Perioperative management - Port Implantation

• Permanent parenteral nutrition
• Intravenous chemotherapy (in the absence of access to peripheral veins)
• Permanent infusion therapy

• Systemic infections with the risk of implant infection
• Thrombosis of the subclavian vein
• Contralateral pneumothorax
• Local skin eczema/fungal infection
• History of local radiation with radiation-induced keloid formation
• Severe coagulation disorder (highly pathological plasma coagulation, platelets < 30 G/l)

• Clinical examination (swelling of the arm, collateral circulation in the shoulder area as an indication of subclavian vein thrombosis, history of ipsilateral axillary dissection and radiation, ipsilateral arm lymphedema with positive Stemmer's sign)
• Preoperative duplex sonography of the subclavian vein in cases of previous punctures/catheter placements in the neck vessels
• Laboratory tests in case of pathological standardized bleeding history: blood count, Quick test, PTT, platelet count

• Placement of a peripheral venous access (contralateral arm) and initiation of an intravenous infusion
• Shaving of the chin, lateral neck triangle, and thorax up to the nipple line
• Sterile washing of the lateral neck triangle from the midline to the nipple

• Risk of pneumothorax in approximately 2% with subclavian vein puncture involving lung injury → placement of a chest drain
• Vascular injury, both venous and arterial, necessitating surgical revision
• Local bleeding and bleeding with vascular injury
• Brachial plexus lesion with persistent numbness and paresis
• Wound infection with potential infection of the port system → surgical removal
• Port dislocation and dysfunction (kinking, inability to puncture, etc.)
• Air embolism during placement with potential subsequent cerebral hypoperfusion and consequent neurological deficits
• Stroke in case of arterial malposition

The procedure is performed under local anesthesia, e.g., 10 ml of 1% Mepivacaine. If available, an anesthesiologist should be on standby, with the possibility of sedation, e.g., Benzodiazepine i.v. (Midazolam 2 mg i.v. after blood pressure and saturation monitoring).

The patient is positioned supine. It is recommended to apply a small pillow, which is folded and placed between the shoulder blades, allowing for a slight retraction of the clavicles bilaterally. The arm on the side to be punctured should be positioned in such a way that, if necessary, a downward longitudinal traction can be applied to expand the subclavian space or the space between the clavicle and the first rib.

The surgeon stands on the right side of the patient's neck. The scrub nurse stands on the left side at the foot of the patient. If necessary, an assistant stands at the left head end. The image intensifier is also brought in from the left when puncturing on the right.

• Port system
• A small clamp covered with rubber tubing as a cushioned clamp for atraumatic clamping of the port tube
• Small sponge forceps for tunneling
• Small Langenbeck hooks for lifting the subcutis and inspecting the port pocket.

postoperative analgesia: Non-steroidal anti-inflammatory drugs are generally sufficient. Follow the link to PROSPECT (Procedures Specific Postoperative Pain Management). Follow the link to the current guideline: Treatment of acute perioperative and post-traumatic pain.

medical follow-up: Postoperative radiological imaging of the port system. Port puncture only with a special needle (Huber needle), which, unlike a regular injection needle, does not punch out particles from the silicone membrane. The port system can be used immediately after placement. Sterile technique is recommended, as well as flushing with 20 ml of physiological saline solution before each infusion. Thrombosis prophylaxis: In the absence of contraindications, due to the low risk of thromboembolism, low molecular weight heparin can be administered prophylactically, possibly in a weight- or risk-adapted dosage until full mobilization is achieved. Consideration: renal function, HIT II (history, platelet monitoring) Follow the link to the current guideline: Prophylaxis of venous thromboembolism (VTE).

mobilization: immediate physical therapy: none dietary progression: regular diet bowel regulation: none work incapacity: dependent on the underlying condition that necessitates port placement