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Cannon Tunneled Hemodialysis Catheter Placement Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
End-stage renal disease with need for long-term dialysis access.

POSTOPERATIVE DIAGNOSIS:
End-stage renal disease with need for long-term dialysis access.

OPERATION PERFORMED:
1.  Placement of Cannon tunneled hemodialysis catheter via the right internal jugular vein.
2.  Placement of a peritoneal dialysis catheter using C-arm fluoroscopy.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  General with oral endotracheal tube.

ANESTHESIOLOGIST:  Jane Doe, MD

INDICATION FOR OPERATION:  This is a patient who has renal failure and needs to be on dialysis therapy. Dr. (XX) has requested placement of a peritoneal dialysis catheter as well as the tunneled hemodialysis catheter. Procedure and risks including bleeding, infection, vascular injury, the possibility of bowel injury, hernia formation and possibility of inadequate dialysis with peritoneal dialysis were all discussed with the patient. All questions were answered, and she appeared to understand and agreed to undergo the above-mentioned procedure.

DESCRIPTION OF OPERATION:  The patient was placed on the operating room table in supine position. General anesthetic was induced and maintained with an oral endotracheal tube. The right and left sides of the neck as well as the abdomen were then scrubbed and prepped with Betadine soap and solution and draped with sterile towels and drapes. The bed was placed in Trendelenburg and the head was turned towards the left. Using a 22 gauge needle, the skin posterior to the sternocleidomastoid muscle at the base of the neck was infiltrated. The needle was advanced towards internal jugular vein and position of the vein was noted. Intervening soft tissues were anesthetized. Successful venipuncture was then accomplished with a thin-walled Cooke entry needle and a guidewire was passed centrally. The tunnel was then anesthetized.

A dermatomy was made in the skin over the guidewire. The tract over the guidewire was then dilated. The dilator sheath was then passed over the guidewire centrally. The dilator and the wires were removed. The sheath was immediately clamped to prevent bleeding and aspiration. The catheter was then passed through the sheath and into the central circulation. Under fluoroscopic guidance, it was positioned in the mid right atrium in supine Trendelenburg position. A 27 cm Tenckhoff catheter was used. The catheter was then brought out through its tunnel and assembled. It was easy to aspirate and infuse through the catheter. The catheter was then flushed with heparinized saline lock. The venipuncture site was closed with 4-0 Vicryl suture. The sterile bandage was then applied.

Next, the bed was placed in Trendelenburg. Using a marking pen, the skin overlying the left rectus sheath below the umbilicus was outlined for transverse incision. The tunnel was outlined, with the exit site being somewhat inferiorly and laterally, and the exit site was positioned so that it was well below the patient's waistband. A 1:1 mixture of 0.5% Marcaine with epinephrine and 1% Xylocaine without epinephrine were used for local anesthetic. The incision was then made for hemodialysis, subcutaneous tissue, with electrocautery. The anterior rectus sheath was identified and infiltrated with local anesthetic solution. The patient was moderately obese, so the incision was about 3 inches deep. The lateral rectus sheath was then excised transversely to expose the underlying rectus muscle. The rectus muscle was then split in the direction of its fibers with a hemostat and held apart with a small Weitlaner retractor. The posterior rectus sheath was then infiltrated.

A small nick was then made in the posterior rectus sheath to enter the peritoneal cavity. A pursestring suture was then placed around the posterior rectus sheath incision. An adolescent length swan-necked, curved peritoneal dialysis catheter was then passed over the catheter guide and then positioned in the pelvis. C-arm fluoroscopy was used to confirm proper positioning within the pelvis. It was used to aspirate and infuse through the catheter in this position. The pursestring suture was then secured both proximally and distally to the distal cuff. Each end of the double 2-0 double-armed Prolene suture was then brought out to the anterior rectus sheath and a second watertight closure was accomplished as the rectus sheath was closed both medially and laterally. The distal cuff was then sandwiched between the posterior and anterior rectus sheath.

The catheter was then brought out through a separate stab wound, oriented inferiorly and laterally. The subcutaneous tissue was irrigated and then closed with running 3-0 Vicryl to subcutaneous tissue. The skin was closed with running 4-0 Vicryl. One liter of Dianeal was then infused and allowed to outflow without difficulty. Sterile bandage was then applied. The patient tolerated the procedure well without complications and left the operating room to go to the recovery room in satisfactory condition.