Placement of a chronic ambulatory peritoneal dialysis (CAPD) catheter is usually indicated largely for patients with chronic kidney disease (CKD) stages 4 or 5 or with a reduced glomerular filtration rate of less than 20 to 30 cc/min. Such patients will have discussed the suitability of peritoneal dialysis versus hemodialysis with their nephrologist. In general, peritoneal dialysis is preferred over hemodialysis for patients with poor cardiac function, prosthetic heart valves, significant vascular disease, hemodialysis vascular access failure, difficult access to a hemodialysis center, and young age OR small body habitus that makes vascular access for hemodialysis challenging. Candidates for CAPD insertion should be deemed capable of maintaining appropriate sterile techniques when using the catheter to avoid developing bacterial peritonitis due to contamination of the catheter. Intra-abdominal adhesions resulting from previous abdominal surgeries or peritonitis can complicate successful CAPD insertion.
The day of surgery the patient should have electrolytes checked to verify the absence of hyperkalemia. Diabetic patients should have their blood glucose checked prior to initiation of the procedure, as well as during the procedure with correction of hyperglycemia when identified. Antibiotic prophylaxis directed at covering skin flora is administered within 1 hour of the procedure. Determination of the catheter exit site is made with the patient standing to ensure the exit site can be seen by the patient for ease of daily exit site care (especially important in the obese patient) and to avoid the beltline.
Local anesthesia accompanied by sedation is adequate for most patients. General anesthesia can be used for patients unwilling or unable to tolerate local anesthesia.
The patient is placed supine on the operating room table with their arms extended out from the table 90 degrees allowing for easy access to IV sites in the upper extremities and to facilitate the surgeon access to the abdomen without interference from an arm that is tucked to the patient’s side.
The surgeon first verifies that the necessary catheter and stylet are available (figure 1). Any hair within the surgical field is removed with clippers immediately prior to the procedure. The abdomen is prepped from the symphysis pubis to midway between the umbilicus and xiphoid process (or more cephalad), and laterally to the midaxillary line.
A 3- to 5-cm midline, generally infraumbilical skin incision (midline approach), or paramedian skin incision (paramedian approach) in made and dissection is carried down to the fascia. A 2- to 3-cm incision is made through the fascia at the midline (midline approach figure 2a) or through the anterior and posterior rectus sheath with splitting of the rectus muscle (paramedian approach figure 2b). The peritoneum beneath the fascia is tented up and ...