A standardized technique of laparoscopic placement of peritoneal dialysis catheter with omentectomy and closure of patent processus vaginalis: a 3-in-1 minimally invasive surgical approach in children

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Omental wrapping is a common cause for catheter failure in children on peritoneal dialysis (PD). Previous studies are conflicting in the benefits of omentectomy. We conducted a retrospective review on consecutive children aged < 18 years who underwent PD catheter placement by a standardized laparoscopic three-in-one (lap3-in-1) technique from 2013 to 2018. The laparoscopic approach combined catheter placement with well-defined indication and extent of omentectomy, and closure of any patent processus vaginalis (PPV). A historical cohort of children who had their first PD catheter placement by open surgery without omentectomy was identified as control for comparison. There were 33 and 32 children in the lap3-in-1 and control cohorts respectively without any difference in gender and median age at the time of surgery. 24/33 (73%) and 14/33 (42%) in the lap3-in-1 cohort required laparoscopic omentectomy and PPV closure. 4/33 (12.1%) had reoperations for catheter failures which equated 1 reoperation per 144 catheter months. None of the patients in lap3-in-1 cohort had reoperation due to omental wrapping or inguinal hernia, compared with 13/32 (41%; p<0.001) and 5/32(16%; p=0.02) in the control cohort. Kaplan Meier survival curves showed significantly longer catheter life in the lap3-in-1 cohort (p<0.001). In multivariate analysis by the COX proportional hazards model, the lap3-in-1 approach was found to have significantly reduced risk of reoperation for catheter failure (HR 0.11; 95%CI: 0.04 – 0.31; p<0.001). The lap3-in-1 technique promotes catheter longevity by accurately selecting those children who would benefit from omentectomy and ascertaining thoroughness of omentectomy. The technique also prevents subsequent development of inguinal hernia.