Should the “Trocar and Cannula” Method be used for Peritoneal Catheter Implantation?

Peritoneal dialysis (PD) catheters are often described as the lifeline of end-stage renal failure patients receiving PD. There is no PD catheter that is definitely better than the conventional double-cuffed Tenckhoff catheter (1,2) and, in general, it is implantation technique rather than catheter design that determines the outcome of the catheter. To achieve good results, implantation must be performed by a competent, experienced, catheter insertion team.

Initially, Tenckhoff catheters were implanted as a surgical procedure by surgeons using a mini-laparotomy technique. This is still the reference standard to which other implantation techniques should be compared. However, referral to surgeons may cause delay in initiating PD therapy, for both the waiting time to see a surgeon and the time required to arrange the operation afterward. The date of implantation is often not under the control of nephrologists and this may make timely implantation of a PD catheter an impossible dream. Some patients may be forced to remain on hemodialysis for months before PD catheters are implanted and they then may become reluctant to change modality to PD. Moreover, although it is a relatively minor surgery, the implantation operation requires dedication and attention to detail by the operator to yield good results. In many centers, such dedicated surgeons are not easily found, resulting in poor catheter outcomes. Therefore, nephrologists are often driven to take on catheter implantation themselves.

The success of PD access procedures performed by nephrologists using various techniques has been well documented (3-7) and increases in PD utilization may result where catheter implantation by nephrologists is introduced (6,8). “Trocar and cannula” and Seldinger techniques are the usual catheter implantation methods employed by nephrologists. These procedures are relatively simple to perform, have a short learning period, and can be performed in a clean side-room.

The trocar and cannula technique using the Tenckhoff trocar was the first method adopted by nephrologists for implantation of Tenckhoff catheters. With this technique, the trocar's sharp pointed stylet is pushed through the linea alba into the lower abdomen. After entry into the peritoneal cavity, the stylet is removed and the Tenckhoff catheter is passed with a stiffening stylet into the peritoneal cavity toward the pelvis. The side pieces of the trocar are removed with the internal cuff of the catheter situated above the linea alba. A subcutaneous tunnel is then created for the exit of the catheter. There is no suturing of the peritoneum or the linea alba. This technique is easy to perform but, due to its blind and blunt entry into the peritoneal cavity with the sharp and thick trocar, complications are common. Leakage of dialysate has been reported in 14% – 24% of cases (9-13) and more serious complications, such as perforation of the bladder or bowel and even laceration of the spleen, have been reported (14,15). The true incidence of these serious complications may be higher as many cases are probably not reported in the literature.

The Seldinger technique was developed to improve the results of bedside PD catheter implantation. With the Seldinger approach, a guidewire is inserted through a priming needle. An introducer, dilators, and a peel-away sheath are then inserted along the guidewire. The guidewire is removed and the PD catheter is inserted with a stiffening stylet through the sheath, as in the trocar and cannula technique. The peel-away sheath is separated and removed and the subcutaneous tunnel is created in the usual way. In contrast to the trocar and cannula technique, this technique is less traumatic and the peritoneal entry site can be located in the lower midline or can be paramedian through the rectus muscle. Although it is also a blind procedure, reported complication rates are much lower compared to the trocar and cannula technique and are comparable to the surgical approach (7,16). However, the cost of the disposable dilators and peel-away sheath may make it unaffordable in certain dialysis centers, particularly those in developing countries.

In recent years, there has been an increase in utilization of peritoneoscopic insertion of PD catheters by nephrologists. This method adopts the Seldinger technique for catheter placement but allows direct visualization of the peritoneal cavity, thus avoiding placing the catheter under bowel loops, under omentum, or against adhesions. It can also be performed in side-rooms under local anesthesia; good results have been reported (3,17). Although peritoneoscopic implantation of PD catheters provides direct visualization, the introduction of the peritoneoscope still involves blind insertion through the abdominal wall; therefore, bowel perforation remains a potential serious complication (8). The major limitation of this approach is the high cost of the peritoneoscope system and the disposable consumables.

In this issue of Peritoneal Dialysis International, Varughese et al. report an incident of massive hemoperitoneum and shock from laceration of the jejunal mesenteric artery after blind catheter insertion with the trocar and cannula method (18). Blood transfusion and urgent laparotomy were needed. Fortunately, the patient survived. Although the patient was not scared away from choosing PD as the mode of renal replacement therapy, it is certain that this was a very traumatic and dreadful experience for the patient and the whole nephrology team.

To reduce the chance of perforating the bowel or intraperitoneal vessels during blind catheter insertion, 2 L priming fluid, preferably PD solution, should be instilled into the peritoneal cavity before the procedure to keep the viscera away from the anterior abdominal wall. It also helps if the patient tenses up the abdominal wall to make it easier for the operator to recognize the feeling of “giving in” when the introducer is pushed through the abdominal wall. Some centers also advocate the use of real-time ultrasound guidance during the abdominal puncture, avoiding the risk of epigastric artery injury (19). A fluoroscopic technique may also be used to confirm the intraperitoneal location of the needle after a small amount of intraperitoneal contrast is injected (20-22).

To prevent such a disastrous event from happening again, Varughese and his colleagues have begun to adopt open surgical implantation by minilaparotomy for catheter implantation. We have been using this approach in our center for almost 20 years. Several nephrologists have been trained to perform surgical implantation of PD catheters competently. The procedure is performed in an operating room under local anesthesia without anesthetist support. Leakage of dialysate is minimized by tight suturing around the peritoneal opening. Subsequent incisional hernia is prevented by the transrectus muscle approach and suturing of the anterior rectus sheath. In our center, intermittent PD is performed in most patients immediately after implantation and yet leakage is almost absent; catheter malfunction from other causes is also very uncommon (23,24). We have not encountered major complications so far. Compared to percutaneous techniques, the learning time for minilaparotomy is longer. Apart from mastering the surgical steps, the nephrologist has to learn to handle potential intraoperative complications such as arterial bleeding. But once this skill is acquired, the nephrologist will find the satisfaction of freedom from the postoperative troubles of blind implantations and will have the control of arranging the catheter implantation and removal procedures in a prompt time frame.

Should nephrologists continue to use the trocar and cannula method for PD catheter implantation? Although it is the cheapest method and is easy to master, the answer, in our opinion, is no. Blind insertion of the sharp and thick trocar is inherently associated with the risk of viscera perforation or damage, no matter how careful and experienced the operator is. There is no comparable complication rate with the standard minilaparotomy approach. Not only might patients suffer complications, but the bad publicity that results could create a bad reputation among both patients and healthcare workers and thus deter patients from choosing PD. In Malaysia, it has been reported that improvement of PD catheter implantation outcome through the adoption of a peritoneoscopic technique was associated with a dramatic increase in PD utilization (6). Even if there are no dedicated surgeons or operating rooms available to dialysis centers, and if the cost of the Seldinger technique or a peritoneoscopic implantation is unaffordable, the choice of the trocar and cannula technique is still a poor compromise.

The peritoneal catheter is the PD patient's lifeline. Advances in catheter implantation technique and knowledge have made it possible to obtain access to the peritoneal cavity safely and to maintain access over an extended period of time. No single catheter insertion technique suits all PD centers. It is important to review the complication rates of the current practice and modify or adopt other better techniques if needed. Dedication in acquiring the appropriate technique is vital to the success of a PD program. Varughese and his colleagues have set a good example here. After experiencing undesirable complications with the old technique, they tried to improve their techniques by using other means. It is this kind of attitude that will help in improving patients’ catheter outcomes.