Oğünç G, Tuncer M, Oğünç D, Yardimsever M, Ersoy F
Department of General Surgery, Akdeniz University Medical School, Dumlupinar Bulvari, 07070, Antalya, Turkey.
Surg Endosc. 2003 Nov;17(11):1749-55. doi: 10.1007/s00464-002-8586-3. Epub 2003 Jun 19.
Continuous ambulatory peritoneal dialysis (CAPD) is an effective form of treatment for patients with end-stage renal disease. Open insertion of peritoneal dialysis (PD) catheters is the standard surgical technique, but it is associated with a relatively high incidence of catheter outflow obstruction and dialysis leak. Omental wrapping is the most common cause of mechanical problems. The purpose of this study was to determine the efficacy of the laparoscopic omental fixation technique to prevent the obstruction caused by omental wrapping and also to compare this laparoscopic technique with open peritoneal dialysis catheter insertion with respect to postoperative discomfort, complication rates, and catheter survival.
Between March 1998 and October 2001, 42 double-cuff, curled-end CAPD catheters were placed in 42 patients. The outcomes of the 21 patients in whom the PD catheters were placed laparoscopically with omental fixation technique were compared with those of the 21 patients in whom the catheters were placed with open surgical technique. Recorded data included patient demographics, catheter implantation method, early and late complications, catheter survival, and catheter outcome.
Early peritonitis episodes occurred in 8 of 21 patients (38.0%) in the open surgical group (OSG) versus 2 of 21 patients (9.5%) in the laparoscopic omental fixation group (LOFG) ( p < 0.05); late peritonitis episodes occurred in 3 of 21 patients (14.2%) in the OSG versus 1 of 21 patients (4.7%) in the LOFG ( p < 0.05). Early exit site infection occurred in 8 of 21 patients (38.0%) in the OSG versus 4 of 21 patients (19.0%) in the LOFG ( p < 0.05), with many catheter-related problems in the conventional surgical group. There was no outflow obstruction in the LOFG. The conventional procedure was faster than the laparoscopic omental fixation technique. Analgesic requirements and hospital stay were less in the laparoscopic group. Laparoscopic surgery also enabled diagnosis of intraabdominal pathologies and treatment of the accompanying surgical problems during the same operation. Occult inguinal hernia was diagnosed in 2 patients, inguinal hernioplasty was performed in 4 patients, adhesiolysis was performed in 8 patients who had previous abdominal surgery, and liver biopsy was taken in 2 patients. Ovarian cystectomy was performed in another patient during laparoscopic CAPD catheter placement.
The laparoscopic omental fixation technique (described by Oğünç and published in 1999) is a highly effective and successful method for preventing obstruction due to omental wrapping with a better catheter survival. Laparoscopic surgery also allows the diagnosis and treatment of the accompanying surgical pathologies during the same operation.
持续性非卧床腹膜透析（CAPD）是终末期肾病患者的一种有效治疗方式。开放式腹膜透析（PD）导管置入是标准的外科技术，但它与相对较高的导管流出道梗阻和透析液渗漏发生率相关。大网膜包裹是机械问题的最常见原因。本研究的目的是确定腹腔镜下大网膜固定技术预防大网膜包裹所致梗阻的疗效，并将这种腹腔镜技术与开放式腹膜透析导管置入在术后不适、并发症发生率及导管存活情况方面进行比较。
1998年3月至2001年10月期间，42根双套囊、卷曲端的CAPD导管被置入42例患者体内。将21例行腹腔镜下大网膜固定技术置入PD导管的患者的结果与21例行开放式手术技术置入导管的患者的结果进行比较。记录的数据包括患者人口统计学资料、导管植入方法、早期和晚期并发症、导管存活情况及导管结局。
开放式手术组（OSG）21例患者中有8例（38.0%）发生早期腹膜炎，而腹腔镜下大网膜固定组（LOFG）21例患者中有2例（9.5%）发生早期腹膜炎（p<0.05）；OSG 21例患者中有3例（14.2%）发生晚期腹膜炎，而LOFG 21例患者中有1例（4.7%）发生晚期腹膜炎（p<0.05）。OSG 21例患者中有8例（38.0%）发生早期出口处感染，而LOFG 21例患者中有4例（19.0%）发生早期出口处感染（p<0.05），传统手术组存在许多与导管相关的问题。LOFG组未出现流出道梗阻。传统手术比腹腔镜下大网膜固定技术速度更快。腹腔镜组的镇痛需求和住院时间更少。腹腔镜手术还能在同一手术过程中诊断腹腔内病变并处理伴随的外科问题。2例患者被诊断为隐匿性腹股沟疝，4例患者接受了腹股沟疝修补术，8例曾接受腹部手术的患者进行了粘连松解术，2例患者进行了肝活检。在腹腔镜下CAPD导管置入过程中，另1例患者接受了卵巢囊肿切除术。
腹腔镜下大网膜固定技术（由奥贡奇描述并于1999年发表）是预防大网膜包裹所致梗阻的一种高效且成功的方法，导管存活情况更佳。腹腔镜手术还能在同一手术过程中诊断并治疗伴随的外科病变。
