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A New Flexible Cannula and Seal to Provide Prolonged Access to the Peritoneal Cavity for Dialysis, Drainage and Other Procedures
,,
THE JOURNAL OF UROLOGY
Vol. 90, No. 1 July 1963 Copyright © 1963 by The Williams & Wilkins Co. Printed in U.S.A.
l 1;
A NEW FLEXIBLE CANNULA AND SEAL TO PROVIDE PROLONGED ACCESS TO THE PERITONEAL CAVITY FOR DIALYSIS, DRAINAGE AND OTHER PROCEDURES KEVIN G. BARRY, GEORGE E. SHAlvfBAUGH
AND
DAVID GOLER
From the Department of 1vletabolism, Division of Medicine, Walter Reed Army Institute of Research, and the Department of Medicine, Walter Reed General Hospital, Washington, D. C.
Improvement in peritoneal catheters, rinsing solutions, and techniques has caused a resurgence in the use of peritoneal dialysis for the treatment of acute and chronic renal failure. 1 Intermittent peritoneal dialysis for treatment of chronic renal failure is being evaluated by Merrill and associates 2 and by Boen and associates.3 To avoid repeated paracentesis in these patients, they have developed rigid plastic conduits which, when surgically implanted and sutured to the abdominal wall at laparotomy, permit prolonged access to the peritoneal cavity. We have devised a self-retaining peritoneal cannula for prolonged use which is introduced through a trocar, fixed, manipulated, and removed without laparotomy or suturing of the instrument to the abdominal wall. A peritoneal sealing device prevents dissemination of peritoneal fluid into tissues surrounding the cannula. DESCRIPTION OF APPARATUS
The apparatus is constructed of polyvinyl chloride (fig. 1). A doughnut-shaped balloon is attached to the flared end of an 18 cm. cannula and fitted with a filling tube. A teflon guide is used to introduce the cannula into the trocar. A plexiglas disc is used to exert counter pressure at the skin surface. A plastic adapter fits into the end of the cannula, and seals the catheter to the cannula. Figure 2 shows the apparatus assembled.
of the cannula is a point in the midline below the umbilicus one-third of the distance to the pubis. Following infusion into the peritoneal cavity of 2 liters of dialysis solution through a 17-gauge needle, the trocar is introduced in the usual manner. The balloon of the cannula con1pressed into its guide is passed through the trocar into the peritoneal cavity. A volume of 0.9 per cent sodium chloride sufficient to distend the balloon (determined prior to sterilization, ordinarily 3 ml.) is introduced through the filling tube using a 22-gauge needle. The tube is clamped and tied with silk suture. The trocar is then removed and the excess suture material cut. The standard nylon peritoneal catheter, lubricated with glycerin, is then introduced through the cannula to the desired depth and position. Slight upward traction is exerted on the peritoneal cannula and the plexiglas disc is applied snugly at the skin surface to maintain the seal between skin and peritoneum. Leakage of peritoneal fluid along the tract between the peritoneal catheter and cannula is prevented by a plastic adapter sealing the cannula to the catheter. At the conclusion of the procedure, the peritoneal catheter is removed. The cannula, left in place, is sealed by folding on itself and applying a sterile dressing. To avoid contamination, the tip of the exposed cannula is trimmed off before the peritoneal catheter 1s again introduced for the dialysis procedure.
METHOD OF USE
The abdomen is prepared in the usual manner for paracentesis. The site of choice for insertion Accepted for publication January 30, 1963. 1 IVIaxwell, !VI. H., Rockney, R. E., Kleeman, C. R. and Twiss, M. R.: Peritoneal dialysis. I. Technique and applications. J.A.M.A., 170: 917924, 1961.
2 Merrill, J. P., Sabbaga, E., Henderson, L., Welzant, W. and Crane, C.: The use of an inlying plastic conduit for chronic peritoneal irrigation. Trans. Amer. Soc. Artif. Intern. Organs, 8: 252-
255, 1962.
3 Boen, S. T., Mulinari, A. S., Dillard, D. H. and Scribner, B. H.: Periodic peritoneal dialysis in the management of chronic uremia. Trans. Amer. Soc. Artif. Intern. Organs, 8: 256-265,
1962.
RESULTS
The cannula has been used in 7 patients for intervals up to 50 days (table 1). Clinical peritonitis confirmed by culture of the peritoneal fluid was present in case 1 prior to cannulation. Appropriate antibiotic therapy and peritoneal dialysis were instituted simultaneously. Clinical and bacteriological evidence of peritonitis rapidly subsided. Postmortem examination, 52 days after the cannula was inserted, revealed only slight granularity of the peritoneum. There was no inflammation about the area of balloon contact. 125
!
