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BackTable / VI / Article
Port Removal Procedure: Ins and Outs
Thomas "T.J." Turner • Apr 11, 2024 • 40 hits
Though port removal procedures are routine amongst most interventional radiologists, mastery of fundamental techniques are imperative to avoid complications, deal with unexpected challenges, and ensure a speedy patient recovery.
Dr. Christopher Beck and Dr. Aaron Fritts share their strategies for routine port removals, how to approach mobilizing the reservoir, and closing the incision site. This article features excerpts from the BackTable Podcast. We’ve provided the highlight reel here, and you can listen to the full podcast below.
The BackTable Brief
• A port removal procedure can be indicated for completion of treatment, infection, malfunction, port fracture, or patient discomfort.
• Clear communication with the patient before and after the procedure are important to support patient comfort and satisfaction.
• Tailor anesthesia for patient comfort while minimizing risk; oftentimes, moderate sedation along with local anesthetic is recommended.
• Make the incision along the initial incision site and carefully dissect over the reservoir to avoid severing the catheter from the reservoir.
• If possible, gain access through the port catheter with a wire to maintain retrieval options in the case of a difficult port removal.
• Curved hemostats can be used to gently mobilize the port reservoir from surrounding tissue.
• Once the port is successfully removed, irrigate the site with saline and suture the deep layers of fascia with 2-0 Vicryl and 3-0 Vicryl for more superficial layers, aiming for close approximation of the tissue.
Table of Contents
(1) Indications for Port Removal
(2) Conversations with Patients about Port Removal
(3) Approaches to Port Removal
(4) Reopening the Site
(5) Closing the Wound
Indications for Port Removal
Port removal often signals the end of cancer treatment for many patients and can thus be a time of celebration for both patients and their care team. Other indications for port removal include infection, malfunction, and fractures. While the subclavian approach to initial port placement is less common, it also can be associated with higher rates of complication, necessitating a procedure to remove the port.
[Dr. Aaron Fritts]
Yes. I didn't use to do that until I think you told me about it and now every port retrieval that comes in as an outpatient post cancer treatment, I do that and they just smile and they're like, "Thank you." It does brighten my day and it makes it a more fun procedure, instead of just like a road, like, "Oh, I don't know. Here's another basic procedure," because we do celebrate around it. That is probably the most common indication is that they're just done with treatment, but some other indications you mentioned infection.
[Dr. Christopher Beck]
Yes, port infection, malfunction or broken fractured port.
[Dr. Aaron Fritts]
Yes. Thankfully, I haven't seen too many fractured ones. The ones that are out there that are placed subclavian seem less and less nowadays. I guess it depends on where you practice.
[Dr. Christopher Beck]
I was about to say there's one hospital that-- you don't want to call anyone out, but one of the hospitals that I work at, there's a couple docs that still do subclavians and one of them never has a problem with their ports as long as I've been there, and the other one, I do more port retrievals or fractured port where you'd form body retrievals from this one provider. They're out there. It's not quite done. It just makes me think there's something about the subclavian approach because two different docs and the one who I never see problems with actually puts in probably more ports than the other one. There's something about-- it's not just like subclavian is bad, they're doing it differently.
[Dr. Aaron Fritts]
Yes. I wonder if it's just the angle at which you go under the clavicle.
[Dr. Christopher Beck]
Right. It's got to be something like that.
[Dr. Aaron Fritts]
Because I think that proximity of the clavicle is what causes it because it's a junction point, right?
[Dr. Christopher Beck]
Pinch point for sure.
[Dr. Aaron Fritts]
Pinch point and that's what's causing it. There's something that's tight in there. Over time as they move their arm up and down their shoulder, it's wearing on that little, silicone. Again, I don't see many of those. If it's not somebody who's done all the treatment, then it's somebody who has an infected port, whether it be bacteremia or their incision opened up. Usually when it's a purulent port pocket, like their incision opened up, it's a case where it was placed probably within the last month and it got infected. When it's bacteremia, it might be somebody who had one placed five years ago and they have a port in place and they're in the hospital sick and maybe it's something entirely different. Because that patient's blood cultures are positive, the ID team or the hospital's team, they're like, "We want that port out."
