Sur gical Inparo scopy, Endoscopy & P ercutaneous Techniques
Vol. 10, No. 4, pp.218)21
O 2(n0 Lippincott Williams & Wilkins, Inc., Philadelphia
Laparoscopic Placement of the Tenckhoff Catheter for
Evangelos C. T. Tsimoyiannis, MD, FACS, FABI, Philipos Siakas, MD, George Glantzounis, MD,
Chrysoula Toli, MD, George Sferopoulos, MD, Michael Pappas, MD, and
Adamandia Manataki. MD
Summary: Continuous ambulatory peritoneal dialysis catheters can be inserted by
open laparotomy as well as by laparoscopy. A prospective randomized study was
scheduled to investigate the results'of the laparoscopic versus open laparotomy tech-
nique for placement of continuous ambulatory peritoneal dialysis catheters. Fifty pa-
tients were enrolled and randomly allocated into two groups of25 patients each. Group
A underwent continuous ambulatory peritoneal dialysis catheter placement via the
open laparotomy technique. ln22patients, catheters were inserted via midline incision,
and in 3 patients with histories of previous catheterization, a paramedian incision was
used. Continuous ambulatory peritoneal dialysis was started 24 to 48 hours later.
Group B underwent laparoscopic placement of the catheter with fixation into the pelvis
and suture closure ofthe port wounds. In 2l patients, this catheter placement was the
first such placement, and in 4 patients, a previous catheter had been inserted by the
open technique and removed for dysfunction. Continuous ambulatory peritoneal di-
alysis was started at the end of the procedure. The mean operative time was 22 minutes
in group A and 29 minutes in group B (P < 0.001). Fluid leakage was observed in eight
patients in group A, but in no patients in group B (P < 0.005). Peritonitis occurred in
five patients in group A and in three patients in group B (P > 0.1). Tip migration
occurred in five patients in group A and no patients in group B (P < 0.005). In group
B, two patients underwent a simultaneous cholecystectomy and one underwent inci-
sional hernia repair. Laparoscopic placement of a Tenckhoff catheter leads to better
function than does the open procedure; it allows immediate start of dialysis without
fluid leakage and permits simultaneous performance of other laparoscopic procedures.
Key Words: Cholecystectomy-Continuous ambulatory peritoneal dialysis-
Continuous ambulatory peritoneal dialysis (CAPD) is
an effective method of renal replacement therapy for
patients with end-stage renal disease. Since the introduc-
tion of a suitable long-term indwelling catheter in 1968
(1), this device has gained widespread acceptance,
thereby populprizing peritoneal dialysis as an acceptable
alternative to hemodialysis (2).
Despite the increased use of the Tenckhoff catheter for
Received November 7,1999; revision received April 18, 2000; ac-
cepted April 21,2000.
From the Departments of Surgery (ET, PS, GG, CT), Nephrology
(GS, MP), and Anesthesiology (AM), G. Hatzikosta General Hospital,
Address correspondence and reprint requests to Evangelos C.
Tsimoyiannis, MD, 3, Hippocratus, Stavraki, GR-45332 Ioannina, Greece.
CAPD and the standardization of surgical techniques,
this device is still associated with a significant number of
complications, such as peritonitis and outflow obstruc-
tion (2,3). Various techniques have been described for
the placement of CAPD catheters. Traditionally, an open
laparotomy technique has been used via a lower abdomi-
nal incision. Recently, laparoscopic guidance has been
used to site the catheter under direct vision (4,5). Lapa-
roscopy has also been used to salvage catheters that are
dysfunctional because of omental adhesions and migra-
tion of the tip (2,6-9).
Until now, there have not been any prospective trials
comparing which technique is best for the placement of
Tenckhoff catheters. Therefore, we designed a prospec-
tive randomized clinical studv to investisate the results
of the laparoscopic versus open laparotomy technique in
the placement of Tenckhoff catheters for CAPD.
