Insertion technique for prevention of peritoneal dialysis catheter tip migration.

Abstract

The peritoneal catheter migration may occur between 12.7 and 35 % of patients [1]. A one-stitch fixation of the catheter to the peritoneum and posterior sheath to prevent catheter tip migration had been advocated [1]. The drawback of this procedure is when the removal of catheter is planned, an elaborate surgery may be required. Another modification proposed is low-site peritoneal catheter implantation. The catheter is inserted approximately 6–8 cm above the pubic symphysis instead of the conventional procedure of using umbilicus as the reference point. By the low-site implantation technique, the catheter is much nearer and straighter to the pelvic cavity, thus preventing migration [2]. We present a modification to the procedure of catheter implantation to prevent its migration from pelvis. At our institute, a swan neck catheter is regularly used for peritoneal dialysis. The catheter insertion is performed by a gastroenterology surgeon under the laparoscopy. The precaution is always taken to direct the exit site caudally. Prior to this modification, we have not followed any surgical method to prevent migration. After insertion of a 10-mm subumbilical and a 5-mm right iliac fossa laparoscopic ports, the laparoscope is then shifted from subumbilical port to the right iliac fossa port. A 2-0 prolene (polypropylene; a non-absorbable suture) is passed around the 10-mm port by inserting a suture passer needle 5 cm below the subumbilical incision. The peritoneal dialysis catheter is then introduced into the peritoneal cavity through 10-mm port. The 10 mm port is then slowly withdrawn over the peritoneal dialysis catheter. The peritoneal dialysis catheter is now hitched to the anterior abdominal wall by tightening the suture around it. The extra length of suture is divided close to skin, as the tied knot gets buried in the subcutaneous tissue (Fig. 1). The peritoneal dialysis catheter is then tunneled in the subcutaneous tissue and brought out through a small skin incision lateral and inferior to the left of umbilical port site. Rectus sheath at 10-mm port is closed with 1-0 vicryl suture (polyglactin 910; an absorbable suture). Skin closed with staples or 2-0 nylon suture. Closure of skin at site of suture passage is optional. Between January 2010 and December 2013, this modification in the procedure of the catheter insertion was adapted. Peritoneal dialysis was initiated in 21 patients during this period. There were fifteen males and six females. The mean age was 51.2 years (range 33–70 years). The mean follow-up of all patients was 19.4 ± 8.3 months (range 3–32 months). The monthly abdominal radiograph did not reveal the migration of catheter in these patients. In 32-month period, prior to January 2010, 17 patients were initiated on peritoneal dialysis. There were 11 males and nine females. The mean age was 57.8 years (range 32–71 years). The mean follow-up of these patients was 25.2 ± 10.2 months (range 8–44 months). In eight patients (47 %), the catheter had migrated. K. Radhakrishna U. Chakarpani V. Venkata Rami Reddy Surgical Gastroenterology, Sri Venkateswara Institute of Medical Sciences, Tirupati 517502, India