Continuous Ambulatory Continuous Ambulatory Peritoneal Dialysis TechniquePeritoneal Dialysis Technique

Dr/Amir SiddigDr/Amir Siddig Department of Surgery Department of Surgery Ribat University Hospital Ribat University Hospital

IntroductionIntroduction

• Peritoneal dialysis (PD) as a treatment for ESRF started in1959 .

• Rigid catheters were used with frequent punctures(IPD) .

• Problem of maintaining access for chronic dialysis.

• Henry Tenckhoff developed home fluid production machine and the soft silicone catheter in 1963.

• Coupling Tenckhoff catheter with the cycling device made by Norman Lasker home IPD program started in 1970

• Monchrieff and Popvich developed the program of Continuous Ambulatory Peritoneal Dialysis (CAPD) in 1975 in response to patients with no vascular access

Types of catheterTypes of catheter

Implantation MethodsImplantation Methods

1. Open Method

2. Blind Method

3. Laparoscopy

1.1. Open MethodOpen Method

• Direct dissection of abdominal layers and peritoneum under vision .

• Deep cuff secured within rectus sheath

• Limited exposure of peritoneal cavity

2- Blind (subcutaneous) Method2- Blind (subcutaneous) Method

• The catheter is inserted blindly over a needle ( Seldinger technique)

• Possible risk of perforation of bowel and mesentery-No visualization of abdominal cavity (against surgical principles)

• The deep cuff is placed outside abdominal musculature

3- Laparoscopy3- Laparoscopy

• Provides excellent visualization of the entire abdominal cavity

• Proper placement of the catheter tip in pelvic cavity and the deep cuff within the abdominal musculature

• Requires expensive equipment and advanced training for doctors

Pre-Operative AssessmentPre-Operative Assessment

1. Exclude active skin or systemic infection

2. Inspect for old scars and skin folds

3. Determine the exit site:

-Avoid bony prominences and belt line

-Should be appropriate and accessible for the patient.

-Mark the exit site with indelible marker

4-Shave abdominal hair.

5-Empty bladder and bowel.

6-Use prophylactic antibiotics prior to the procedure.

AnaesthesiaAnaesthesia

• General anaesthesia (GA) is not recommended and should be avoided whenever possible -ESRF patients have altered metabolism and excretion of anaethetics

• Local anaesthesia(LA) in the form of Lidocaine 1% or 2% with or without epinephrine is adequate.

• The maximum recommended dose :

Lidocaine without epinephrine=3mg/Kg

Lidocaine with epinephrine =7mg/Kg

• Gentle handling and retraction is essential to reduce pain and discomfort .

• The patient should have a venous access , HR and SPO2 monitoring.

• Resuscitation facilities should be available.

The ProcedureThe Procedure

• Monitor HR and SPO2 and get a peripheral venous line

• Give prophylactic intravenous antibiotic (Cefazoline)

• Prepare the skin with antiseptic and drape• Expose prei-umblical area and exit site• Use LA in adequate dosage –dilute with saline• Infiltrate LA in the skin and subcutaneous tissue

down to linea alba. • Wait for 2 minutes for the anaesthesia to be

profound and test for pain.

• Make 2-3 cm longitudinal incision starting 1 cm below the umbilicus

• Infiltrate more LA for the linea alba as it is exposed and also infiltrate the recti on each side of the wound

• After incising the linea alba , gently retract the recti to expose the posterior rectus sheath and parietal peritoneum

• Give further doses of LA for the parietal peritoneum

• Grasp the parietal peritoneum with twoartery forceps after palpation to avoid catching

bowel• Open the peritoneum under direct vision• Place the catheter tip with the help of a long

artery forceps low in the left side of the pelvic cavity –warn the patient that this step may cause some discomfort

• Test the patency of the catheter• Fix the deep cuff to the posterior rectus sheath

with 2/0 prolene

• Approximate the muscles• Close the anterior rectus sheath (linea

alba) meticulously with prolene or nylone no 1

• Give LA at the exit site and the tunnel• Create a subcutaneous tunnel using an

artery forceps or a tunneler.The recommended subcutaneous tunnel is slightly arcuate and directed downwards

• Puncture the exit site and pull the catheter by a forceps inserted through the exit wound so that

the superficial cuff will be placed within the subcutaneous tissue just deep to the exit wound.

• No need to fix the catheter at the exit site• Test filling and drainage.• About 250 ml may be left inside the abdominal

cavity – this may prevent omentum and debris from blocking the catheter.

Postoperative CarePostoperative Care

1. Dressing is only changed if it becomes soaked or after one week.

2. Strict aseptic technique in dressing.

3. Shower is allowed after two weeks.

4. Keep the catheter immobilized to the skin.

5. Avoid constipation.

ComplicationsComplications

1. Intra-abdominal injuries.

2. Dialysate leaks.

3. Catheter malposition and migration.

4. Catheter obstruction and poor drainage.

5. Incisional and inguinal hernia.

6. Pain.

7. Infection –peritonitis.

Thank You