W. Back1, O. Obaid1, T. Torres-Ruiz1, J. Sferra2 1The University of Toledo College of Medicine and Life Sciences, Department Of Surgery, Toledo, OH, USA 2Promedica Toledo Hospital, General Surgery, Toledo, OH, USA
Introduction:
Advanced laparoscopic techniques such as rectus sheath tunneling and lysis of adhesions have expanded patient eligibility for laparoscopic PD catheter placement. However, rare circumstances of complex incarcerated ventral hernias and extensive abdominopelvic adhesions have proven prohibitive. The introduction of the robotic surgical platform has allowed more precise and safe dissection in intra-abdominal surgery, but there is no reported use of robotic assistance in PD catheter placement. This study aims to describe the use and outcomes of robotic-assisted laparoscopic PD catheter placement.
Methods:
This was a retrospective case series over a 2-year period (2021-2023) at a large tertiary US hospital. We included adult chronic kidney disease (CKD) patients undergoing robotic-assisted PD catheter placement. The indication for robotic assistance over pure laparoscopic placement was abstracted, along with demographics, socioeconomic characteristics, comorbidities, intraoperative details, and postoperative dialysis clinic visit compliance. Outcomes included long-term PD catheter related infectious and mechanical complications, and catheter survival.
Results:
We identified 20 patients. The mean age was 69 years, mean BMI was 32, 70% of patients were male, and 75% were White. All patients had CKD (60% CKD V, 30% CKD IV, 10% CKD III) with varying comorbidities, and most (60%) were currently undergoing hemodialysis treatment at the time of surgery. The most common indication for robotic assistance was concurrent hernia repair (average hernia defect size of 3.1 cm, 12.5% were incarcerated, with 81% of patients undergoing mesh placement), followed by extensive abdominopelvic surgical history (50% hysterectomy, 30% prostatectomy, 20% colectomy), then prior PD catheter failure due to extensive adhesions (10%). Omentopexy was employed in 15%, rectus sheath tunneling in 100%, and lysis of adhesions in 85%. Average OR duration was 1 hour and 59 minutes with mean EBL of 11 ml. Average follow-up duration was 11 months. Early (<4 weeks) and late (>4 weeks) exit-site infections occurred in 0%, catheter leakage in 15%, peritonitis in 15%, and catheter displacement in 10%. Overall, 40% required catheter revision/replacement. Over the study period, 55% patients underwent catheter removal, most commonly due to inadequate dialysis (27%), followed by catheter-related infections (18%). Average time to catheter removal was 236 days.
Conclusion:
Our study describes a novel use of the robot surgical platform, potentially broadening the eligibility of patients for PD utilization. Robotic-assisted PD catheter placement is safe and effective for patients with prohibitive adhesions from previous major abdominopelvic surgical history and those with large complex incarcerated ventral hernias at the time of hernia repair. This was not associated with a substantially higher rate of infectious or mechanical complications compared to the previously reported literature on pure laparoscopic placement. Although catheter removal rates were higher than expected, the surgical complexity of our patient population must be considered.