I 'I
126
BARRY, SHAMBAUGH AND GOLER 6"
e.
BALLOON FILLED WITH SALINE
@~
~J
g.
FIG. 1. .i\rtist 's sketch of ca°:nula a_nd its component parts: a, balloon; b, cannula; c, filling tube; d., teflon gmde; e, trocar; f, plexrglas disc; g, plastic adapter.
FIG. 2. Apparatus assembled
The cannula has been in place for 50 days in case 6. This patient spends several days at home each week and has experienced no disability from the cannula. Only one trocar insertion for initial placement of the cannula has been required to permit prolonged intermittent access to the peritoneal cavity for multiple dialysis procedures. Figures 3 and 4 show the cannula in place with a peritoneal catheter inserted. The cannula had been in place during the last 12 days of the patient's life (case 2). There has been no clinical or postmortem evidence of trapping of viscera, peritoneal reaction, or other complication attributable to the cannula in any patient.
DISCUSSION
Prolonged access to the peritoneal cavity is required for the treatment of chronic renal failure by repeated peritoneal dialysis. Inherent limitations restrict the ultimate value of conduits in current use. They are constructed of rigid plastic and require surgical fixation within the abdominal wall. The flexible peritoneal cannula should overcome these limitations. Since the instrument is introduced through a standard trocar, insertion may be performed by any physician trained in abdominal paracentesis. The instrument is not sutured nor otherwise directly attached to the
NEW FLEXIBLE PERITONEAL CANNULA AND SEAL TABLE
Case No.
Sex
Age
No. Days Cannula in Place
No. Separate Dialysis Procedures
127
1
Peritonitis at Autopsy
Diagnosis and Remarks
yrs.
1
F
40
52
6
Absent*
2
6 7
M
27 21 49 23 39 34
12 5
4 5
M M M M
1 2 1 3 4 1
Absent No autopsy Absent Absent Still living Absent
3
F
11
20 50 1
:Malignant hypertension, arteriolar nephrosclerosis Chronic glomerulonephritis Acute tubular necrosis Hepatorenal syndrome Chronic glomerulonephritis Lupus erythematosis, nephritis Refractory cardiac failure. Peritoneal balloon ruptured after 12 hours. Cannula withdrawn without difficulty.
* See text.
FIG. 3. Cannula is in place with semi-rigid
nylon catheter inserted for peritoneal dialysis. tissues of the abdominal wall but operates on the principle of moderate pressure exerted between the distended balloon on the peritoneal surface and the plexiglas clamp on the skin surface. The cannula may be manipulated at any time by releasing the plexiglas clamp. It may be withdrawn after aspirating the fluid from the balloon or bursting the balloon by application of excess pressure through the filling tube. The peritoneal catheter may be manipulated during dialysis with a great degree of freedom since the cannula is flexible and not attached to the catheter except externally. There has been no evidence of skin or peritoneal reaction to the implanted cannula.
FIG. 4. Postmortem photograph shows distended balloon resting against peritoneal surface. Nylon catheter is in place. Peritoneum is smooth and glistening and shows no evidence or reaction to balloon.
At our institution, commercially available nylon catheters introduced through a No. 17 Duke trocar have been used for peritonea.J dialysis. Frequently, fluid from the peritonea.I reservoir has disseminated upward around the catheter. A purse-string suture at the skin surface has prevented leakage across the skin but occasionally has diverted fluid into the subcutaneous and deeper tissue planes. In addition, when it has been necessary to leave the skin sutures in place for several clays local inflammation and infection have occurred. The peritoneal seal provided by the new can-
128
BARRY, SHAMBAUGH AND GOLER
nula solves the problems of fluid dissemination and skin sutures. When in place at the site of peritoneal perforation, the distended doughnutshaped balloon forms a seal between the peritoneal reservoir and the peritoneal origin of the potential tract for fluid dissection. The peritoneal seal circumvents the need for skin sutures. The simplicity of placement and the lack of reaction to the cannula suggest that it might be used in many circumstances in which peritoneal drainage or intermittent sampling of peritoneal fluid is required for therapy or diagnosis.
SUMMARY
A simple peritoneal cannula with a seal permits prolonged access to the peritoneal cavity without surgical fixation of the instrument to the abdominal wall. Initial studies in humans suggest that this device may be profitably used for acute and prolonged access to the peritoneal cavity for dialysis, drainage and other purposes. The authors are indebted to Mr. Frank E. Matthews and Mr. Charles Black of Matthews Research, Inc., for assistance in converting the idea to an instrument.
