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Laparoscopic Extracorporeal Clot Extrusion Under Local Anesthesia for Removal of Intraluminal Fibrin Clot
ORIGINAL ARTICLE
Laparoscopic Extracorporeal Clot Extrusion Under

Local Anesthesia for Removal of Intraluminal Fibrin

Clot of Peritoneal Dialysis Catheters

Amir Keshvari
Department of Surgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Iran

Abstract
In this publication, we present our technique with 14 cases for clot removal using a laparoscopic method under local anesthesia that we
have called the procedure “extra-corporeal clot extrusion” (ECCE). The result was that laparoscopic “ECCE” should be a considered
option for management of catheter malfunction due to fibrin clot.
Keywords: Laparoscopic clot extrusion, removal of intraluminal fibrin clot, management of intraluminal fibrin clot.

INTRODUCTION limits set at 8 mm Hg and increased up to 12 mm Hg as
The success of peritoneal dialysis depends on the presence needed. Intravenous sedation is used if needed for patient
of functional long-term catheter access to the peritoneal comfort or to relieve fear and anxiety. The procedure
cavity. Mechanical problems of peritoneal dialysis catheter involves the placement of 2 or 3 laparoscopic ports.
are the second most common cause of depriving patients Laparoscopic procedure was initiated by introducing a
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from peritoneal dialysis, next to infectious problems. 1 5 mm disposable trocar at palmer’s point to permit
Intraluminal fibrin clot is one type of mechanical problems insufflations of gas and insertion of laparoscopic camera.
that mostly treated conservatively by nonsurgical The details of local anesthesia, gas insufflations and first
managements like forced flushing of the catheter, push- trocar position in all cases were like our technique for
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and - suck maneuver, infusion accelerator, intraperitoneal laparoscopic implantation of peritoneal dialysis catheter. 13
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administration of urokinase or streptokinase, 5, 6 instillation The laparoscope was used to assist in the placement of a
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of tissue plasminogen activator manipulation by guide-wire 8 second 5 mm port at a left pararectus area or infraumbilical
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or endoscopy brush 9,10 or fogarty catheter. Failure to push area depending to the site of previous catheter insertion. In
out the clot by the above mentioned methods call for surgical some cases, we inserted an additional 5 mm port at the
intervention. same side of the second port and with 5 cm distance from
it, for releasing adhesions of catheter.
SUBJECTS AND METHODS Under laparoscopic vision from the left upper quadrant
Between April 2004 and September 2009, fifty laparoscopic of abdomen, and after exploration of peritoneal cavity for
procedures for restoring function of malfunctioning the cause of malfunction of the catheter, we followed the
peritoneal dialysis catheters were performed. Conservative tip of the catheter and released it from adherent organs if
managements of catheter malfunction failed in all patients. needed by one or two laparoscopic forceps. In the presence
In 15 cases, clot removal was needed. All but 1 case (the of intraluminal fibrin clot, and if it dose not push out by
first one) we removed the clot, using laparoscopic forced flushing, the tip of the catheter was pulled out along
extracorporeal clot extrusion (ECCE). with the port device through abdominal wall onto the surface
of the abdomen. Out of peritoneal cavity and under direct
PROCEDURE
vision, the clot was extracted often using milking the catheter
All procedures were performed in the operating room with by hand toward the tip and sometimes it must be push by
an anesthesiologist in attendance. Under local anesthesia, needle of syringe through holes of the catheter. After
peritoneal insufflations of N O is established, with pressure complete extraction of the clot, irrigating the catheter and
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World Journal of Laparoscopic Surgery, May-August 2010;3(2):55-58 55