Ancillary Procedures

Joan L. Walker

INTRAPERITONEAL CATHETER AND PORT PLACEMENT

Procedure Overview

The placement of an intraperitoneal (IP) catheter and access port should ideally occur at the time of resection and staging for advanced-stage ovarian cancer confined to the peritoneal cavity. This requires the preoperative expectation that cancer will be found and subsequent consent for planned chemotherapy on a clinical trial or using chemotherapy delivered to the peritoneal cavity. The ease of removal of the device makes it a better choice to place an IP port at initial surgery rather than to have to schedule a second surgery to implant the device.

Alternatively, the device can be placed at an interval procedure using interventional radiologic techniques, laparoscopy, or a 2- to 4-cm laparotomy incision in the right or left lower quadrant. It is preferred to avoid the previous midline incision, when trying to introduce the catheter into the peritoneal cavity.

Preoperative Preparation

The location of the planned device port should not interfere with the patient’s undergarments or her sleeping position. The size of the port relative to the size of the patient may cause discomfort and require altering the choice of devices. The nursing staff must be able to palpate the port, and it must be secured to a platform, such as the fascia overlying the ribs, to prevent complications during insertion of the Huber needle. The operating room staff must have the device available, as well as 2-0 prolene sutures, Huber needles, and heparin 100 units/mL for flushing. The patient must be sterile and draped from the nipples to the middle thighs and laterally to the posterior axillary line.

The preferred device is a subcutaneously implanted port attached to a silicone catheter. Do not use products with Dacron cuffs. A Bardport silicone peritoneal catheter 14.3 French is the preferred device, and it has been Food and Drug Administration approved for use in IP therapy. The 9.6-French, single-lumen intravenous (IV) access device, also made of silicone, can be substituted if the peritoneal catheter is not available. The firmness of the catheter prevents kinking, and the silicone prevents adherence to peritoneal structures so the catheter can be withdrawn without difficulty.^1,2

Operative Procedure

Laparotomy

The port pocket is created by making a 5- to 6-cm incision 3 finger-breadths above the lower costal margin, at the midclavicular or anterior axillary line, and 4 prolene sutures are placed in the fascia overlying the ribs and through the port to stabilize the device to this platform (Figure 33-1). A long tonsil clamp is tunneled subcutaneously (just above the rectus fascia) to approximately the level of the umbilicus and then through the fascia, muscle, and peritoneum to grasp the nonfenestrated end of the catheter, which pulled it into the port pocket (Figure 33-2). The 2 ends of the catheter are trimmed so that approximately 15 cm of catheter is located within the peritoneal cavity and the tip is not long enough to reach the bladder or vagina. The catheter should not be left between the transverse colon and the abdominal wall, because it is likely to be entrapped in adhesions between those 2 structures due to the omentectomy. The catheter is attached to the port and fixed in place with 2-0 prolene sutured to fascia overlying ribs (Figure 33-3). The port pocket is closed in 2 layers with 3-0 absorbable suture and flushed with 100 units/mL of heparin to document that the system functions prior to leaving the operating room.

FIGURE 33-1. Intraperitoneal port placement: incision above left costal margin.

FIGURE 33-2. Intraperitoneal port placement: tunneling of catheter.

FIGURE 33-3. Intraperitoneal port placement: fixation of port reservoir.

Mini-Laparotomy

An IP port can be placed as an interval procedure remote from the primary debulking operation via mini-laparotomy. The port pocket is created as described earlier. Entry into the peritoneal cavity should be away from previous midline wound and avoid areas of bowel resections or extensive dissection. Free peritoneal space is generally available overlying the cecum and is often the ideal site for incision to obtain entry into the peritoneal cavity. After identifying the peritoneal cavity, under direct visualization, the catheter is drawn through the full thickness of the peritoneum, muscle, and fascia into the subcutaneous tissue. The catheter is then pulled through the subcutaneous tissue layer above the fascia into the port pocket, trimmed to length, sutured, and positioned as described earlier. Every layer of the peritoneum, fascia, and skin should be closed individually at the mini-laparotomy site to avoid leakage. The device should not be used for at least 24 hours.

