Asian Cardiovasc Thorac Ann 2003;11:362-363
© 2003 Asia Publishing EXchange Ltd
Suprahepatic Approach for Peritoneal Dialysis in Neonatal Cardiac Surgery
Anil Kumar Dharmapuram, MCh,
Timothy Boyd Cartmill, FRACS,
Ivatury Mrutyunjaya Rao, MCh
Department of Cardiac Surgery, Al Mafraq Hospital, Abu Dhabi, United Arab Emirates
For reprint information contact: Ivatury M Rao, MCh Tel: 971 2 503 1336 Fax: 971 2 582 2870 email: imrao{at}emirates.net.ae Al Mafraq Hospital, PO Box 2951, Abu Dhabi, United Arab Emirates.
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ABSTRACT
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For peritoneal dialysis of neonates after cardiac surgery under cardiopulmonary bypass, a Tenckhoff catheter was inserted via the sternotomy wound and guided suprahepatically into the abdomen. The technique was used in 84 neonates and found to be safe, simple, and reproducible.
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INTRODUCTION
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There is considerable controversy regarding peritoneal dialysis in neonates after cardiopulmonary bypass for complex cardiac surgery, which is partly due to the lack of a safe technique for insertion of the peritoneal dialysis catheter.1 The use of a silicone catheter via a subcutaneous tunnel in the abdomen was found to improve safety.2 Our experience of a new technique is described.
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TECHNIQUE
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The peritoneal catheter is introduced after administration of protamine at the end of cardiopulmonary bypass. At the lower end of the sternotomy wound below the xiphisternum, the extraperitoneal fat is gently dissected with cautery to expose the glistening peritoneum above the liver. Using a fine right-angled forceps, a subcutaneous tunnel is created towards the right side of the lower end of the wound, and a separate small skin stab incision made. The right-angled forceps is brought out through the skin, and a 42–46-cm silicone Tenckhoff peritoneal dialysis catheter (Quinton Instrument Co, Bothell, WA, USA) is held between the teeth of the artery forceps and withdrawn into the wound. A pursestring suture of 4/0 Tevdek (Deknatel, Inc., Fall River, MA, USA) is made on the peritoneum, and a hole is created in the center with cautery. Using a long curved forceps, the catheter is guided into the abdomen suprahepatically towards the left flank (Figure 1
). The pursestring suture is tied just loosely enough to allow the catheter to be removed. The catheter is fixed at skin level with silk suture. The subcutaneous tissues are approximated in layers with interrupted sutures, to isolate the catheter from the pericardium. The catheter is tested for patency by allowing normal saline to drain into the peritoneum by gravity, and syphon out. It is connected to a closed drainage system for peritoneal dialysis. A postoperative radiograph is shown in Figure 2.
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Figure 1. The catheter is seen in the lower part of the operative wound; the Dacron cuff is above the skin level and the catheter is visualized going into the abdominal cavity above the liver.
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Figure 2. Postoperative radiography in a neonate. The catheter is seen emerging from above the liver and coursing towards the left flank.
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DISCUSSION
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We used this technique in 84 neonates undergoing complex cardiac surgery. In all cases, peritoneal dialysis was performed electively in the immediate postoperative period. The technique was found to be safe, simple, and easily reproduced.
Capillary leak syndrome is common in neonates after cardiopulmonary bypass for complex cardiac surgery. This can cause acute renal failure with increased mortality. Postoperative peritoneal dialysis has been shown to reduce this complication.3 Placement of a peritoneal catheter by the conventional trocar technique may cause bowel perforation and bleeding, especially when clotting factors are abnormal. Bacterial peritonitis is also a cause for concern.1 Some surgeons employ a soft silicone catheter inserted through the infraumbilical or paraumbilical region via a separate small incision.4 In our experience with this technique, there was a considerable incidence of omental prolapse during removal of the catheter; suprahepatic introduction of the catheter was employed to avoid this.
During suprahepatic insertion of the catheter into the peritoneal cavity, there is no fear of injury to the liver as the procedure is performed under direct vision. Because the catheter is inserted superior to the omentum, herniation cannot occur. Furthermore, the relatively small omentum in neonates cannot trap the catheter and displace or occlude it when it is introduced from above. Care must be taken to ensure an adequate length of catheter inside the abdomen to reach the flank for satisfactory drainage. Therefore, a 42–46-cm catheter, depending upon the size of the baby, was selected. The soft silicone catheter is safe and nonirritant, reducing the risk of peritoneal infection or irritation. Use of a low volume (10 mL•kg-1 cycled each hour) and low osmolarity dialysate with a short indwelling time has not caused peritoneal irritation, and the closed drainage system has avoided infection. Removal of the catheter is easy and has not been associated with omental prolapse.
Elective postoperative dialysis in addition to intraoperative modified ultrafiltration markedly reduced edema and renal failure after complex cardiac surgery under cardiopulmonary bypass in neonates. This enabled earlier extubation and reduced the surgical mortality. Suprahepatic introduction of the peritoneal catheter has the advantage of being performed through the operative wound. It can be used routinely in all neonates after cardiopulmonary bypass for cardiac surgery. However, it is not advocated for chronic peritoneal dialysis or for older patients.
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ACKNOWLEDGMENTS
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This technique was taught to us by Professor Richard B Chard, Westmead Hospital, Sydney, Australia.
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REFERENCES
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- Werner HA, Wensley DF, Lirenman DS, LeBlanc JG. Peritoneal dialysis in children after cardiopulmonary bypass. J Thorac Cardiovasc Surg
1997;113:64–70.[Abstract/Free Full Text]
- Swan P, Darwish A, Elbarbary M, Al Halees Z. The safety of peritoneal drainage and dialysis after cardiopulmonary bypass in children. J Thorac Cardiovasc Surg
1997;114:688–9.[Free Full Text]
- Bokesch PM, Kapural MB, Mossad EB, Cavaglia M, Appachi E, Drummond-Webb JJ, et al. Do peritoneal catheters remove pro-inflammatory cytokines after cardiopulmonary bypass in neonates? Ann Thorac Surg
2000;70:639–43.[Abstract/Free Full Text]
- Dittrich S, Dahnert I, Vogel M, Stiller B, Haas NA, Alexi-Meskishvili V, et al. Peritoneal dialysis after infant open heart surgery: observations in 27 patients. Ann Thorac Surg
1999;68:160–3.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