THE JOURNAL OF UROLOGY
Vol. 90, No. 1 July 1963 Copyright © 1963 by The Williams & Wilkins Co. Printed in U.S.A.
l 1;
A NEW FLEXIBLE CANNULA AND SEAL TO PROVIDE PROLONGED ACCESS TO THE PERITONEAL CAVITY FOR DIALYSIS, DRAINAGE AND OTHER PROCEDURES KEVIN G. BARRY, GEORGE E. SHAlvfBAUGH
AND
DAVID GOLER
From the Department of 1vletabolism, Division of Medicine, Walter Reed Army Institute of Research, and the Department of Medicine, Walter Reed General Hospital, Washington, D. C.
Improvement in peritoneal catheters, rinsing solutions, and techniques has caused a resurgence in the use of peritoneal dialysis for the treatment of acute and chronic renal failure. 1 Intermittent peritoneal dialysis for treatment of chronic renal failure is being evaluated by Merrill and associates 2 and by Boen and associates.3 To avoid repeated paracentesis in these patients, they have developed rigid plastic conduits which, when surgically implanted and sutured to the abdominal wall at laparotomy, permit prolonged access to the peritoneal cavity. We have devised a self-retaining peritoneal cannula for prolonged use which is introduced through a trocar, fixed, manipulated, and removed without laparotomy or suturing of the instrument to the abdominal wall. A peritoneal sealing device prevents dissemination of peritoneal fluid into tissues surrounding the cannula. DESCRIPTION OF APPARATUS
The apparatus is constructed of polyvinyl chloride (fig. 1). A doughnut-shaped balloon is attached to the flared end of an 18 cm. cannula and fitted with a filling tube. A teflon guide is used to introduce the cannula into the trocar. A plexiglas disc is used to exert counter pressure at the skin surface. A plastic adapter fits into the end of the cannula, and seals the catheter to the cannula. Figure 2 shows the apparatus assembled.
of the cannula is a point in the midline below the umbilicus one-third of the distance to the pubis. Following infusion into the peritoneal cavity of 2 liters of dialysis solution through a 17-gauge needle, the trocar is introduced in the usual manner. The balloon of the cannula con1pressed into its guide is passed through the trocar into the peritoneal cavity. A volume of 0.9 per cent sodium chloride sufficient to distend the balloon (determined prior to sterilization, ordinarily 3 ml.) is introduced through the filling tube using a 22-gauge needle. The tube is clamped and tied with silk suture. The trocar is then removed and the excess suture material cut. The standard nylon peritoneal catheter, lubricated with glycerin, is then introduced through the cannula to the desired depth and position. Slight upward traction is exerted on the peritoneal cannula and the plexiglas disc is applied snugly at the skin surface to maintain the seal between skin and peritoneum. Leakage of peritoneal fluid along the tract between the peritoneal catheter and cannula is prevented by a plastic adapter sealing the cannula to the catheter. At the conclusion of the procedure, the peritoneal catheter is removed. The cannula, left in place, is sealed by folding on itself and applying a sterile dressing. To avoid contamination, the tip of the exposed cannula is trimmed off before the peritoneal catheter 1s again introduced for the dialysis procedure.
METHOD OF USE
The abdomen is prepared in the usual manner for paracentesis. The site of choice for insertion Accepted for publication January 30, 1963. 1 IVIaxwell, !VI. H., Rockney, R. E., Kleeman, C. R. and Twiss, M. R.: Peritoneal dialysis. I. Technique and applications. J.A.M.A., 170: 917924, 1961.
2 Merrill, J. P., Sabbaga, E., Henderson, L., Welzant, W. and Crane, C.: The use of an inlying plastic conduit for chronic peritoneal irrigation. Trans. Amer. Soc. Artif. Intern. Organs, 8: 252-
255, 1962.
3 Boen, S. T., Mulinari, A. S., Dillard, D. H. and Scribner, B. H.: Periodic peritoneal dialysis in the management of chronic uremia. Trans. Amer. Soc. Artif. Intern. Organs, 8: 256-265,
1962.
RESULTS
The cannula has been used in 7 patients for intervals up to 50 days (table 1). Clinical peritonitis confirmed by culture of the peritoneal fluid was present in case 1 prior to cannulation. Appropriate antibiotic therapy and peritoneal dialysis were instituted simultaneously. Clinical and bacteriological evidence of peritonitis rapidly subsided. Postmortem examination, 52 days after the cannula was inserted, revealed only slight granularity of the peritoneum. There was no inflammation about the area of balloon contact. 125
!