[Dr. Christopher Beck]
Yes. Want that port out, want that pacemaker out, whatever central line is giving them access to the antibiotics should come out. VP shunts come out. Everything. That's standard operating procedure. I don't mean to make fun of ID docs, but I think that's page 1 of the playbook, like, "Take out all things that do not belong to the patient."
[Dr. Aaron Fritts]
Yes. Whatever it could be. An -itis or the source.
[Dr. Christopher Beck]
Yes, exactly. An -itis.
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Conversations with Patients about Port Removal
The premature removal of a port can be a frustrating experience for patients. Being knowledgeable about the indication for their port removal can help you better answer any questions or concerns they may have. Additionally, discussions should include setting realistic expectations regarding potential changes in scarring and the method of anesthesia used during the procedure.
[Dr. Aaron Fritts]
We'll talk about infection a little bit, what you do for those, but I want to talk about the conversation that we have with the patient. Mostly it's congratulatory. When it is infected, what kind of conversation do you have with a patient about the infection and why we have to take it out? Do you ever talk to them about that sort of thing?
[Dr. Christopher Beck]
Only I talk to them and it's just a little bit firm in that, "It's too bad that this got infected." I try not to dwell on the past. I don't know why it got infected. I don't try and cover a lot of the past ground. I just say, "This is where we are and this is what we have to do to move forward." Because a lot of times it feels like a step in the wrong direction for them. I just tell them that, "This is just a part of the process. We got to get this old one out. The old one's bad. The new one will be good as soon as we can clear the infection." In the informed consent, that's where I stand.
Because I think a lot of them wonder how they got there, what happened. I just try and focus on where we're at and not really how the port got infected or why it did. Because sometimes they even internalize it. They're like, "Oh, is it anything I did? Is it because I took an extra bath or I take long hot showers?" I'm like, "No, no, no. It's none of those things." Even if it were, which it probably is not, I'm just like, "It's infected. We think it's infected. Let's get it out, get the infection treated, and then get you some new access until we can get you another port in."
[Dr. Aaron Fritts]
Yes. The other thing that I talk to them about, especially if you can see the incision opened up, it's pus coming out, purulent stuff coming out. I let them know, "Hey, I'm not going to be able to suture this back up the way it was. You're probably going to have a bigger scar than you would have," because sometimes they're not prepared for that, for the sort of secondary closure and everything like that. That's the only other thing other than what you said already.
I also talk to them about the anesthesia. I say, "Look, it's very similar to when you had it placed." I use moderate sedation for virtually everybody unless there are some hospitals where they book them, but just local. Then I talk to them, I say, "Look, I'm going to put a lot of lidocaine in there to try and make you as comfortable as possible. If you want to be sedated, then I'm happy to reschedule you and have you come back another time."
Because sometimes people aren't prepared for that either. Again, it's just because sometimes, I'm covering for the doctor. That other doc might do all theirs under local and they convince the patients to do it under local. I just feel like it's not that different from when you put it in. There's a lot of scar tissue that you have to dissect through and that can be painful. That's why all mine are moderate.
Approaches to Port Removal
Port removal procedures often pose some level of complexity, necessitating meticulous dissection during removal due to the formation of scar tissue around the port site. Moderate sedation should be utilized during removal to ensure patient comfort while keeping in mind that sedation needs vary based on patient circumstances such as transportation limitations or adverse reactions to anesthesia. Exceptions for local anesthesia are considered for specific cases, underscoring the aim to tailor the approach to individual patient needs.
[Dr. Christopher Beck]
There's way more dissecting on the port removal than there is the port placement. Whenever I'm placing a port, it's almost easy to find a nice clean pocket to tuck it in. Don't get me wrong. I dissect with my finger and I do have to make sure I have adequate local anesthesia on board.
Whenever it's a port removal, it's a little bit more of like, you're dissecting around those boundaries and sometimes cutting into scar tissue. To me, it's not dissimilar from putting it in. I use moderate sedation for placement, but if it's working for other docs then kudos to them. There's certain patients who the risk of anesthesia certainly is outweighed by the benefits. If the patients are up for it, I don't disagree necessarily. For me, it feels like moderate sedation right on board.
