Laparoscopic omental fixation technique versus open surgical placement of peritoneal dialysis catheters.

摘要

Background: Continuous ambulatory peritoneal dialysis (CAPD) is an effective form of treatment for patients with end-stage renal disease. Open insertion of peritoneal dialysis (PD) catheters is the standard surgical technique, but it is associated with a relatively high incidence of catheter outflow obstruction and dialysis leak. Omental wrapping is the most common cause of mechanical problems. The purpose of this study was to determine the efficacy of the laparoscopic omental fixation technique to prevent the obstruction caused by omental wrapping and also to compare this laparoscopic technique with open peritoneal dialysis catheter insertion with respect to postoperative discomfort, complication rates, and catheter survival. Methods: Between March 1998 and October 2001, 42 double-cuff, curled-end CAPD catheters were placed in 42 patients. The outcomes of the 21 patients in whom the PD catheters were placed laparoscopically with omental fixation technique were compared with those of the 21 patients inwhom the catheters were placed with open surgical technique. Recorded data included patient demographics, catheter implantation method, early and late complications, catheter survival, and catheter outcome. Results: Early peritonitis episodes occurred in 8 of 21 patients (38.0%) in the open surgical group (OSG) versus 2 of 21 patients (9.5%) in the laparoscopic omental fixation group (LOFG) ( p < 0.05); late peritonitis episodes occurred in 3 of 21 patients (14.2%) in the OSG versus 1 of 21 patients (4.7%) in the LOFG ( p < 0.05). Early exit site infection occurred in 8 of 21 patients (38.0%) in the OSG versus 4 of 21 patients (19.0%) in the LOFG ( p < 0.05), with many catheter-related problems in the conventional surgical group. There was no outflow obstruction in the LOFG. The conventional procedure was faster than the laparoscopic omental fixation technique. Analgesic requirements and hospital stay were less in the laparoscopic group. Laparoscopic surgery also enabled diagnosis of intraabdominal pathologies and treatment of the accompanying surgical problems during the same operation. Occult inguinal hernia was diagnosed in 2 patients, inguinal hernioplasty was performed in 4 patients, adhesiolysis was performed in 8 patients who had previous abdominal surgery, and liver biopsy was taken in 2 patients. Ovarian cystectomy was performed in another patient during laparoscopic CAPD catheter placement. Conclusion: The laparoscopic omental fixation technique (described by Ogunc and published in 1999) is a highly effective and successful method for preventing obstruction due to omental wrapping with a better catheter survival. Laparoscopic surgery also allows the diagnosis and treatment of the accompanying surgical pathologies during the same operation.