Percutaneous reduction of omental prolapse following temporary peritoneal dialysis in a child.

Prolapse of omentum through peritoneal dialysis (PD) catheter puncture site is a rare complication of PD, and there is no well-established guideline for management of omental prolapse. We report a case of omental prolapse through rigid PD catheter puncture site following removal of the catheter in a 3-year-old child and describe a technique for percutaneously reducing omental prolapse which could be performed by the nephrologist at the bed side. A 3-year-old male child who was on medical management for end-stage renal disease resulting from infantile nephrotic syndrome presented with profound uremic manifestations necessitating urgent start of PD. A pediatric rigid PD catheter (3 mm external diameter) with stylet was inserted about 1 cm above the umbilicus over the linea alba. Continuous exchange PD was performed for 48 h, and there was resolution of uremic manifestations. The rigid catheter was removed, and the puncture wound was left open since there was leakage of residual fluid. Four hours later omentum prolapsed through the puncture wound and the prolapse increased to attain a length of 3 cm during the next 4 h (Figure 1(a)). Abdomen remained soft and omentum appeared viable with pinkish hue and reddish submucosal capillary striae. Surgical reduction under general anesthesia with fascial closure was contemplated, however, considering the delay and complexity with such approach, percutaneous reduction of prolapsed omentum was attempted. Under intravenous midazolam sedation and local anesthesia, the distal part of the omentum was held with a non-toothed forceps and the proximal part emerging from the skin was gradually pushed millimeter-by-millimeter back into the peritoneal cavity through puncture site, using the tip of a disposable syringe. The last trace of omentum was pushed deep into the abdomen by inserting the entire length of the tip of the syringe into the puncture site. Abdomen after reduction of prolapsed omentum is shown in Figure 1(b). Skin and superficial fascia at the puncture site were closed with one through stitch. The procedure was performed at the bed side and completed in about 20 min. Prophylactic antibiotic was prescribed. A week later, the child appeared well, abdomen was soft, and there was no incisional hernia. Although rigid PD catheters are less preferred to flexible catheters, they find their utility in the treatment of acute kidney injury in resource poor setting. Omental prolapse following PD is a surgical emergency and prompt reduction is needed to prevent infection. There are scarce data on management of omental prolapse following PD. Backman et al., reported prolapse of omentum through a 2-mm