Transperitoneal guide-wire or drainage catheter placement for guidance of laparoscopic marsupialization of lymphocoeles post renal transplantation
Mark L. H. Tie1,,
M. Mohan Rao2,
Chris Russell2 and
Kanchanabat Burapa2
1 Department of Radiology
2 Renal Transplant Unit, North Western Adelaide Health Service, The Queen Elizabeth Hospital Campus, Woodville, Adelaide, South Australia 5011, Australia
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Abstract
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Background. Lymphocoeles post renal transplantation can be difficult to see laparoscopically. The objective of this study was to report a new technique of catheter or guide-wire placement for the guidance of laparoscopic marsupialization of symptomatic post renal transplant lymphocoeles, refractory to conservative therapy.
Methods. Conventional aseptic technique under local anaesthesia was used for guide-wire or catheter insertion, with the difference being the use of a transperitoneal approach. Computerized tomography (CT) or ultrasound (US) guidance was used. All lesions were confirmed to be sterile lymphocoeles beforehand by either needle aspiration or previous catheter drainage.
Results. Four catheters and one guide-wire were placed pre-operatively without complication. All cases underwent satisfactory laparoscopic marsupialization. No immediate complications were noted in any patient. The drainage catheters were inserted between 5 and 19 days before laparoscopic marsupialization, and guide-wire inserted immediately before. All patients proceeded to laparoscopic marsupialization.
Conclusions. This technique offers precise guidance on laparoscopic surgery, is relatively simple to perform and no complications were experienced in this study. Its use is limited to sterile and benign lesions due to the risks of peritoneal seeding, making recurrent post-operative lymphocoeles ideally suited for this application.
Keywords: catheter; guide-wire; laparoscopy; lymphocoele; transperitoneal
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Introduction
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The use of guide-wires for pre-operative localization of lesions in bone [1], lung [2] and breast [3] lesions is widely accepted. Laparoscopic marsupialization of pelvic lymphocoeles is also a well proven technique [4]; however, a combination of the two techniques has not been reported. Five cases with a refractory symptomatic post renal transplant lymphocoele and in whom either a transperitoneal guide wire or drainage catheter were inserted prior to laparoscopic marsupialization of the lymphocoele are described.
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Case 1
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A 48-year-old obese male with chronic renal failure due to streptococcal glomerulonephritis received a second cadaver renal transplant. This was complicated by wound infection, resulting in partial dehiscence and a peri graft fluid collection requiring percutaneous drainage under ultrasound (US) guidance. The wound cultures revealed methicillin-resistant Staphylococcus aureus (MRSA), while the lymphocoele fluid was sterile. Because of the risk of infecting the lymphocoele, the drain was removed from the peri renal fluid collection. Subsequent imaging showed reaccumulation of fluid in the lymphocoele. Due to the risk of MRSA peritonitis, a repeat percutaneous catheter placement was contraindicated.
After informed consent, the patient's infraumbillical anterior abdominal wall, away from the dehisced part, was prepared and draped in the usual sterile manner. Lignocaine 1% solution (10 ml) was used for local anaesthesia. Under fluoroscopic CT guidance (C.A.R.E Vision, Somatom Plus4, Siemens, Forcheim, Germany) a 20 cm 18G trocar needle (Cook, Bloomington, IN, USA) was introduced through the anterior abdominal wall,
2 cm below the umbilicus, and advanced into the medial wall of the lymphocoele, taking care to avoid the sigmoid colon. It was apparent that the needle would traverse the sigmoid mesocolon at this time. The location of the needle was confirmed by real-time CT images and by aspiration of 5 cm3 of clear fluid. The lymphocoele was not aspirated further as it was not desirable for the lymphocoele to be collapsed at the time of the laparoscopy. A 90 cm long, 0.015 mm tetrafluoroethylene-coated curved tip angiographic guidewire (Cook) was inserted through the guide needle into the lymphocoele and multiple coils of wire were left within the cavity (Figure 1
). The guide needle was then carefully removed over the wire and the wire left in situ. The wire was kinked to be parallel with the skin, coiled neatly and taped to the skin prior to transfer of the patient from the CT suite directly to the operating room.

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Fig. 1. Fluoroscopic CT image obtained from a 48-year-old male renal transplant recipient during guide-wire insertion. Note the coils of wire within the lymphocoele cavity, which help stent the cavity open during marsupialization.
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At laparoscopy, the guidewire was clearly visible. As suspected at the time of CT, it did traverse the sigmoid mesocolon but it could be followed to the lymphocoele. Multiple coils of wire were easily seen within the opened lymphocoele. The guide-wire was removed at laparoscopy. The lymphocoele was marsupialized and packed with omentum. Follow-up by US showed complete resolution of the lymphocoele within 2 weeks and with no recurrence to date, 12 months post-procedure.
