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The Virginia Department of Social Services (VDSS) will issue additional Pandemic Electronic Benefit Transfer (P-EBT) benefits to eligible households this summer to further assist students in meeting their nutritional needs while schools are out of session. Under the American Rescue Plan Act of 2021, students who qualified for free or reduced-price meals during the 2020-2021 school year, regardless of the learning method (fully remote, hybrid or in-person), will receive a one-time, lump sum benefit of $375 on August 25, 2021.
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Laparoscopic PD catheters implantations using conventional laparoscopic equipment started in 1993 at the University Hospital Sveti Duh, Department of Surgery, Zagreb, Croatia. However, using the standard laparoscopic instruments, relatively high incidence of PD catheter insertion technic complications or technical failures was observed. To reduce the incidence of PD failure due to catheter placement technic based on personal data we developed several modifications of the trocar for PD catheter insertion and surgical approach in order to overcome limitations of available instruments [13] . Technically improved trocar combined to catheter placement surgical procedure conceived in 1994 is still in use today. In the last 22 years, this trocar has been distributed to surgeons and urologists in Croatia, Slovenia and Bosnia and Herzegovina with good results regarding functional and technical aspects of catheter placement [4] [14] [15] and also to promote minimally invasive surgical approach in the view to promote PD as treatment modality. The purpose of this retrospective study is to describe and evaluate designed laparoscopic technique, the trocar developed and investigate the outcomes.
1) Patients. Retrospective analysis of 804 patients with the end-stage renal disease that underwent laparoscopic PD catheter placement using specially designed trocar from September 1993 to January 2016 in eight Departments of Surgery and two Departments of Urology in Croatia, Slovenia and Bosnia and Herzegovina is presented. All operations were performed by experienced laparoscopic surgeons, previously well educated in the technic of PD catheter placement and the use of trocar. Departments with less than 25 laparoscopic insertions have not been included in this study. Postoperative follow up was performed by same surgeon and data collection.
In our series, combined operations concomitant with PD catheter placement were also performed. Seventy patients had an inguinal or an umbilical hernia and underwent hernia repair before, simultaneously or after the PD catheter insertion. Inguinal hernias were treated using the open Lichtenstein procedure or endoscopic total extraperitoneal procedure (TEP) that is preferred technique for hernia repair in PD patients due to preserved peritoneal integrity [21] . Umbilical hernias were repaired using the open method with direct suturing or Mayo technic. Three patients underwent salpingectomy and tumor excision prior to catheter implantation due to intraoperative finding i.e. laparoscopic exploration. Twenty laparoscopic cholecystectomies were performed for cholelithiasis in asymptomatic patients. In patients with acute cholecystitis and candidates for laparoscopic PD insertion laparoscopic cholecystectomy was performed and after a disease free interval of three weeks the procedure finalised. Four endoscopic nephrectomies and one cardiac operation were also performed and no additional surgical and non surgical complication observed related to concomitant procedures.
Third and important observation to our study is that laparoscopic method is particularly useful in patients with previous abdominal operations. In this setting, adhesiolysis is safely performed to prevent nor catheter malfunction to unssufficient PD due to reduced exposure to parietal and visceral peritoneum in the case of multiple adhesions. Importantly, the situation allows peritoneal dialysis also in patients who would otherwise require hemodialysis, as we did in 27 cases. The primary causes of catheter dysfunction, as reported in review publications and PD guidelines, are compartmentalization from adhesions, catheter tip migration and omental wrapping or entrapment [22] . Our technique of laparoscopic PD catheter placement directly addresses these issues by allowing long rectus sheath tunneling along with adhesiolysis and omentopexy [23] [24] . However, only adhesions that may obstruct catheter function should be treated. Adhesions in the upper part of the abdomen usually do not interfere with dialysate drainage and therefore does not mandate surgical management. Moreover, unnecessary adhesiolysis may increase the risk of postoperative bleeding [25] and intestinal trauma.
Although several publications recommend routine omentectomy or omentopexy, we found that unnecessary. These procedures may prolong operation, and could result in complications such as postoperative bleeding, catheter obstruction, and internal herniation [24] [25] . Omentopexy should be done selectively in patients having extremely long omentum to reduce the incidence of omental wrapping and dialysat compartmenisation. In our study, the omentopexy was performed in three cases with the additional two cases of catheter suture fixation.
Special care should be taken to avoid visceral injuries during coagulation and manipulation with the instruments. Damage to the small or large bowel may not be visible during the operation with clinical and laboratory findings presentation up to 3 - 6 days later. Although, this complication is rare (0% - 2%) clinical situation after laparoscopic PD catheter insertion, we reported two visceral perforations in our study. The gastric perforation was due to the Veress needle insertion and the small bowel injury occurred during adhesiolysis in low BMI patient after massive weight loss and abdominal wall distension. Recent studies also propose, that the use of peritoneal dialysis may offer advantages in patients with the intra-abdominal foreign body, such as vascular grafts, due to better hemodynamic control and avoidance of anticoagulation, also supported by our study. In our study, with respect of graft positioning time, one patient with vascular graft underwent laparoscopic PD catheter insertion without any complication. Free interval in between two procedures is highly recommended, mostly more than 4 months allows complication free procedures, also VGI that is an absolute contraindication for PD and PD catheter placement. 2ff7e9595c
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