I. Pre-operative treatment specifications
1. Preoperative preparation.
① Thought preparation, including conversation with the patient himself and the patient’s family, so that the patient can fully understand and appreciate the purpose and risks of the surgery.
② Patient preparation, 1 to 3 days before the proposed surgery, appropriate medication and dialysis treatment, so that the patient’s general condition improves significantly and can successfully withstand the surgery. Prepare the patient as required for surgical abdominal surgery 1 day before the operation, especially instruct the patient to defecate or laxate. On the day of surgery, the patient should have his bladder emptied. Both laxation and bladder emptying are necessary to ensure smooth catheter placement. Prophylactic antibiotics can be administered on the day of surgery. The appropriate catheter is chosen according to the patient’s needs.
(iii) Positioning of the incision and exit: It is best to make the exit avoiding the scar, loincloth area and skin folds, and to mark the location when the patient is seated. The incision is usually positioned in the median or lateral abdomen via the parietal side, which can be positioned so that the deep polyester sleeve is located within the rectus abdominis muscle or under the rectus abdominis muscle. Because the muscle tissue is richly vascularized, it facilitates the growth of fibrous tissue into the polyester sleeve. The paramedian position also provides better structural support and creates a strong fibrous wrap around it, reducing the risk of peritoneal dialysis leakage.
The superior border of the pubic symphysis is used as a body positioning marker for the incision, and the position of the peritoneal portal is adjusted appropriately up and down according to the patient’s height and distance from the pubic symphysis. If a straight Tenckhoff tube with an inner polyester sleeve to the end of 15 cm is used, it is recommended to position the tube around 10.0 cm from the superior border of the pubic symphysis at 2.0 cm next to the midline of the abdomen. In contrast, the inner polyester sleeve of the convoluted tube to the lowest point of the tube is 16.0-18.0 cm, which can be positioned at about 12 cm of the superior border of the pubic symphysis as the insertion position. The tunnel exit is usually horizontal or slightly downward, and the outer polyester sleeve is 1.5-2.0 cm from the exit.
④ Surgical consent form, on the basis of full communication with the patient and his family to sign the surgical consent form, the surgical consent form should not copy the template, must be modified on the basis of the template with the specific condition of the patient to make it relevant to the patient’s reality, the consent form should be read in full by the signatory or read in full by the doctor to the signatory, so that the signatory really knows the significance and risks of the surgery. Chen Feng, Department of Nephrology, Xinqiao Hospital, Third Military Medical University
2.Surgery notification form: need to have the second-line teacher sign before sending to the operating room, otherwise it is regarded as invalid notification.
3.Surgeon’s qualification: The participation of personnel with corresponding surgical qualification announced by the department is required to perform the relevant surgery. Otherwise, it is regarded as a violation of medical operation routine.
II. Intraoperative treatment norms
1.Patient position: The patient should be in a lying position.
2.Patient anesthesia: local anesthesia with 2% lidocaine
3, surgical procedure: under local anesthesia, cut the skin, bluntly separate the subcutaneous tissue, cut the anterior rectus abdominis sheath longitudinally, and bluntly separate the rectus abdominis muscle. Make a small incision in the posterior sheath of the rectus abdominis muscle and/or the peritoneum, so that only the peritoneal dialysis tube can be passed, otherwise it is easy to ooze fluid. The posterior rectus abdominis sheath and/or peritoneum is lifted with hemostatic forceps, and after identifying no misclamped bowel or greater omentum, a loop of purse string is made along the perimeter of the incision to confirm that the greater omentum or bowel is not sutured, otherwise displacement and adhesion of the peritoneal dialysis tubing may occur. When there is more ascites, release some first to reduce tension. Before catheter placement, the polyester sleeve should be adequately soaked in sterile saline to squeeze out the gas inside it to facilitate tissue adhesion to the polyester sleeve and reduce the chance of leakage and infection, and the lumen should be flushed with a small amount of heparin solution.
