Unless otherwise contraindicated due to previous surgery or skin issues, we prefer to place a five-millimeter trocar in the right upper quadrant. It is important to avoid periumbilical incisions, as this location does not provide for adequate visualization of the tunnel, and may lead to future hernia. Entrance into the abdomen is performed using a 5 mm, 0-degree scope as well as an optical viewing trocar. Once the abdomen has been accessed, CO₂ insufflation is begun and the 0-degree scope is switched out for a 30-degree scope. A careful diagnostic laparoscopy is performed.

Before the placement of additional trocars, the location of adhesions and/or previously undiagnosed hernias is appreciated. Additional 5 mm trocars are placed as necessary for adhesiolysis or herniorrhaphy. If no adhesions are present, then a second 5 mm port is routinely placed in the right lower quadrant. Further details regarding lysis of adhesions and concurrent hernia repair are described in further detail below.

Adhesions lead to abdominal and pelvic compartmentalization that can cause incomplete dialysate drainage during PD. Similarly, such scarring can prevent visualization of the posterior abdominal wall where the intramuscular tunnel is to be created. For these reasons, adhesions in the pelvis and lower abdominal wall should be addressed at the time of PD catheter placement. Please keep in mind that excessive adhesiolysis is oftentimes not beneficial for PD catheter function and therefore more superior adhesions can be left alone [4]. Indeed, upper abdominal adhesions between the omentum and the abdominal wall may sometimes serve as a natural omentopexy, keeping the omentum out of the retrovesical space.

If indicated, our practice is to perform adhesiolysis using sharp dissection without the use of an energy device, if possible. Although this method is a bit more tedious, we feel that it minimizes the risk of thermal injury to other intra-abdominal structures. Previous abdominal or pelvic surgery should not be a deterrent to attempting laparoscopic PD catheter placement. However, it is important to realize that intra-peritoneal adhesions are sometimes so severe that the PD catheter cannot be safely placed. Therefore, the possibility that catheter placement may not be feasible should be discussed in detail prior to surgical intervention with any patient who has a history of previous major abdominal and/or pelvic surgery. Nevertheless, we do not feel that prior abdominal surgery is a contraindication to catheter placement as it is impossible to predict the extent of adhesive disease preoperatively [6, 7].

Catheter obstruction or dislodgement is most often caused by the omentum falling into the retrovesicular space and less frequently by the epiploic appendages occluding the PD catheter. Because catheter obstruction is the most common reason for abandonment of PD for HD, it is imperative to preemptively address these causes at the time of PD catheter placement.

In order to determine if the patient requires an omentopexy, the patient is placed into the steep reverse Trendelenburg position. If the omentum falls into the retrovesicular space, then the omentum will have to be retracted out of the deep pelvis. It should be noted that omentopexy is at least equivalent to omentectomy for the management of the omentum in these cases. As omentopexy has decreased associated morbidity, it is the preferred option for the management of the omentum [4].

In order to perform an omentopexy, the patient is placed back into the supine position and a small stab incision is made in the left upper quadrant with an 11-blade scalpel. This incision is usually above the planned PD catheter exit site. The omentum is then retracted into the upper abdomen using a laparoscopic soft bowel grasper. A suture passer with a nonabsorbable suture is used to take several bites of the omentum. The suture is then grasped with a Maryland forceps and the suture passer is withdrawn. Through the same skin incision, but with a different trajectory through the fascia, the suture is handed back to the suture passer and brought out through the skin. The stitch is then used to secure the omentum to the abdominal wall and out of the pelvis (Fig. 8.4). Great care must be maintained in order to remain well away from the transverse colon during this portion of the procedure. The efficacy of the omentopexy is confirmed by placing the patient back into the steep reverse Trendelenburg position to ensure that the omentum no longer falls into the retrovesicular space. If the omentum still falls into the pelvis, then the omentopexy should be redone, either at a point superior to the original incision or with a larger bite of omentum secured to the abdominal wall.

Epiploic appendages are fat-filled projections most commonly found in the region of the sigmoid colon [4]. When small, these appendages do not interfere with PD catheter function. However, these attachments can be up to 15 centimeters in length. The longer the epiploic appendage, the more mobile it is, and the more likely it is to lead to PD catheter occlusion. When these structures are noted to interfere with PD catheter function, there are two options for their management. Firstly, the epiploics can be removed with the use of an energy device. A bowel grasper holds the appendage in place while the energy device is used to amputate it from the colon. Care must be taken to ensure that the site of resection is far enough away from the colon so that the colon does not sustain inadvertent thermal injury. These appendages should be removed either through a 10-mm port or with the assistance of a specimen collection bag if more than one appendage is removed. Far easier in our opinion is to simply secure one or two of the epiploics to the lateral abdominal wall in a manner, which is very similar to an omentopexy (Fig. 8.5). Again, through a two-millimeter stab incision, the suture passer and a permanent suture can be used to ‘lasso’ the distal epiploics and secure them to the upper and lateral abdominal wall. Again, great care has to be maintained when performing this procedure in order to prevent injury to the colon.

Careful consideration must be given to repairing previously undiagnosed abdominal wall or inguinal hernias that are detected at the time of laparoscopy, due to the risk of hernia enlargement or symptom progression with the initiation of PD. The decision to proceed with hernia repair must be considered in the context of the specific risks and benefits of hernia repair in this patient population. Specifically, hernia repair with mesh increases the potential for catheter non-function from omental and bowel adhesions as well as mesh infection should the patient experience PD catheter-associated peritonitis [8, 9]. On the other hand, hernia repair utilizing primary suture repair has led to an unacceptably high rate of recurrence in our experience, except when the hernia defects are quite small. Surgeons must be mindful of these very real risks when deciding how best to manage previously undiagnosed abdominal wall and inguinal hernias at the time of laparoscopy.