[Dr. Aaron Fritts]
Some patients are totally fine because they're like, "Look, I couldn't get a ride home." It's just a pain in the butt to have to do sedation because they've already been through it. Or it's an elderly patient who the family is like, "Look, she doesn't do well with sedation. Can you just give her a lot of lido?" Those are the kinds of things, exceptions to the rule. Not to say that I'd never do it local only, but I just prefer moderate because I want them to be comfortable. Every time you're dissecting through that scar, they're flinching. I just want them to be comfortable.
[Dr. Christopher Beck]
I totally agree. Totally agree.
[Dr. Aaron Fritts]
We covered anesthesia.
[Dr. Christopher Beck]
Hold on. Can I back it up almost like the very first part. I know when you were introducing the topic, you called it a Mediport. Is that what you call? You call them always Mediports?
[Dr. Aaron Fritts]
Mediports. Yes. What do you call them?
[Dr. Christopher Beck]
I just call them ports.
[Dr. Aaron Fritts]
Yes. That's what we call them on our website too. Mediport.
[Dr. Christopher Beck]
I noticed that. I just call them ports.
[Dr. Aaron Fritts]
Let's see. This is a good thing to cover. What else are they known as? Because they're known by multiple names. There's some places where they call them port-a-caths.
[Dr. Christopher Beck]
Port-a-caths. Mediports-
[Dr. Aaron Fritts]
Mediport, PowerPorts.
[Dr. Christopher Beck]
-and ports is what I see all the time. I didn't know what the actual official-- if you look at the CPT code, I wish I had it in front of me, but we'll have to look it up and include in the show notes. There's a CPT code. It's subcutaneous tunneled central catheter or something with port.
[Dr. Aaron Fritts]
With port. Yes, you're right. It really says Mediport.
[Dr. Christopher Beck]
It doesn't roll off the tongue, certainly.
[Dr. Aaron Fritts]
Yes. I don't know. I'm sure I got it from training somewhere.
[Dr. Christopher Beck]
No doubt.
[Dr. Aaron Fritts]
What else? There's something else that it's called. It's escaping me, but yes, it's known by multiple things. Actually, that's what I was thinking of. When I'm looking for a dictation, like I'm at a new hospital or something, it's like, yes, not everybody calls it Mediport. Sometimes people just call it the PowerPort. Because they're like, "Mediport is what my grandma put in."
[Dr. Christopher Beck]
That's right. Yes. I see PowerPorts, which is probably more accurate. Everything I put in is a PowerPort.
Reopening the Site
After ample local anesthesia, an incision is made along the previous incision site to minimize additional scarring. The primary goal is to carefully dissect down to the port without damaging the catheter, avoiding severing the catheter which could cause the catheter to be drawn into the patient's body, a serious complication. Strategies to avoid cutting the catheter include precise incision and dissection towards the reservoir and employing techniques such as using curved hemostats to gently mobilize the reservoir away from surrounding tissue.
[Dr. Christopher Beck]
Let's jump into the typical procedure. You'll just walk us through how once the patient's on the table, got your local in-- tell us how you put your local in.
[Dr. Christopher Beck]
First I like to know a little bit about the patient ahead of time. How long has it been in and are they having any problems with it? I want to know if it's subclavian or IJ. I want to know if I put it in. Ideally, if there's a note, because I don't suture mine in, but there are plenty of docs that do. I want to know those things ahead of time. If I don't, it's all things that I can figure out, but I just wanted to say that.
At the patient on the table, anesthetize, I use a lot of anesthetic. I know that we talked about on the podcast about anesthesia, about the dose limits for lidocaine. I use a lot of lidocaine. I've never had a patient who had side effects from lidocaine. I use a large amount of lidocaine a lot of times with Epi, but if for some reason it's not with Epi or there's a contraindication, then I don't sweat that.