Laparoscopy

Either right or left upper quadrant entry techniques can be used for laparoscopic IP port placement. The stomach should be aspirated with an oral gastric tube or nasogastric tube prior to initiating the procedure. Open laparoscopic techniques or mini-laparotomy may prove to be more advantageous when adhesions are expected. Blind Veress needle technique in the left upper quadrant should only be undertaken if knowledge of the anatomy in that location indicates it is free of adhesions or if ascites is present and ultrasound guidance can be used. A 5-mm trocar is placed 2 to 3 finger-breadths below the costal margin in the midclavicular line. The laparoscope is inserted and used to guide placement of a second 5-mm port. The IP catheter is inserted through the lower trocar under direct visualization and the trocar removed over the catheter (Figure 33-4). The port pocket is then created overlying the fascia of the lower ribs as described earlier, and the catheter is pulled from the lower insertion site with a long tonsil up into the port pocket. The catheter is trimmed to proper length, attached to the port, and sutured to the fascia overlying the ribs with 2-0 prolene sutures. The port and catheter are flushed with 10 mL of heparin 100 units/mL using a Huber needle, and the port pocket is closed in 2 layers.

FIGURE 33-4. Laparoscopic intraperitoneal port placement.

Postoperative Care

Complications are categorized into port access problems, inflow obstruction, abdominal pain, infections, and leaking into wound, bowel lumen, or bladder or out of the vagina. The expected complication rate is 10%.

Difficulty accessing the port or inflow obstruction is evaluated by fluoroscopy with infusion of a small amount of dilute solution of IV contrast dye. Surgical correction of the device can be considered, but usually the device is removed and IV chemotherapy is given. Successful correction is dependent on the cause being a mechanical problem, rather than a patient-specific problem, such as adhesions.

A fever in an IP chemotherapy patient can be evaluated by irrigating and aspirating saline from the port to send to microbiology, for cell count and culture, to look for evidence of peritoneal or catheter infection. Cellulitis surrounding an IP port is rarely treated with antibiotics alone; the port and catheter are generally removed. Leaking around the port or subcutaneous tissues is often an indication of inflow obstruction or intra-abdominal adhesions surrounding the catheter with retrograde flow of fluid back into the port pocket. Fluoroscopy will usually be diagnostic.

The device leaking into the vagina, bladder, or bowel is generally corrected by percutaneous removal of the catheter. Fistulas do not always occur as a result, and a laparotomy is not generally needed, unless the patient appears to have peritonitis, free air, or a urinoma. Complaints of diarrhea or incontinence of urine with IP chemotherapy administration should be investigated with contrast dye to determine a potential communication between bowel, bladder, peritoneum, and infusion with the catheter.

INTRAPERITONEAL PORT REMOVAL

Procedure Overview

An IP port can be removed either in the operating room under sedation and local anesthesia or as an office procedure using only local anesthetic. It is best to remove these devices as soon as their useful life is over, so a complication will not interfere with the patient’s quality of life.

Preoperative Preparation

The patient should not be neutropenic or thrombocytopenic, and medications that inhibit platelet function should be withheld. A list of equipment needed for office removal is provided in Table 33-1.

Table 33-1 Equipment Needed for Intraperitoneal Port Removal

Operative Procedure

Sterile skin preparation is first, followed by placement of a disposable sterile drape with a perforation at the site of the port. The skin surrounding the port pocket is infiltrated with 1% lidocaine. A skin incision is made overlying the port through old scar. The adipose tissue is dissected down to the palpable port where the catheter is attached. A dense fibrinous sheath is found over the port and the catheter, and this sheath has to be incised without cutting the catheter itself. A hemostat is used to undermine the catheter and pull it up and out of the abdomen, and this is used for traction. The port is elevated, and the 4 prolene sutures are cut, while cutting through the fibrinous sheath surrounding the port, and the port and catheter are removed. The port pocket is closed in 2 layers.

Postoperative Care

A prescription for narcotics is often given, but nonsteroidal pain medications are generally adequate. Covering the incision for 24 hours is all that is required.

MANAGEMENT OF INTRAOPERATIVE HEMORRHAGE

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