MATERIALS AND METHODS
The study was approved by the Scientific Committee
on Human Rights in Research of the G. Hatzikosta Gen-
eral Hospital, Ioannina, Greece. Adult patients undergo-
ing insertion of a Tenckhoff catheter for CAPD gave
their informed consent to participate in this study. Pa-
tients were excluded only if a problem for general anes-
thesia was found. Fifty patients were randomly assigned
(a closed envelope contained information regarding
placement into group A or B) to one of two groups of 25
patients each. Group A underwent an open laparotomy
technique with local anesthesia. In22patients, the cath-
eter was inserted through a 3- to 4-cm midline incision,
and in 3 patients with histories of a previous catheteiza-
tion, a small paramedian incision was used. No intraab-
dominal fixation of the catheter was performed. After the
procedure, the patients were transported to the nephrol-
ogy department. Continuous ambulatory peritoneal di-
alysis was started 24 to 48 hours later using small
amounts offluid, and several days later, the full program
of CAPD was started. Group B underwent laparoscopic
placement of the catheter. With general anesthesia, the
patient was placed in a supine 30o Trendelenburg posi-
tion. We inserted three 10-mm tfocars; the first was in-
serted infraumbilically with a Hasson technique, the sec-
ond was inserted suprapubicly, and the third was inserted
at the left midcostal line between the iliac fossa and
umbilicus. A fourth 5*mm trocar was inserted at the left
iliac fossa (5). The laparoscope (0'or 30o) was placed
through the infraumbilical port. A Tenckhoff catheter
was introduced through the suprapubic port, which was
then removed over the catheter, leaving the catheter to
pass through the abdominal wall. The hole was sutured
around the catheter on the inside cuff with an Endoclose
needle (United States Surgical Corp., Norwalk, CT,
USA) and nonabsorbable suture. Using the other two
ports as working ports, we placed the catheter tip into the
pelvis. The catheter was then secured to the back wall of
the uterus in women or to the peritoneum ovedying the
back wall of the bladder in men, with 210 polypropylene
laparoscopically placed sutures. The holes of the work-
ing ports were closed as the catheter hole with the En-
doclose needle, using full-thickness nonabsorbable su-
tures, and the umbilical hole was sutured with open
manner. A grasping forceps was placed through the
wound of the midcostal working port and oriented to the
suprapubic wound so as to create a subcutaneous tunnel
for pa'ssage of the outer end of the catheter. This subcu-
taneous tunnel was continued between the two working
por"ts so that the final exit of the outer end of the catheter
was to be the port wound of the left iliac fossa. In 21
patients, this catheter was the first catheter inserted,
whereas in 4 patients, a previous catheter inserted by
open technique was removed (for dysfunction). In these
four patients, the catheter placement was performed after
laparoscopic lysis of adhesions. Immediately after the
end of the procedure, the CAPD was started, and the
patient was transported to the nephrology department to
continue the CAPD program. Data were analyzed using
the unpaired two-tailed r test and X2 analysis. Signifi-
cance was defined as P < 0.05.
Demographic characteristics of patients were compa-
rable for the two groups (Table 1). Six patients were
excluded from the study because they developed severe
cardiovascular or respiratory disease, which contraindi-
cated general anesthesia; all of these patients were oper-
ated on using the open technique with local anesthesia.
The mean operative time was significantly lower in
group A than in group B (Table l). The difference in
postoperative peritonitis was not statistically significant,
whereas the fluid leaking and tip migration of the cath-
LAPAROSCOPIC PLACEMENT OF TENCKHOFF CATHETER
TABLE l. Demographic data and operative variables
Results by group
Mean operative time (min)
Fluid leaks (no. patients)
Peritonitis (no. patients)
Tip catheter migration (no. patients)
Removal of the catheter (no. patients)
E t test
I X' test.
Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, Vol. 10, No. 4, 2000
E, C. T. TSIMOYIANNIS ET AL.
eter had a significantly lower incidence in group B than
in group A. In group A, three of five patients with peri-
tonitis had their catheter removed after 6, 11, and 15
months postoperatively, respectively. In group B, one of
three patients with peritonitis had the catheter removed
12 months later.
In group A, there were two coexisting diseases (cho-
lelithiasis in one patient and a small inguinal hernia in
one patient), but no simultaneous therapy was per-
formed. In group B, there were three coexisting diseases
(cholelithiasis in two patients and incisional hernia in
one), and simultaneous cholecystectomies and a laparo-
scopic incisional hernia repair were performed. Addi-
tionally, five patients in group B who underwent
previous laparotomies had an extended adhesiolysis
performed before catheter placement. In group A, in
three patients with a history of previous catheterization
and in one patient with a previous midline laparotomy, a
paramedian incision was used with adhesiolysis near the
incision because the small laparotomy made extensive
In both groups, the remaining catheters are functioning
well (4-36 months; mean,2I +10), except for three pa-
tients in group A with diminished fluid return because of
migration of the tip.