I usually will try and use the same incision that they used to place it. People place their ports differently, but I'll try and make the incision that the original provider who placed the port used. Don't have to, but that's what I try and do. 90% of the time and a hundred percent of the time when it's me, that's at the top end of the Mediport. It's where the reservoir meets the port of catheter.
I do the anesthetic, I cut down deep and break through the sub-Q layer, careful to not cut the actual port catheter. That's the one thing. I feel like the golden rule of removing ports is, you don't want to cut that catheter. I'm not saying it's going to get sucked into the patient's body, but it can.
[Dr. Aaron Fritts]
It could.
[Dr. Christopher Beck]
Yes, for sure. There's no doubt. There's a surgeon at one of the hospitals that I work at. He's a good buddy. He just sometimes is a little bit lackadaisical with hooking up his reservoir with his catheter. He'll just take his eyes off at a second, then they get sucked into the body and we'll go retrieve it in the OR in the cath lab the next day.
[Dr. Aaron Fritts]
Oh my God.
[Dr. Christopher Beck]
It happens enough to where we started giving him a really hard time about it. It's really funny. I think now that we've started giving him a hard time, he's making more effort. Anyway, I cut down and I try and cut down deep, but care to air towards the side of the reservoir because I do not want to cut that catheter. Then once I've made that first incision, I dig straight down on both sides of the reservoir and near the tip of the reservoir where it connects to the catheter. I go deep on the right side, deep on the left side. Then I try and loop or try and scoop a pair of curved hemostats underneath that.
Then once I can connect those two things, I can inch it cranially. Then I'm always trying to birth the catheter first. Once I have the catheter out, then it's game over and you just have to go to the workmanship of-- it's the blocking and tackling of just getting the reservoir out. That to me is-- priority one is to not cut the catheter, get the catheter out. Then once the catheter is out, then you know the game is won, is just getting the reservoir.
[Dr. Aaron Fritts]
Yes, I completely agree. That's the big thing that you're scared of is cutting that catheter. One thing when I was a fellow that Robbie Morrison, my co-fellow taught me actually, and I guess one of the fellows before him taught him was to hold the incision scar over-- you'll grab the skin and pull it over top of the actual port reservoir. Then when you're making your incision, you're making it over the port reservoir and not over where the catheter is.
Then you can basically cut down to it. Even if we cut the silicone at the top, it's not a big deal, but at least you know you're safe and you're not going to cut that catheter. That's what I do to prevent that. Because yes, that's my worst-- It's not a worst nightmare, but just to watch that catheter get sucked up into the body.
[Dr. Christopher Beck]
Have you ever seen that? Have that ever happened to you?
[Dr. Aaron Fritts]
No.
[Dr. Christopher Beck]
Oh, yes. Never happened to me either.
[Dr. Aaron Fritts]
No, absolutely not.
Closing the Wound
The pocket previously housing the port is irrigated, followed by brief inspection with digital palpation. The closure of the surgical site involves the use of 2-0 Vicryl for the deep layer and 3-0 Vicryl for more superficial layers, aiming for close approximation of the tissue to promote healing. This meticulous approach to closure reflects the procedural priority on minimizing potential complications and ensuring a smooth recovery for the patient.
[Dr. Aaron Fritts]
Yes. You got the catheter out. You got the reservoir out, ports out. Sometimes a joke I say, "It's a boy," and if the patient's awake, they get a little laugh.
[Dr. Christopher Beck]
Sure.
[Dr. Aaron Fritts]
Then what do you do?
[Dr. Christopher Beck]
I'll usually irrigate the pocket a little bit just out of habit. I'll come dunk some water in it and then clean that out. I don't know why but I just inspect the pocket very briefly. Like digital palpation. Then once that's done, I'll usually close with 2-0 Vicryl, for the deep layer 3-0. I'll try and bring it as close to approximated as possible. Then if I can, if I feel like it's coming together nicely the rub on the top.
Podcast Contributors
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Dr. Aaron Fritts
Dr. Aaron Fritts is a Co-Founder of BackTable and a practicing interventional radiologist in Dallas, Texas.
Cite This Podcast
BackTable, LLC (Producer). (2023, December 25). Ep. 396 – How I Perform a Port Removal [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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