Jejunal mesenteric artery laceration following blind peritoneal catheter insertion using the trocar method.

Abstract

Editor: Percutaneous peritoneal catheter insertion for peritoneal dialysis (PD) is widely used and success rates similar to those with open placement are reported. Percutaneous insertion is typically done using either a Seldinger technique or the Trocar method. We report a case where blind percutaneous catheter insertion using the Trocar method resulted in jejunal mesenteric arterial laceration and severe intra-abdominal bleeding. A 56-year-old man with diabetic nephropathy, chronic kidney disease stage 5, and ischemic heart disease presented with fluid overload. He was stabilized with ultrafiltration and hemodialysis over 2 weeks. A month later, he underwent blind percutaneous PD catheter insertion in which the trocar and cannula method was used. After a dose of preoperative intravenous vancomycin and sedation with intramuscular pentazocine, a midline incision 2.5 cm long was made about 2 cm below the umbilicus. The peritoneal cavity was filled with 1.5 L saline using an 18F intravenous cannula. The trocar and cannula were vertically maneuvered to make a point incision in the linea alba big enough to admit the lubricated permanent PD catheter, which was then secured in place by purse-string proline sutures. About 1 L PD fluid was instilled in the peritoneal cavity via the PD catheter. The drain was initially mildly blood tinged. The subcutaneous tunnel was made and the distal end of the catheter exteriorized. The incision wound was closed in layers. The effluent continued to be blood tinged and the patient’s blood pressure began to decrease. Despite two units of whole blood and fluids, the patient continued to be in hypovolemic shock. At laparotomy, the peritoneal cavity was filled with blood: a laceration of the jejunal mesenteric artery was identified and ligated. Further blood transfusions after surgery stabilized the patient. The catheter position and tunnel were left untouched. The laparotomy incision was made in the midline immediately below the incision made for catheter insertion. The patient subsequently underwent regular PD exchanges without any impediment to either inflow or drainage of PD fluid. This is the only such complication that has been experienced in over 30 percutaneous catheter insertions. Blind percutaneous PD catheter insertion is a relatively easy procedure that can be done by nephrologists without requiring a dedicated operation theater and anesthesia time. The procedure is safe when done by experienced personnel. There are two percutaneous techniques. The more common is the procedure using a peel-away sheath with the Seldinger technique (1). The other, using a trocar and cannula, is employed at our center. The laparoscopic and open surgical techniques require obtaining specialized surgical and anesthetic services, are more expensive, and increase the duration of hospital stay. The open surgical method is routinely preferred in those with prior abdominal surgeries with likelihood of adhesions. However, in the blind procedures, there always exists the unavoidable risk of misadventure and surgical backup is necessar y. The technique of catheter insertion using the peel-away sheath obviates the need of the sharp trocar and is less likely to cause injury to viscera. The fluoroscopy-guided procedure is perhaps safer and, although the two have not been directly compared, results and safety are comparable to the directly visualized surgical method (2). While the usefulness remains unproven, the surgical method has been more commonly employed in obese patients (3) and we began to adopt this practice after the occurrence of this complication. Minor hemorrhage following PD catheter placement is usually caused by abdominal wall blood vessel injury and can easily be controlled. Mital et al. (4) reported a retrospective case series of surgical placement of 292 catheters where there was major hemorrhage in 6 patients (2%). However, this was due to perioperative anticoagulation, aspirin use, or thrombocytopenia in all but 1 patient. Smith et al. reported the occurrence of bleeding associated with percutaneous placement of PD catheters in 2 of 31 (6.4%) catheter placements (5). Neither patient required exploration or blood transfusions but settled with PD fluid exchanges. One required transfusion of platelets for thrombocytopenia. When the effluent is bloody with hemodynamic compromise, as in our patient, immediate explorative