Laparoscopic Tenckhoff insertion

•Preoperative marking of the site (usually on the pts left side and just below the level of the umbilicus) so that it does not sit in a crease or belt line
•Preop shave and betadine prep
•Betadine prep and square drape
•Ioban
•Surgeon stands on pts right and the tower is at the pts feet.
•If the preop marking is on the pts right side then all the ports and surgeon positions is opposite.
•Most of the tubes/wires come from the feet and place the quiver at the pts left hip.
•First incision is left and caudal of the umbilicus, transverse incision just a bit off the midline to go through the left rectus sheaths.
•Local anaesthetic in skin and peritoneum
•Transverse incision and use S shaped retractors to retract tissue
•Hold up the ant sheath with a stay 3/0 dexon suture on each side of the planned longitudinal incision. Incise the rectus sheath longitudinally b/w the stay sutures.
•Part the rectus muscle with blunt parting dissection of the scissors and S retractors.
•Get down to the post sheath and place an artery forcep in the planned entry point of the port and hold it up, place a running dexon suture around the planned port site as a purse string stitch.
•Incise into the post sheath and place a 12mm port in. This will be the camera port.
•Hold the port in with the ant dexon stay sutures and tie it to the port and hold it anteriorly together with one artery clip.
•Place the other 5 mm port site on the pts right side, one at the level of the 12mm port and the other in the RIF.
•Before putting in the ports using the endoclose. To place a dexon tie in one angle and out another so that the peritoneum can be sealed appropriately at the end. The port is passed through the dexon tie.
•Place the suture through the end of the tenchoff catheter, flatten the needle so that it can come out a 5 mm port. Now pass the suture in through the 12 mm port, place a stitch into the dome of the bladder and bring out of the 5mm RIF port. On the other end of the catheter place a dexon tie.
Use the x2 5mm working ports to place a stitch into the dome of the bladder or the uterus (preferably), so that the catheter stays in the pelvis. Place the stitch first and once it has been passed out of the RIF port then pass the catheter into the 12mm port and adjust the position of the catheter accordingly and bring the other end of the stitch out the RIF port.
•Bring out the stitch through the RIF port and do an extra-corporeal knot and pass it down with a knot pusher, will need 5 throws on maxon or PDS sutures.
•Once secured then bring out the tail end of the catheter making sure that no loops of bowel are caught up in it.
•Make sure the cuff is just above the post sheath and place one throw. Test the catheter and irrigate peritoneal dialysis fluid into the peritoneum 20mls x3 at a time till the fluid out is clear or coming freely.
•Then put the trochar on the end of the catheter and pass it up behind the ant rectus sheath and down and around to the X mark on the skin. Making sure the second cuff on the tenchoff is at least an inch away from the skin.
•Then irrigate dialysis fluid in for 2 minutes and check the outflow. If the fluid coming out is still heavily blood stained then peritoneal irrigation will need to be started in recovery to prevent blockage of the catheter.
•Close the anterior sheath with running maxon suture. Then close the fat with maxon and then skin with a continuous dexon subcuticular stitch.
•Close the other port sites with the dexon ties on the peritoneum with the aid of a stitch pusher and then the skin.

Post op issues:
oIf the peritoneal fluid is blood stained than the peritoneum will need to be washed several times in the post op recovery to prevent clotting
oIf catheter is blocked than it can be mechanical or clot blocking the catheter
oTrial of urokinase can sometimes work to unblock it
oDialysis does not start up for roughly 3 weeks