Although the pediatric surgeon’s role in the care of the child with end-stage renal disease is primarily technical, it is extremely important that every detail of the operation to place a peritoneal dialysis catheter be performed with the utmost care. For children with renal failure, these catheters are lifelines and any complication can have profoundly deleterious effects. This means that the catheter must work reliably, without leakage, and the risk of infection should be minimized. I find little advantage to the laparoscopic approach except for some redo operations and to troubleshoot a malpositioned or poorly functioning catheter. The critical maneuvers are to use an appropriate-length curled catheter placed carefully in the pelvis, to place a precise purse-string suture, to perform a partial omentectomy, to tunnel the catheter in such a way that it stays in the pelvis, and to close all layers with running suture to prevent leaks.
The catheter should be placed as though it were permanent: don’t cut corners so that it will be easier to remove it someday. A catheter placed on the right side will usually find the right place in the pelvis more easily because the sigmoid colon is less likely to get in the way. The stylet used to place the catheter is usually very long and can easily become contaminated on the surgeons mask or an unsterile object outside the field, in which case it must be removed from the field and replaced with a new one. Place the purse string with small bites before entering the peritoneum and catch a tiny bite of cuff so that it stays snug against the posterior rectus sheath. The catheter should be brought out the lateral aspect of the rectus sheath so that the anterior sheath can be closed water-tight. A second cuff is generally superfluous. Finally, do not leave the operating room until the catheter functions perfectly and there is zero leakage; otherwise, you will be sure to return in the near future to repair or replace it. You should have the confidence to let the nephrologists use it the night of surgery, if this becomes necessary.
Inguinal hernias are probably not caused per se by the dialysis but it is more likely that a pre-existing hernia is made clinically apparent sooner due to the increased intra-abdominal pressure created by the infusion of dialysate. Given that repair of these hernias can be challenging and prone to recurrence, perhaps it makes sense to use laparoscopy to assist in the placement of the catheter (this would obviate the need for fluoroscopy) and rule out the presence of an inguinal hernia. Removal of the catheters can be difficult due to the adhesions at the cuff. It is ideal (but probably not critical) to close the peritoneum to prevent leaks and hernias. A rare but devastating complication of peritoneal dialysis is sclerosing encapsulating peritonitis (SEP), which causes recurrent bowel obstruction and chronic bowel dysfunction. The cause is unknown but it is clearly associated with the use of chlorhexidine-based antiseptics (formerly used to clean the tubing and equipment used for peritoneal dialysis) and immunosuppression. Treatment includes radical excision of the extensive fibrotic peel that envelops the bowel, but the recurrence rate and mortality are high.