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Laparoscopic rescue of dysfunctional Tenckhoff catheters in continuous ambulatory peritoneal dialysis patients.

Dr. Seh-Huang Chao, MD, Department of Surgery, National Taiwan University Hospital, No. 1 Chang-Te St., Taipei, Taiwan (ROC) Dear Sir, Among uremic patients on continuous ambulatory peritoneal dialysis (CAPD), mechanical dysfunction of Tenckhoff catheters can occur either as a result of inner chamber obstruction or omental entrapment [l^l·]. Failure to recover the drainage function of the original catheter by intracatheter irrigation with fibrinolytic agents like streptokinase or urokinase should be followed by surgical reposition or replacement of the catheter; otherwise, abandon of the CAPD management can be the result [5,6]. We report a novel approach using a laparoscopic technique to rescue the dysfunctional Tenckhoff catheter in 2 patients on CAPD. Two male uremic patients, aged 32 and 37, with a Tenckhoff catheter at the left parame-dian site of the lower abdomen for CAPD, were found to have progressive drainage dysfunction of the catheter 1 and 2 months, respectively, after the catheter implantation. Repeated rescue attempts using a streptokinase solution (50,000 U/100 ml of normal saline. Streptase Behring Institute) to irrigate the catheters had been tried in vain for both patients before performance of laparoscopic procedures. Laparoscopic procedures were performed under general anesthesia with endo-tracheal intubation for the 1st patient. For the 2nd patient, the procedures were performed only with local perfusion of a 2% xylocain solution around the sites for trocar insertion. To the 2nd patient, gas containing 60% oxygen was insufflated via ventilation mask during the operation. The laparoscopic procedures were initiated by introducing a gas-insufflation needle through the right pararectus site of the abdomen. After C02 gas was insufflated into the peritoneal cavity of the patient and maintained at a pressure of 15 mm Hg, a 10-mm trocar port (AutoSuture Co, USA) and a 5-mm trocar port were introduced through the right pararectus area of the abdomen. There was a 15-cm distance spanned between the two ports. In this procedure, the 10-mm port was used for introducing the laparoscope, and the other port was used for introducing hand instruments. In both patients, the Tenckhoff catheters were found to be almost completely wrapped by the greater omentum in the lower peritoneal cavity (fig. la). Some adhesive bands hooking the omentum to the parietal peritoneum were visible around the inlet site of the catheter. The catheter rescue was started by adhesiolysis and catheter mobilization which was performed with the aid of dissecting forcepts (fig. lb, c). Mibilization of the whole entrapped catheter