INSERTION OF CHRONIC AMPULATORY PERITONEAL DIALYSIS

INSERTION OF CHRONIC AMPULATORY PERITONEAL DIALYSIS
Indications
1. Chronic ambulatory peritoneal dialysis is suitable for the majority of the patients with chronic renal failure
2. Patient in the remote areas distant from the heamodialysis
3. Any vascular diseases
4. Long term heamodialysis
5. Contraindicated to renal transplantation
6. After renal rejection

Contraindication:

Problems may be anticipated in the following group of patients those who have undergone :
1.Previous abdominal surgery where adhesions may obliterate the peritoneal cavity.
2.Those with large polycystic kidneys causing abdominal distention
3.Those with any abdominal hernias. These should be repaired before the insertion of peritoneal dialysis
4.A Cutanious Enterostomy or urinary diversion are relative but not absolute contraindication to peritoneal dialysis

Pre operative management
1. Staphylococcus aureus is an important pathogen and steps should be taken to identify and treat patients who are carriers of organism
2. Nasal and groin swabs are taken before surgery

Patient Preparation:
1. Position –Patient is positioned on the supine position
2. Anaesthesia—The Anaesthesia preferred is general anaesthesia or local anaesthesia
3. Skin preparation—determine the site of incision , begin the parts preparation, include area from the chest to mid thigh and down to the table at the

sides
4. Draping—four folded towels and a Laprotomy sheet
CAPD trolley
Procedure::
1. Under general anaesthesia, the abdomen is opened through the left or right lower paramedian incision of 2m length.
2. Anterior sheath is opened, rectus muscle is split open.
3. The peritoneum is opened for approximately 1cm or less.
4. Using a Roberts forceps the Oreopoulos catheter is inserted into the peritoneal cavity and positioned in the pelvis in front of the rectum but behind

the bladder ( uterus in women)

Wound Closure
1. The peritoneum is tightly closed around the catheter using a continous 2-0 chromic catgut suture the first of the two Dacron cuffs lying in the

muscle layer.
2. The final sutures may be placed through the cuff itself to encourage secure peritoneal closure this being facilitated by gentle traction on the

catheter . following peritoneal closure
3. Free inflow and drainage are tested using a saline filled syringe
4. The skin exit side is identified such that the second Dacron cuff lies 3cm away from the exit site is the subcutaneous tunnel; through a small stab

incision
5. A sharp plunger / introducer is pushed through the subcutaneocs tissues to the operative wound and the catheter is withdrawn
6. The rectus sheath is sutured with an absorbable suture eg. Dexon as is the deep fascia
7. The skin is sutured with 2-0 nylon
8. A titanium adaptor isintroduced into the end of the catheter and 5ml of dilute heparin solution (1000units/ml) are instilled into the catheter which

is the capped. Separate dressing are applied to the Laprotomy wound and exit site. The catheter is also taped to the skin to prevent excessive movement at

the exit site.
POST OPERATIVE CARE
The catheter should be flushed with 500ml dialysis solution.
Each day until CAPD is commenced. It is advisable to commence peritoneal dialysis 5-10 days after catheter insertion.
Earlier use of the catheter risks leakage of fluid around the catheter.
While a large interval may allow the intestine or omentum to become adherent to the catheter causing poor inflow or drainage.
The exist site dressing is changed daily using aseptic technique

Complication:
Failure of drainage is almost invariably caused by intestine or omentum wrapped around the catheter
Fluid leakage may manifest around the catheter
Pain and swelling into the anterior abdominal wall may occur due to the extravasation of fluid
Sepsis may develop around the cutaneous exit site. Antibiotics should be given.