Laparoscopic Placement of the Tenckhoff Catheter with a New Regional Anesthesia: A Two-Year Experience

Abstract

Background: The peritoneal dialysis (PD) catheter is commonly placed using an open surgery approach. However, mechanical peritoneal catheter-related complications are common causes of peritoneal dialysis technical failure. In recent years, laparoscopic procedures have been recommended because of less invasiveness and high effectiveness in reducing catheter dysfunction; however, this approach is burdened by higher costs and higher risks related to general anesthesia. Methods: We have developed a new advanced video-laparoscopy (ALS) approach with a simple technique that does not require general anesthesia. By using an ultrasound-guided procedure it is possible to place a PD catheter by regional anesthesia (Transversus Abdominis Plane (TAP) block associated with bilateral quadratus lumborum (QLB) block). Results: We here report the outcomes of 20 patients who underwent ALS implantation of straight-neck, double-cuffed Tenckhoff catheters using cutaneous anesthesia with TAP and QLB block. No major complications, including bleeding, were reported. No patient needed intravenous treatment for pain control, and all procedures were well tolerated. During a median follow-up of 21 months [IQR, 15–35] no mechanical complication was reported. Conclusions: ALS without general anesthesia is a simple and well-tolerated technique that can be used in patients at high risk. It therefore allows recruiting a greater number of patients for PD and ensuring well-performing catheters with lower risk of mechanical complications.

1. Introduction

Despite the advantages of peritoneal dialysis (PD) in terms of clinical outcomes and costs [1], early catheter-related complications, such as dislocation and omental wrapping, are a major relevant cause of PD technical failure and withdrawal of patients [2,3].

Currently, PD catheter implantation is mainly accomplished by open surgery (OS) or, alternatively, percutaneous techniques or advanced video-laparoscopy (ALS). Percutaneous catheterization uses the Seldinger technique and can be performed blindly or under fluoroscopy or ultrasonography. In recent years, ALS has been recommended because of the greater and adequate visibility during the catheter placement that allows adjunctive procedures to reduce the risk of mechanical complications, e.g., rectus sheath tunneling, omentopexy, adhesiolysis, epiploectomy, and colopexy [4]. Several meta-analyses have documented the high effectiveness of laparoscopic catheter placement technique versus the OS and percutaneous approach [5,6]. In particular, a recent network meta-analysis revealed that in comparison to OS, laparoscopy might be significantly effective by decreasing catheter mechanical dysfunction by 69% [7]. When comparing ALS with percutaneous approach, no significant difference in terms of mechanical disfunction was found but ALS was associated with higher 1-year catheter survival [7]. Furthermore, for patients with a history of previous abdominal surgery, and greater risk of post-surgical adhesions, ALS allows procedures such as adhesiolysis or hernioplasty in the same surgical session and enables a suture fixation of the catheter distal tip in Douglas’s pouch or a lower abdominal suture sling to promote pelvic orientation of the catheter, which is an acceptable alternative if not performing rectus sheath tunneling, therefore reducing the risk of mechanical complications. However, the meta-analysis found that a laparoscopic approach was associated with higher bleeding risk and higher costs related to hospitalization [7]. Moreover, significant limitations in ALS implementation are the need for pneumoperitoneum, the Trendelenburg position and the higher risk of general anesthesia, which is not unlikely in patients with end-stage kidney disease (ESKD), typically characterized by older age and several comorbidities. A previous study reported interesting results by performing the laparoscopic procedure using helium insufflation and local infiltration anesthesia of the peritoneum [8].

Nowadays, the Transversus Abdominis Plane (TAP) block and bilateral quadratus lumborum (QLB) block are considered part of the several multimodal analgesic strategies for minor abdominal surgery optimizing post-operative management and analgesia [9,10,11]. We here report a two-year experience of a new video-laparoscopic technique that uses cutaneous regional TAP and QLB block instead of general anesthesia for PD catheter implantation.

2. Materials and Methods

2.1. Study Population

This is a retrospective study of a series of 20 cases of patients with ESKD that underwent the new procedure from January 2021 to December 2022 in Castellammare di Stabia Hospital. Each patient was instructed on the procedure and provided written informed consent. Straight-neck, double-cuffed Tenckhoff catheters were used in all cases.

2.2. Anesthetic Procedure

TAP block is a fascial plane block attained by injecting local anesthetics in the plane between transversus abdominis and internal oblique muscles. The TAP block targets the nerves derived from the anterior rami of thoracolumbar spinal nerves (T6-L1) as they pass through the TAP to provide analgesia for abdominal surgical procedures. Instead, QLB block is performed by injecting local anesthetic in planes defined by the thoracolumbar fascia around the quadratus lumborum muscle, providing an abdominal visceral analgesia. We performed ultrasound (US)-guided regional anesthesia, that is, bilateral anterior (QL3) with patients in a lateral position (Figure 1). QLB block is guaranteed with 30 mL of anesthetic solution composed of ropivacaine 0.2%; thereafter, we administered a bilateral TAP block with 15 mL of ropivacaine 0.2% to reinforce the QLB block, given the low concentrations used, and to ensure a better postoperative analgesia. Intraoperative sedation was provided by midazolam 3 mg, allowing patients to continue breathing on their own. The anesthesiologic procedure lasted about 15–20 min before commencing the PD catheter insertion procedure; to keep time use more efficient, the regional blocks were performed in an anesthesia block room around the time of an operating room turnover.

