METHOD OF LAPAROSCOPIC OMENTOPERITONEOPEXY AS A MEANS FOR PROLONGING EFFECTIVE FILTRATION IN PERITONEAL DIALYSIS

Abstract

Although the peritoneum has a significant reparative potential, it should be remembered that the effect of dialysate in case of peritoneal detoxification on the average within 5-6 years leads to irreversible process, namely, total peritoneal sclerosis. Therefore, limiting the part of peritoneum from aggressive effects of dialysis solution for its further use is an important task of the present-day nephrology. The authors of research have developed hermetic limiting models of the upper and lower floors by means of omentoperitoneopexy, as well as strong and hermetic connection applying proper tissues. Omentoperitoneopexy has been technically performed by two methods: ligation or bioelectric welding of tissues. The operation part of the research has been carried out under aseptic operating conditions with inhalation ETH. The control group included 21 patients with classical method application for placement of peritoneal drainage for dialysis. The comparison group consisted of 8 patients with laparoscopic sac formation of the peritoneal upper floor which was planned to be involved in the dialysis process after the possibilities of the lower floor have been exhausted. Sac formation was carried out in 4 patients by fixing a greater omentum to the parietal peritoneum; omentoperitoneopexy with bioelectric welding was performed in 4 other patients. Modified peritoneal double-probe drainage was introduced in patients with peritoneopexy. One canal was used for dialysis itself; another was placed in the upper floor to control hermeticity (if dialysate appears along the upper drainage – hermeticity does not occur). The level of urea, creatinine and potassium was compared directly before and after dialysis. The average weekly dynamics of changes in indicators as well as the average monthly indicators have been also determined in the study. The effectiveness of hermeticity in omentoperitoneopexy was compared and evaluation of early and late postoperative results was carried out. Wound suppuration in the postoperative period was observed in 1 patient of the control group which was eliminated with antibiotic therapy and did not require drainage removal. The episodes of suppuration were not observed in the comparison group, but drainage migration was determined in 2 cases in patients of this group with ligation. In 1 case, the drainage with a gas cylinder migrated to the lower floor; in one more case, the dialysis drainage migrated to the area above omentoperitoneopexy. It should be noted that in both cases the loss of hermeticity of the abdominal cavity floors was determined. Drainage migration in the first case (shifting above the line of omentoperitoneopexy) made it impossible to continue detoxification stage, because it was not possible to evacuate dialisate completely. It was caused by formation of small sac around the drainage. When the drainage was applied again, the areas of damaged peritoneum forming the sac around the drainage were observed. The histological examination of material has determined the absence of surface epithelium, thickened basement membrane and abundant fibrous deposits in the form of lymphocytes, fibrocytes, fibrous and elastic fibers. The model of hermetic limiting the upper and lower floors of the abdominal cavity by means of bio-welding was proposed in the study. Delimited peritoneum floor which was actively used for dialysis provided sufficient and adequate level of detoxification and was not statistically different from the control group. Early postoperative histological data did not determine the difference in the comparison groups; however, the issue on «peritoneum ageing» rate in group with a smaller dialysis area requires the further study.

Keywords

• omentoperitoneopexy
• peritoneal dialysis
• peritoneum
• peritoneal sclerosis.