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Case 2
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A 50-year-old man with end-stage renal disease due to chronic glomerulonephritis received a cadaver graft. He developed a painful recurrent peri-graft fluid collection around the lower pole, measuring up to 8 cm in diameter refractory to percutaneous aspirations. A smaller fluid collection was also noted around the upper pole. A 12F APDL drainage catheter (Meditech, Boston Scientific, MA, USA) was placed in the lower pole collection under US guidance, over a 0.015 mm guide-wire using the standard sterile technique and under local anaesthetic. Pre- and post-contrast CT sinograms of the lesion, performed immediately before definitive laparoscopic surgery, confirmed the potential cavity. Successful marsupialization was performed and follow-up scans showed resolution of the large lower pole collection but persistence of the small crescentic collection around the upper pole, measuring 0.4x3.2 x2.8 cm. This has remained asymptomatic and has gradually decreased in size on subsequent US scans performed over the 3 month follow-up period.
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Case 3
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A 50-year-old male with adult polycystic kidney disease presented with pelvic pain over the graft 4 months after the renal transplantation. Initial US showed a large lymphocoele, which was aspirated percutaneously, but it recurred after 5 weeks, requiring US-guided insertion of a 12 F Ring McLeans Sump drain (Cook Australia, Eight Mile Plains, Queensland, Australia). Because of persistent drainage, further imaging was performed. The drainage catheter was left in situ for guidance at laparoscopic marsupialization 5 days later. No reaccumulation of fluid was detectable on subsequent US scans to date, at 26 months post-procedure.
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Case 4
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A 43-year-old male with renal failure due to IgA nephropathy received a cadaver graft. This was complicated by a large collection of fluid, causing pain and impaired renal function. Needle aspirations relieved symptoms and improved renal function, but recurrence of fluid collection resulted in the US-guided insertion of a 10F APDL drainage catheter. Persistent drainage required a CT scan and CT sinogram 12 days later. Transperitoneal course and position of the catheter tip was confirmed by CT scan and CT sinogram via the catheter prior to laparoscopic marsupialization. US scans performed up to 27 months later showed no reaccumulation of fluid.
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Case 5
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A 48-year-old male with renal failure due to glomerulonephritis was found to have a 10x12x13 cm collection of fluid between the renal graft and bladder following renal transplantation. This caused pain, impaired graft function and leg swelling due to impaired venous drainage. Multiple aspirations relieved the symptoms but failed to prevent recurrence. A 12F APDL drainage catheter was put in place under US guidance. A CT scan after drainage catheter insertion confirmed the paravesical location of the transperitoneal catheter. Due to persistent drainage through the catheter and allograft dysfunction, a sinogram was performed concomitantly with nephrostogram and showed the catheter in the paravesical fluid collection. Laparoscopic marsupialization was performed uneventfully 4 days later. A follow-up US scan 2 months later showed no recurrent pelvic fluid collections.
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Discussion
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Lesions obscured by anatomic distortion, fat or pathological processes and extraperitoneal lesions can be difficult to localize during laparoscopic surgery. This is the first reported series of patients in whom a drainage catheter or guide-wire placement was used. Having used the drains for initial drainage and realizing how helpful they were in identifying the lymphocoele, we used the guide-wire just before surgery (due to the risk of infection) for the guidance of a laparoscopic procedure. Other techniques of laparoscopic localization have included laparoscopic US [5] and percutaneous staining after percutaneous drainage [6].
Peri-graft fluid collections were aspirated initially, the fluid was cultured and biochemical analysis was performed. Sterile fluid collections (lymphocoeles) were aspirated completely. If they recurred, a drain was inserted under radiological control and Povidone iodine (Betadine; Faulding Pharmaceuticals, Salisbury, Australia) was instilled through the drain once daily for 1 week, similar to methods reported previously [7]. Lymphocoeles that continued to accumulate fluid were operated on surgically if they resulted in pain, pressure symptoms or obstruction of urinary drainage.
Advantages vs disadvantages
This is a simple, safe and efficient procedure aimed at easier localization of lesions, thus reducing operating time and preventing visceral damage during laparoscopic marsupialization. Lesions anticipated as being difficult to visualize because of their anatomical location (postero-medial to the transplant) or because they are covered with excess peritoneal fat can be localized accurately. Stenting of the cavity by the catheter or guide-wire facilitates the resection of the cyst wall at laparoscopic surgery. When aspiration fails, percutaneous drainage catheters can be inserted for sclerotherapy. This is a good initial therapeutic option for post-operative pelvic lymphocoeles [8]. Guide-wires can be inserted where there are relative contra-indications to catheter insertion, e.g. adjacent wound infection. There is no requirement for expensive laparoscopic US hardware. Percutaneous staining may not be visible during laparoscopy if there is excess fat obscuring the lymphocoele.