I 'I
126
BARRY, SHAMBAUGH AND GOLER 6"
e.
BALLOON FILLED WITH SALINE
@~
~J
g.
FIG. 1. .i\rtist 's sketch of ca°:nula a_nd its component parts: a, balloon; b, cannula; c, filling tube; d., teflon gmde; e, trocar; f, plexrglas disc; g, plastic adapter.
FIG. 2. Apparatus assembled
The cannula has been in place for 50 days in case 6. This patient spends several days at home each week and has experienced no disability from the cannula. Only one trocar insertion for initial placement of the cannula has been required to permit prolonged intermittent access to the peritoneal cavity for multiple dialysis procedures. Figures 3 and 4 show the cannula in place with a peritoneal catheter inserted. The cannula had been in place during the last 12 days of the patient's life (case 2). There has been no clinical or postmortem evidence of trapping of viscera, peritoneal reaction, or other complication attributable to the cannula in any patient.
DISCUSSION
Prolonged access to the peritoneal cavity is required for the treatment of chronic renal failure by repeated peritoneal dialysis. Inherent limitations restrict the ultimate value of conduits in current use. They are constructed of rigid plastic and require surgical fixation within the abdominal wall. The flexible peritoneal cannula should overcome these limitations. Since the instrument is introduced through a standard trocar, insertion may be performed by any physician trained in abdominal paracentesis. The instrument is not sutured nor otherwise directly attached to the
NEW FLEXIBLE PERITONEAL CANNULA AND SEAL TABLE
Case No.
Sex
Age
No. Days Cannula in Place
No. Separate Dialysis Procedures
127
1
Peritonitis at Autopsy
Diagnosis and Remarks
yrs.
1
F
40
52
6
Absent*
2
6 7
M
27 21 49 23 39 34
12 5
4 5
M M M M
1 2 1 3 4 1
Absent No autopsy Absent Absent Still living Absent
3
F
11
20 50 1
:Malignant hypertension, arteriolar nephrosclerosis Chronic glomerulonephritis Acute tubular necrosis Hepatorenal syndrome Chronic glomerulonephritis Lupus erythematosis, nephritis Refractory cardiac failure. Peritoneal balloon ruptured after 12 hours. Cannula withdrawn without difficulty.
* See text.
FIG. 3. Cannula is in place with semi-rigid
nylon catheter inserted for peritoneal dialysis. tissues of the abdominal wall but operates on the principle of moderate pressure exerted between the distended balloon on the peritoneal surface and the plexiglas clamp on the skin surface. The cannula may be manipulated at any time by releasing the plexiglas clamp. It may be withdrawn after aspirating the fluid from the balloon or bursting the balloon by application of excess pressure through the filling tube. The peritoneal catheter may be manipulated during dialysis with a great degree of freedom since the cannula is flexible and not attached to the catheter except externally. There has been no evidence of skin or peritoneal reaction to the implanted cannula.
FIG. 4. Postmortem photograph shows distended balloon resting against peritoneal surface. Nylon catheter is in place. Peritoneum is smooth and glistening and shows no evidence or reaction to balloon.
At our institution, commercially available nylon catheters introduced through a No. 17 Duke trocar have been used for peritonea.J dialysis. Frequently, fluid from the peritonea.I reservoir has disseminated upward around the catheter. A purse-string suture at the skin surface has prevented leakage across the skin but occasionally has diverted fluid into the subcutaneous and deeper tissue planes. In addition, when it has been necessary to leave the skin sutures in place for several clays local inflammation and infection have occurred. The peritoneal seal provided by the new can-
128
BARRY, SHAMBAUGH AND GOLER
nula solves the problems of fluid dissemination and skin sutures. When in place at the site of peritoneal perforation, the distended doughnutshaped balloon forms a seal between the peritoneal reservoir and the peritoneal origin of the potential tract for fluid dissection. The peritoneal seal circumvents the need for skin sutures. The simplicity of placement and the lack of reaction to the cannula suggest that it might be used in many circumstances in which peritoneal drainage or intermittent sampling of peritoneal fluid is required for therapy or diagnosis.
SUMMARY
A simple peritoneal cannula with a seal permits prolonged access to the peritoneal cavity without surgical fixation of the instrument to the abdominal wall. Initial studies in humans suggest that this device may be profitably used for acute and prolonged access to the peritoneal cavity for dialysis, drainage and other purposes. The authors are indebted to Mr. Frank E. Matthews and Mr. Charles Black of Matthews Research, Inc., for assistance in converting the idea to an instrument.