Peritoneal dialysis continues to gain popularity for
treatment of patients with end-stage renal disease. De-
spite the widespread acceptance of CAPD, success is
limited by the need for a functioning Tenckhoff catheter
(2). In 1991, approximately 20Vo of the 4,300 patients
who discontinued peritoneal dialysis did so because of
catheter failure (10). Many reports describe the compli-
cations of CAPD as peritonitis, outflow obstruction, ex-
traperitoneal placement of catheters, genital edema,
hernias, dialysate leak, cuff extrusion, and respiratory
compromise (2,3,11-14). The improvement of surgical
technique in open surgery has decreased the incidence of
these complications (3,1 1,15).
Laparoscopy has been reported in small series of pa-
tients for placement of Tenckhoff catheters for CAPD
(5,16*18). In addition, some papers have described lap-
aroscopic management of malfunctioning peritoneal di-
alysis catheters (2,19-21). These papers have shown that
the laparoscopic approach is a useful addition to the sur-
gical armamentarium for patients with malfunctioning
CAPD catheters and that laparoscopic placement of the
CAPD catheters has significant advantages over open
Surgical Laparoscopy, Endoscopy & Percutqneous Techniques, VoL 10, No. 1, 2000
There were two distinct advantages to laparoscopic
placement of CAPD catheters. First, suture fixation of
the tip catheter prevents catheter migration. The inci-
dence of catheter tip migration, resulting in poor return
of dialysate, is significantly higher when the catheter has
not been sutured into the pelvis (23). An open laparoto-
my technique can be used to enable suture fixation to
overcome the problem of catheter migration. However,
the associated pain and morbidity are significant because
of the lower abdominal incision. The laparoscopic inser-
tion of the Tenckhoff catheter reduces wound-related
morbidity while still allowing suture fixation of the cath-
eter tip. In the current study, catheter migration was pre-
vented in all patients in the laparoscopic group, whereas
in the open laparotomy group, this problem was observed
in 207a of cases.
The second advantage of laparoscopic placement of
CAPD catheters is that closure of the port wounds pre-
vents fluid leaking so that the commencement of dialysis
is started immediately. We believe that leakage was less
significant in the laparoscopic group because the port
wounds are significantly smaller than those resulting
from small laparotomy in open surgery, which means
that the closure is more water-tight for the laparoscopic
than for the open laparotomy group.
The ability to perform simultaneous operative proce-
dures during laparoscopic placement of CAPD catheters
is essential. Avoidance of an incision and the reduction
of surgical procedures are of vital significance for these
high-risk patients. Laparoscopic hernioplasty is an easy
procedure (24) and facilitates CAPD, whereas an open
hernia repair can be accompanied by fluid leakage and is
associated with a high incidence of recurrence. There-
fore, we believe that for patients with coexisting surgical
abdominal diseases who are in good condition for gen-
eral anesthesia and in whom placement of a CAPD cath-
eter is indicated, the laparoscopic approach is preferable.
Conversely, in patients with contraindications to general
anesthesia, the open technique with local anesthesia is
the procedure of choice.
In the current study, no morbidity from general anes-
thesia was observed, but patients with problems contra-
indicating this type of anesthesia were excluded. Perhaps
spinal anesthesia will minimize the anesthesia contrain-
dications of the laparoscopic approach, but this type of
anesthesia must be investigated for laparoscopic place-
ment of CAPD catheters.
In conclusion, the laparoscopic placement of Tenck-
hoff catheters currently necessitates more operative time
and general anesthesia, but it leads to accurate place-
ment of the catheter tip with better catheter function,
and it allows for immediate dialysis. Fluid leakage is
minimized, and other laparoscopic procedures can be Download full-text
performed simultaneously. Therefore, the laparoscopi-
capproach for placement of CAPD catheters is an excel-
lent alternative to the open approach.
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LAPAROSCOPIC PIACEMENT OF TENCKHOFF CATHETER
Surgical lnparoscopy, Endoscopy & Percutaneous Techniques, Vol. 10, No. 4, 2000