Crabtree J H
Department of Surgery, Southern California Permanente Medical Group, Kaiser Permanente Bellflower Medical Center, Bellflower, CA 90706, USA.
Kidney Int Suppl. 2006 Nov(103):S27-37. doi: 10.1038/sj.ki.5001913.
Many burdensome interventions that adversely affect the utilization of peritoneal dialysis as renal replacement therapy and patient satisfaction with this treatment modality can be avoided by early peritoneal access placement with embedded catheters, implantation techniques that preempt common catheter complications, and the use of access devices that provide flexibility in exit site location. Catheter embedding consists of subcutaneously burying the external limb of the catheter tubing at the time of the insertion procedure. Interval exteriorization of the catheter is performed when dialysis is needed. Earlier commitment by patients to peritoneal dialysis can be achieved by elimination of catheter maintenance until dialysis is necessary. Catheter embedding is a practical strategy to avoid temporary hemodialysis with vascular catheters and reduces stress on operating room access by allowing more efficient scheduling as non-urgent procedures. Laparoscopic catheter placement enables proactive techniques not available to other conventional insertion methods. These techniques include rectus sheath tunneling to prevent catheter tip migration, selective prophylactic omentopexy to prevent omental entrapment, selective resection of epiploic appendages to prevent catheter obstruction, adhesiolysis to eliminate compartmentalization, and diagnosis and simultaneous repair of previously undiagnosed abdominal wall hernias. Both standard and extended 2-piece catheter systems are necessary to customize the peritoneal access to a variety of body configurations. Catheters should be able to produce lower abdominal, mid-abdominal, upper abdominal, and upper chest exit site locations that facilitate management by the patient without sacrificing deep pelvic position of the catheter tip or resulting in excessive tubing stress during passage through the abdominal wall.
通过早期植入带嵌入式导管的腹膜通路、采用可预防常见导管并发症的植入技术以及使用能在出口部位定位上提供灵活性的通路装置，可以避免许多对腹膜透析作为肾脏替代疗法的使用以及患者对这种治疗方式的满意度产生不利影响的繁重干预措施。导管嵌入是指在插入过程中将导管 tubing 的外部肢体皮下埋入。在需要透析时进行导管的间歇性外置。通过在透析必要之前消除导管维护，可以使患者更早地接受腹膜透析。导管嵌入是一种实用策略，可避免使用血管导管进行临时血液透析，并通过允许更高效地安排非紧急手术来减轻手术室通路的压力。腹腔镜导管置入可采用其他传统插入方法无法实现的主动技术。这些技术包括腹直肌鞘隧道术以防止导管尖端移位、选择性预防性网膜固定术以防止网膜包裹、选择性切除网膜附件以防止导管阻塞、粘连松解以消除分隔以及诊断并同时修复先前未诊断出的腹壁疝。标准和加长的两件式导管系统对于根据各种身体构型定制腹膜通路都是必要的。导管应能够产生下腹、中腹、上腹和上胸部出口部位，便于患者进行管理，同时又不牺牲导管尖端的深盆腔位置，也不会在穿过腹壁时导致过多的 tubing 应力。