A metal guidewire is inserted into the peritoneal dialysis tubing (when placing the guidewire, note that the distal end is left about 2.0 cm to avoid damage to the abdominal organs at the end of the metal guidewire) to assist the dialysis tubing to be placed slowly from the surgical port toward the vesico-rectal fossa (utero-rectal fossa for women). Gently lift the peritoneum and insert the peritoneal dialysis tubing gently downward along the abdominal wall. When the patient has the urge to urinate or has resistance, back off 2.0-3.0 cm and then insert it obliquely downward, with a sense of falling out. When inserting the catheter, ask the patient how he or she feels. If the patient feels a feeling of cramping in the perineum or a desire to urinate, the dialysis tube is in the right position. If the patient feels obvious pain in the perineum, the catheter is inserted too deep and can be slowly pushed out 0.5-1.0 cm, so that there is no obvious discomfort in the perineum.
If the dialysis tubing encounters resistance, it may be due to the entanglement of the omentum or the dialysis tubing touching the intestinal loops, which should be withdrawn and reinserted at a different angle. After the catheter is in place, fix the inner polyester sleeve, gently withdraw the guidewire backward, and inject 50-100 ml of saline through the catheter. if water does not come out after injection, it is not advisable to pump back, otherwise the large omentum may be inhaled. if water does not come out, inject about 100-200 ml of water again. if water still does not come out, the peritoneal dialysis tube can be pulled out and reinserted. If the catheter is properly positioned, the patient will feel only bowel movements without pain, and the saline will drain smoothly and in a line. Many patients do not feel anything when the tube is inserted, and there is no sense of emptying, but as long as the tube is inserted in the right direction, there is no resistance, and the saline drains smoothly, it also means that the dialysis tube is placed in the right position.
Next, the peritoneum can be gently lifted upward and the purse tightened under the inner polyester sleeve, taking care not to tie the greater omentum. When tying the first knot, gently pull on the peritoneal dialysis tubing to check for tightness and test the water again to check for seepage and unobstructed flow. If the peritoneum is torn, repair is possible. If the water test is not clear, note whether the purse is tied too tightly. The internal polyester sleeve is buried into the rectus abdominis muscle and the upper end of the anterior sheath is first sutured with 1-2 stitches at a distance of about 5 mm, which can reduce the incisional hernia. Then the tube is sutured from below upward so that the tube travels upward in its natural direction, which can reduce the incidence of peritoneal dialysis tube displacement; and even if there is peritoneal dialysis tube displacement, it can be taught to reset easily.
Then, under the traction of a tunneling needle, a subcutaneous tunnel (usually done with a tunneling needle) is constructed in the fatty layer of the abdominal wall on the left side of the incision, following the natural course of the dialysis tubing, and the peritoneal dialysis tubing is led out with an external titanium tip and a short tube. After checking that the catheter is free of distortion and displacement, the subcutaneous fat and skin incision is sutured, and then the incision and exit are covered with gauze. Install the titanium connector and short tubing.
III. Postoperative treatment specification
1. Precautions: eat a semi-liquid diet on the same day after surgery, take bed rest, and monitor ECG and blood pressure.
2. Bleeding: If a large amount of progressive bleeding is mostly caused by injury to internal organs, dialysis should be stopped and treated appropriately; promptly notify the chief resident and the surgeon, and if necessary, go to the operating room for treatment; if a small amount of blood leaks from the surgical incision, a pressure bandage should be given and close observation should be made, and dialysis can still be continued.
3, dialysis fluid leakage: can leak from around the dialysis tube during the operation, may also leak from the incision after the operation; common in the peritoneal packet suture is not tight, dialysis tube placed too shallow or outward, if found from the incision leakage, should be immediately sutured, bandage; if the leakage is serious, should be re-surgical placement of the tube.
4, poor drainage: mostly due to adhesions or intestinal tubes, large omentum blocking the dialysis tubing hole, the application of heparin saline repeated flushing; if still ineffective, then dialysis should be stopped. Perform abdominal plain film to check whether the dialysis tubing drift tube is displaced, and consider re-tubing if necessary.