The only disadvantage of this method is that it is an additional radiological procedure. We have used drains placed transperitoneally for sclerotherapy and to facilitate laparoscopic marsupialization later, if warranted. Trans-peritoneal guide-wires are placed on the day of surgery, which requires coordination between the radiologist and the surgeon. The risk of transgressing the mesentery should be weighed against the advantages the catheter or guide-wire offer.
The standard aseptic technique of percutaneous catheter or guide-wire placement was used and the usual contraindications for interventional procedures (e.g. coagulopathy and the patient being unstable) apply. The position of placement and modality for guidance is dictated by the need for a transperitoneal approach and the location of the lesion relative to bowel and other vital structures. US is often the modality of choice, but some lesions may be difficult to visualize due to poor sonographic windows requiring the use of CT.
In all cases, multiple loops of redundant wire or locking loop catheters were placed into the lesion to reduce the risk of inadvertent displacement and to act as a stent, holding the walls of the lymphocoele apart, making marsupialization easier. The catheter sizes used ranged from 10 to 12 F. Larger catheters were unnecessary as the drainage fluid was thin and serous. The standard 0.015 mm angiographic guide-wire was used in this case, although use of a smaller wire is possible.
Potentially malignant neoplasms, infected fluid collections and urinomas must be excluded.
Timing of placement
Catheters were put in place 519 days prior to surgery while the guide-wire was inserted immediately before surgery. The risks of peritoneal infection and displacement are minimized when the wire or catheter is inserted immediately prior to surgery and removed during the operation.
Complications and follow-up
No immediate or late complications (peritonitis, haemorrhage, bowel perforation or intestinal ischaemia) occurred, even though all patients were immunosuppressed for their renal transplant.
All catheters and guide-wire was removed intra-operatively after the completion of marsupialization. The lymphocoeles gradually decreased in size during the follow-up, as shown by CT scans or US, over a period ranging from 2 to 27 months. No symptomatic recurrence of lymphocoeles has occurred to date.
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Conclusion
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Transperitoneal percutaneous CT- or US-guided wire or drainage catheter placement is a safe, convenient and a useful procedure for the localization of lymphocoeles prior to laparoscopic marsupialization. This is particularly useful in selected patients in whom lesions or normal anatomical landmarks may be difficult to visualize as a result of previous surgery, pathology or excessive peritoneal fat, particularly in the case of extraperitoneal lesions. This technique is limited to sterile and benign lesions, making recurrent post-operative lymphocoeles particularly suitable. (Table 1
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Notes
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Correspondence and offprint requests to: Dr Mark L. H. Tie, Department of Radiology, North Western Adelaide Health Service, The Queen Elizabeth Hospital Campus, Woodville, SA 5011, Australia. 
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References
|
---|
-
Magre GR, Menendez LR. Preoperative CT localization and marking of osteoid osteoma: description of a new technique. J Comput Assist Tomogr1996; 20: 526529[ISI][Medline]
-
Sartoris F, Cittadini G, Saitta S et al. CT-guided needle localization of lung nodules for thorascopic resection. Eur Radiol1996; 6: 420424[ISI][Medline]
-
Walker HC Jr, Delaney JP, Gedgaudas E, et al. Locating nonpalpable breast lesions for the surgeon. State of the art. Minn Med1985; 68: 437439[ISI][Medline]
-
Hamilton BD, Winfield HN. Laparoscopic marsupialization of pelvic lymphocoeles. Tech Urol1996; 2: 220224[Medline]
-
Melvin WS, Bumgardner GL, Davies EA et al. The laparoscopic management of post-transplant lymphocoele. A critical review. Surg Endosc1997; 11: 245248[ISI][Medline]
-
Schilling M, Abendroth D, Kunz R. Treatment of lymphocoele in renal transplant recipients by laparoscopic fenestration after transcutaneous staining. Br J Surg1995; 82: 246248[ISI][Medline]
-
Gilliland JD, Spies JB, Brown SB et al. Lymphocoeles: Percutaneous treatment with Povidone-Iodine Sclerosis. Radiology1989; 17: 227229
-
Kim JK, Jeong YY, Kim YH, Kim YC, Kang HK, Choi HS. Postoperative pelvic lymphocoele: treatment with simple percutaneous catheter drainage. Radiology1999; 212: 390394[Abstract/Free Full Text]
Received for publication: 28. 6.00
Revision received 26.10.00.