this procedure is identical to the open procedure described previously

including testing for function of the catheter, securing the ﬁ rst cuff, bringing out the end of

the catheter at the exit site, and closing the wounds (Figure 91-8).

Second trocar site

Catheter in pelvis

Closed incision

over the catheter

First trocar site

FIGURE 91 –8

CHAPTER 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 individual-

izes 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 fas-

cia, 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 tan-

gentially 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.

1018

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 sterno-

cleidomastoid muscle and the clavicle and under the platysma muscle. It is encased in the

ﬁ brous 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 ca-

rotid 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 conﬂ uence

of the posterior fascia of the abdominal musculature with the peritoneum.

CHAPTER

Insertion of Peritoneal

Venous Shunts

Kristene K. Gugliuzza

CHAPTER 92 • Insertion of Peritoneal Venous Shunts 1019

Internal jugular vein

Common carotid artery

Omohyoid muscle

anterior belly

Anterior jugular vein

Vagus nerve

Sternocleidomastoid muscle

(clavicular head)

Sternohyoid muscle

Sternothyroid muscle

Sternocleidomastoid muscle

(sternal head)

Right recurrent

laryngeal nerve

Ansa cervicalis

External juglar vein

Phrenic nerve

Anterior scalene muscle

Sternocleidomastoid

muscle

Omohyoid muscle

posterior belly

Subclavian

artery

Right thoracic duct

Clavicle

Ansa cervicalis

External juglar vein

Phrenic nerve

Anterior scalene muscle

Sternocleidomastoid

muscle

Omohyoid muscle

posterior belly

Subclavian

artery

Internal jugular vein

Common carotid artery

Omohyoid muscle

anterior belly

Anterior jugular vein

Sternocleidomastoid muscle

(clavicular head)

Sternohyoid muscle

Sternothyroid muscle

Sternocleidomastoid muscle

(sternal head)

Vagus nerve

Left thoracic duct

Clavicle

FIGURE 92 –1

1020 Section XII • Vascular

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ The patient should be placed supine with the head rotated to the contralateral side from the

planned incision. Left or right sides may be used, but care must be taken not to injure the

thoracic duct on the left. A roll or bump under the ﬂ ank may facilitate exposure of the

lateral upper abdomen (Figure 92-2, A).

◆ If one of the jugular veins has been dissected or catheterized previously, using the other

untouched vein may be prudent.

STEP 3: OPERATIVE STEPS

1. INCISION

◆ The patient is placed supine with the head rotated to the side opposite the vein being used.

The patient is placed in a Trendelenburg position to engorge the vein by increasing the ve-

nous pressures. A roll or bump under the ﬂ ank may facilitate exposure of the lateral upper

abdomen. The venous incision is made approximately 1 ﬁ ngerbreadth above the clavicle

and between the two heads of the sternocleidomastoid muscle. The abdominal incision is

made lateral to the rectus muscle, approximately 2 ﬁ ngerbreadths below the costal margin

and transversely for approximately 3 to 5 cm (Figure 92-2, B).