title: Flexible endoscopic single-incision extraperitoneal implant and fixation of peritoneal dialysis catheter: proof of concept in the porcine model.
abstract: BACKGROUND
  Peritoneal dialysis (PD) catheters placed in the pelvic space without anchoring present a high rate of migration. We aimed to assess the feasibility of a single-incision approach, using a flexible endoscopic preperitoneal tunneling for catheter implantation and fixation.
  
  
  METHODS
  Eight pigs were involved in this experimental study. A 2/0 Vicryl loop was sutured at the tip of a PD catheter. In 4 pigs, a 1.5 cm incision was made on the left paramedian line and the parietal peritoneal layer was identified by splitting rectal muscles. A gastroscope was inserted in the incision and advanced in the extraperitoneal space. An exit hole was made in the peritoneum over the low pelvic cavity. A guidewire was left in the abdominal cavity, and the PD catheter was inserted over the guidewire. The endoscope was inserted in the tunnel again, and endoscopic clips were deployed over the Vicryl loop to fix the catheter. In 4 pigs, the PD catheter was inserted laparoscopically using a two-port approach. The catheter's tip was fixed with laparoscopic clips on the Vicryl loop. A strain test to assess the force required to detach clips was performed using a digital dynamometer.
  
  
  RESULTS
  Operative time for flexible endoscopic tunneling was longer when compared to the laparoscopic implant (29.5 ± 4.43 vs. 22.7 ± 2.51 min). Mean force to displace the catheter was similar after flexible endoscopic fixation when compared to laparoscopic clip fixation (5.57 N ± 2.76 vs. 4.15 N ± 1.76).
  
  
  CONCLUSIONS
  Flexible endoscopic extraperitoneal tunneling allows for minimally invasive single-incision PD catheter placement and fixation.
authors.affiliation: IRCAD, Digestive and Endocrine Surgery, University of Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France.
authors.forename: Yu-Yin
authors.initials: YY
authors.lastname: Liu
authors.forename: Michele
authors.initials: M
authors.lastname: Diana
authors.forename: Peter
authors.initials: P
authors.lastname: Halvax
authors.forename: Sungwoo
authors.initials: S
authors.lastname: Cho
authors.forename: András
authors.initials: A
authors.lastname: Légner
authors.forename: Amilcar
authors.initials: A
authors.lastname: Alzaga
authors.forename: Lee
authors.initials: L
authors.lastname: Swanström
authors.forename: Bernard
authors.initials: B
authors.lastname: Dallemagne
authors.forename: Jacques
authors.initials: J
authors.lastname: Marescaux
mesh_terms: D000818:Animals; D002408:Catheters, Indwelling; D019723:Endoscopes; D005240:Feasibility Studies; D005548:Foreign-Body Migration / Q000517:prevention & control*; D010535:Laparoscopy; D023421:Models, Animal; D010530:Peritoneal Dialysis / Q000295:instrumentation*; D010537:Peritoneum / Q000601:surgery; D013552:Swine