Tenckhoff CAPD Insertion

Farid Setyono
 Introduction

—  In 1959, Richard Ruben was the first to use

peritoneal dialysis (PD) successfully in a patient
with end-stage renal disease (ESRD) for 6 months

—  Three years later, Fred Boen from the Netherlands

described the first automatic cycling PD machine

—  In 1964, he reported about two patients who were

treated with this machine, with long-term survival
of 2 years
 Introduction

—  In 1968, Henry Tenckhoff developed the indwelling

peritoneal catheter, which was inserted following an
open surgical technique

—  In 1970, he reported about 16 patients being treated

with the self-PD for up to 4 years

—  The PD was popularized by Popovich and Moncrief

who developed continuous ambulatory peritoneal
dialysis (CAPD)
Anatomy
Anatomy
Anatomy
 Physiology : Peritoneal Dialysis

—  Involves the passage of solutes and water across a

membrane that separates two fluid containing
compartments-blood and dialysate

—  During dialysis 3 transport processes occur

simultaneously
—  Diffusion
—  Ultrafiltration
—  Absorption

http://www.dialyse-45.net/int/info/techniques.htm
 Physiology : Peritoneal Dialysis

—  2 types

—  CAPD – continuous ambulatory peritoneal dialysis

—  Involves on average 4 dwells per day of 4-8 hours of 2
– 2.5L each
—  APD – automated peritoneal dialysis
—  Involves 3-10 exchanges overnight of varying amounts
—  Usually but not always a daytime dwell
Physiology : Peritoneal Dialysis
CAPD – continual ambulatory peritoneal
dialysis
NIPD – night intermitent peritoneal
dialysis (cycler)
CCPD – continual cyclic PD
 Indication &
contraindications
•  ESRD
•  80% of patients have no contra-indication to any of the
dialysis methods and may choose according to their
life style between HD or PD
•  Absolute contra-indications of PD:
•  1.peritoneal fibrosis and adhesions following intraabdominal
operations
•  2.inflammatory gut diseases
Relative contraindications of PD

ü  pleuro-peritoneal leakage

ü  hernias

ü  significant loin pain

ü  big polycystic kidneys

ü  significant decrease of lung functions

ü  diverticulosis

ü  colostomy

ü  obesity

ü  blindness
 INSTRUMENTATION

}  Scalpel blade and handle

}  Metzembaom scissors and
Surgical scissor curved
}  Sponge holding forceps
}  Wound and vein Retractor
}  Haemostatic forcep
mosquito pean
}  Needle holder
}  Tissue forcep and
dissecting forcep
}  US army Retractor
}  Sterilized hand scoen
}  Linen set

Glyconate Monofilament 4.0 Plain Cut Gut 3.0 PGA 2.0/1.0

 PICTURE

Metzembaom scissors and

Scalpel blade and handle
Surgical scissor curved

Needle holder
Haemostatic forcep mosquito pean
 PICTURE

Tissue forcep and US army Retractor

dissecting forcep

Sponge holding forceps

 Procedure
Informed Consent

Patient In Supine Position

Disinfection with bethadine 10%

Demarcation of the operation field

Surgical Safety Checklist

 Open surgical technique

—  In this technique, the patient is placed in the supine

position

—  General anaesthesia is inducted and the intravenous

antibiotics are administered

—  A vertical incision of 2-5 cm is made in the midline, 2–3

cm below the umbilicus or Paramedian umbilical
Incition, the incision position is corelated to the
intraperitoneal thankhoff catheter length

—  The subcutaneous layer is dissected, till the sheath of the

rectal abdominal muscle is reached.
ü  The anterior rectus
sheath is opened and
the muscle fibres are
bluntly dissected.

ü  Subsequently, the
posterior sheath is cut
to 3–4 cm and the
abdominal cavity is
opened after dissecting
the peritoneum.
—  The abdominal wall is inspected for adhesions
—  After this, a retractor is used to lift the anterior
abdominal wall.

—  The patient is placed in a Trendelenburg position and the

catheter is placed over a stylet and advanced into the
peritoneal cavity.

—  The intraperitoneal segment is slid off the stylet and the

cuff is advanced to the peritoneal layer à tabac sac
suture with PGA 2.0 and performe fixation suture
between Cuff and Peritoneum
—  A tunnel is created to the preferred exit site using a needle and
care should be maintained to ensure that the exit site is facing
downward.

—  The distal cuff is placed subcutaneously, 2 cm from the exit

site.

—  After haemostasis, the incision is closed (Fascia, subcutaneous

and skin) and the catheter itself is not fixated with a suture.

—  The functioning of the catheter is tested by filling the abdomen

with 100 cc saline and the entrance site is checked for leakage.

—  The saline is allowed to drain and isinspected for evidence of

haemoperitoneum and faecal contamination.
 Post surgical care

Wound Care
Analgetics
if Needed

Wound
Clossing
 COMPLICATIONS

Catheter misplacement
Perforation of Hollow Organ
During Injury of intraabdominal organ
operation Bleeding
HaematoPneumoPeritoneum

Peritonitis
Early Diarrea

Enterocutaneous fistule
Late Peritonitis
SSI