Introduction

Chronic renal failure and end-stage renal disease are increasingly significant public health problems both medically and economically. Approximately 3 million persons in the United States have chronic renal failure, as defined by a glomerular filtration rate of less than 60 mL/min/1.73 m. Many of these patients progress to end-stage renal disease, the prevalence of which in the United States was almost 1400 per million, or a total of 406,081 patients in 2001, with an average age of 57.8 years. The prevalence of endstage renal disease has increased every year since 1980, although the rate of increase has slowed to 2.4% per year (1).

The etiology of this persistent increase in end-stage renal disease is multifactorial. The four most common causes of end-stage renal disease in the United States are diabetes mellitus (138,483 total cases and 41,312 new cases in 2001), hypertension (91,636 total cases and 24,942 new cases in 2001), glomerulonephritis (60,888 total cases and 7687 new cases in 2001), and cystic kidney diseases (17,112 total cases and 2143 new cases in 2001) (1). The incidence of diabetic nephropathy, which is the leading cause of end-stage renal disease in adults, continues to increase. Another factor is the improved survival of patients with severe cardiovascular disease and diabetes, who are at high risk for end-stage renal disease, and our increasing acceptance of the placement of persons with severe comorbid illnesses on treatment for end-stage renal disease. Also, endstage renal disease has increased dramatically in the elderly population and this has coincided with the increasing age of the U.S. population.

The annual cost of the end-stage renal disease treatment program consumes an ever-increasing portion of the Medicare budget—22.8 billion dollars in 2001, amounting to 6.4% of the annual Medicare budget (1). Treatment options for end-stage renal disease include hemodialysis, peritoneal dialysis, which may be continuous ambulatory peritoneal dialysis or continuous cycling peritoneal dialysis, cadaveric renal transplantation, or living donated renal transplantation.

The 2003 annual data report from the U.S. Renal Data System listed 86,289 patients initiated on hemodialysis and 6991 initiated on peritoneal dialysis for the preceding calendar year. From 1997 to 2001, the incident rates for initiation of peritoneal dialysis dropped by 4%, whereas the incident rates for hemodialysis increased 3.3% and the incident rate for renal transplant as the initial end-stage renal disease treatment modality increased 8.9%. The prevalent end-stage renal disease population currently includes 264,710 patients treated with hemodialysis and 24,268 treated with peritoneal dialysis; 113,866 patients have a functioning renal transplant. Thus 65% of prevalent end-stage renal disease patients are treated with hemodialysis, 28% are treated with a functioning renal transplant, and 7% are treated with peritoneal dialysis (1).

The incidence of peritoneal dialysis indicates that approximately 7000 new peritoneal dialysis catheters are placed each year in the United States and that approximately 24,000 must be properly maintained. Many different renal replacement therapies are available for the treatment of end-stage renal disease patients. The most commonly utilized renal replacement therapies are hemodialysis, peritoneal dialysis, and renal transplantation. Outcome comparisons suggest that renal transplantation is the best overall treatment for end-stage renal disease patients. Specific patient characteristics supporting the use of one modality over another have previously been described. Renal replacement therapy is preserved longer on peritoneal dialysis than on hemodialysis (2).

Continuous ambulatory peritoneal dialysis is an established and effective method for end-stage renal failure patients. Open surgical insertion is often associated with significant morbidity. Percutaneous and laparoscopic catheter placement has been used increasingly in recent years (3).

The abdominal wall (Fig. 1) extends from the osteocartilaginous thoracic cage to the pelvis. It is helpful for descriptive purposes to subdivide it into anterior abdominal wall, right and left abdominal walls (loin and flanks), and posterior abdominal wall. The combined term "anterolateral wall" is used because some structures (the external oblique muscle and cutaneous nerves) are located in the anterior and lateral walls (4-6).

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