2.3. Surgical Procedure

(1) Surgical incision (2–2.5 cm) was performed on the left paraumbilical region at the level of the belly of the rectus abdominis muscle (Figure 2-A); the anterior rectus sheath was opened and identified with two threads of braided absorbable suture material, nr 0; then, the muscle fibers were spread apart, and the posterior sheath of the rectus abdominis/peritoneum was identified.

(2) The posterior sheath and the peritoneum were lifted, and an incision of about 2–2.5 cm was made. The purse string suture was prepared and, finally, a 12 mm Hasson trocar was introduced in the peritoneal cavity.

(3) Pneumoperitoneum was obtained by inflating CO₂, through the Hasson trocar (VersaOne^TM Medtronic Italia SpA, Milan, Italy) to maintain an abdominal pressure around 8–10 mmHg, under videoscopy using a 5 mm camera; two other 5 mm trocars were inserted in the right hemiabdomen, one subcostal (Figure 2-C) and one in the right flank (Figure 2-D), similar to the procedures performed under general anesthesia.

(4) The catheter passed through the 12 mm trocar with the distal tip positioned in the Douglas pouch (rectal–bladder space); an internal suture fixation of the catheter to the abdominal wall on the midline (Figure 2-E) was performed by using a Reverden needle with a suture thread (non-absorbable monofilament—2/0).

(5) The trocars were removed under videoscopy. A cuff was positioned above the peritoneum, the purse string suture was pulled up, and catheter functioning was tested with PD fluid; once it was ascertained that the suture was tight, the anterior sheath of the rectus abdominis was finally closed.

(6) After the deep cuff was secured between the anterior and posterior rectus sheaths, the catheter was tunneled subcutaneously to an exit site via a counter-opening in the left iliac fossa/flank (Figure 2-B). All the surgical incisions were sutured.

2.4. Data Collection

Medical and surgical history, demographics, and laboratory data were collected at baseline, before surgery. The eGFR was calculated by the 2009 CKD-EPI creatinine equation. Length of surgical and anesthesiologic procedures were reported. We registered the onset of post-operative mechanical complications such as catheter dislocation, omental wrapping, leakage and onset of bleeding, vessel lesions or gut perforation. During the follow-up, similarly we collected information about the onset of mechanical complications but also infective complications related to PD, death, kidney transplantation and shift to hemodialysis.

2.5. Statistical Analysis

Continuous variables were reported as either mean and standard deviation (SD) while categorical variables were reported as percentages. The data were analyzed using SPSS version 26 (IBM, Armonk, NY, USA). Our institutional review board approved the study (committee: University of Campania Luigi Vanvitelli; ID: 1257; date: 17/11/2016).

3. Results

Baseline characteristics of enrolled patients are reported in

Table 1. Basal features of patients who underwent PD catheter implantation by the new technique.

Patient	Age	Gender	GFR	BMI	Kidney Disease	DM	CVD	Prior Abdominal Surgery	Concomitant Surgery
1	44	M	8	29.7	Unknown	NO	NO	Inguinal hernia + sleeve GS	NO
2	58	M	9	27.4	GN	NO	NO	NO	NO
3	33	M	7	24.2	DKD	YES	NO	NO	NO
4	22	M	7	35.0	Unknown	NO	NO	NO	NO
5	62	M	8	25.2	HTN	NO	NO	NO	NO
6	65	M	10	25.3	DKD	YES	NO	NO	NO
7	71	F	9	28.2	DKD	YES	NO	NO	NO
8	71	M	8	24.5	Unknown	NO	YES	Inguinoscrotal hernia	Inguinal hernia
9	71	M	10	23.2	TIN	YES	YES	Cholecystectomy	NO
10	71	M	10	28.3	GN	NO	NO	Inguinoscrotal hernia	Inguinal hernia
11	56	F	9	29.7	Unknown	NO	NO	NO	NO
12	44	F	10	35.5	TIN	NO	NO	NO	NO
13	53	M	9	27.4	Unknown	NO	NO	NO	NO
14	69	F	10	31.4	Unknown	NO	YES	NO	NO
15	62	M	7	28.5	Unknown	NO	NO	NO	NO
16	46	F	6	25.4	Unknown	NO	NO	NO	NO
17	74	M	7	26.4	DKD	YES	NO	NO	NO
18	52	M	8	34.8	DKD	YES	YES	NO	NO
19	69	M	8	26.3	Unknown	NO	YES	NO	NO
20	69	F	3	24.9	ADPKD	NO	YES	NO	NO

GS, gastrectomy; GFR, glomerular filtration rate; CVD, cardiovascular disease; DM, diabetes mellitus; BMI, body mass index; GN, glomerulonephritis; DKD, diabetic kidney disease; TIN, tubular–interstitial nephropathy; HTN, hypertensive nephropathy; ADPKD, autosomal dominant polycystic kidney disease.

. The mean age was 58 ± 14 years; 30% were female and mean body mass index (BMI) was 28 ± 4 Kg/m². The baseline estimated GFR was 8 ± 2 mL/min; 30% of patients were diabetic and 30% had CVD. A previous abdominal surgery was reported in about 20% of the cohort.

3.1. Post-Operative Outcomes

The entire surgical procedure had an average duration of 56 ± 16 min including the regional anesthetic procedure. Two patients underwent inguinal hernia correction concomitant with catheter placement. We registered only one episode of dislocation with outflow failure 10 days after surgery in a patient with a large scrotal hernia, whose video-laparoscopic review showed the loss of the catheter’s suture to the abdominal wall and an omental wrapping; the dislocation and wrapping were corrected during a review procedure without a need for catheter removal. No major complications such as bleeding, vessel lesions or gut perforation were reported. No patient needed intravenous treatment for pain control, and all procedures were well tolerated without any sign of systemic toxicity related to local anesthetic used. All the patients started dialysis treatment after a break-in period of 14 days and no urgent start was needed. No episodes of early leakage were reported.

3.2. Long-Term Outcomes

During a median follow-up of 21 months [IQR, 15–35], no mechanical complications were reported. Six patients needed a shift to hemodialysis (five for ultrafiltration failure; one patient had burn-out of PD technique); three patients died, while one underwent kidney transplantation. Two patients had an episode of exit-site infection resolved by antibiotics. No cases of peritonitis occurred.

4. Discussion

We have developed a new ALS approach with a simple technique that does not require general anesthesia for PD catheter placement. According to our results, this is a simple and well-tolerated technique that offers several advantages.

First, the use of a mini (less)-invasive surgery allows an early recovery with the patient being able to move autonomously as soon as 12 h after the procedure. Indeed, it is well known that the postoperative pain’s intensity after a laparoscopic procedure is lower than that after a conventional OS [5,6,7]. Second, suture fixation of the catheter distal tip or a lower abdominal suture sling to promote pelvic orientation of the catheter with ALS could reduce the risk of mechanical complications such as dislocation or catheter migration [7]. Third, due to the application of regional anesthesia, this technique can also be conducted safely in uremic patients as it allows avoiding the risks dependent on general anesthesia in the multimorbid population of patients with ESKD. The main cause of discomfort and pain with classical ALS was related to CO₂ used for pneumoperitoneum; in fact, insufflation of CO₂ gas causes immediate and profound acidification of the parietal peritoneum. Specifically, it is well recognized that CO₂ dissolves in tissue fluids; it pushes the reaction equation towards carbonic acid and the release of protons. Tissue acidosis is known to trigger nociceptor stimulation and pain, possibly originating from proton-gated acid-sensing ion channels of peripheral nerve fibers in the peritoneum. With TAP and QLB blocks, we have optimal pain control without the need for general anesthesia.

Previous studies have also evidenced that laparoscopy could be feasible under regional anesthesia by infiltrating the soft tissue and peritoneum with lidocaine HCL-1% [12,13,14]; however, the TAP block associated with QLB block could guarantee better post-operative pain control and more comfort for the patient [15]. An interesting experience was also reported in older ESKD patients with thoracic spinal anesthesia, thus supporting the advantages related to ALS in the absence of general anesthesia [16]. A laparoscopy with regional anesthesia (epidural, spinal) has been described for gasless laparoscopic surgery and it has been used in the gynecological field and for cholecystectomy; it could also be an interesting alternative for PD catheter placement. However, the QLB and TAP block used in our approach did not require lumbar puncture and, potentially, could be more tolerated by the patients. Finally, another interesting procedure is the use of a very small laparoscope for visual aid in placement of catheters by peritoneoscopy; this procedure utilized a 2.2 mm scope and manual air inflation, in patients receiving only local anesthesia and mild sedation if needed [17].

The main limitations of our study are the monocentric nature of this preliminary report and the absence of a control group; a large randomized controlled trial comparing the outcomes in terms of efficacy and mechanical complications between OS and ALS without general anesthesia is therefore needed. Furthermore, the group of patients enrolled is very heterogeneous. There are several very young ones, with a very good BMI and no need for concomitant surgical repair. This new technique is probably more suitable to offer the possibility of PD catheter implantation in high-risk fragile patients such as those with cardio-renal disease. However, we considered that this approach could be potentially useful for all patients with the advantages of the laparoscopy technique to prevent mechanical complications and the possibility to overcome the limits related to general anesthesia.

5. Conclusions

In conclusion, ALS without general anesthesia might be a safe technique for peritoneal catheter implantation in patients with advanced CKD because it ensures a well-performing catheter and limits the risk of mechanical complications. This new technique may increase the number of patients enrolled for PD.