Technique

Peritoneal dialysis catheters may be placed via a percutaneous, a laparoscopic, or an open

surgical route. Open surgical and laparoscopic techniques are preferred because of their safety
and good initial results. Although less invasive, percutaneous peritoneal dialysis catheter
placement has the risks of unsatisfactory placement and bowel injury.

Open surgical technique

See the list below:

 The patient is placed in a supine position. General anesthesia is used and intravenous
antibiotics are administered.
 An infraumbilical midline incision is made. The subcutaneous layer is dissected down to
the sheath of the rectus abdominal muscle. The anterior rectus sheath is opened, and the
muscle fibers are bluntly dissected. The posterior sheath is incised, and the abdominal
cavity is opened after dissecting the peritoneum. The abdomen is inspected for adhesions,
and, if any are present close to the abdominal wall, they are dissected.
 Next, the patient is placed in a Trendelenburg position, and the catheter is placed over a
stylet and advanced into the peritoneal cavity. The intraperitoneal portion is slid off the
stylet, and the cuff is positioned in the preperitoneal space.
 The peritoneum and posterior and anterior rectus sheaths are closed with absorbable
sutures taking care to prevent catheter obstruction and leakage of dialysate. A tunnel is
then created to the preferred exit site, which is usually lateral and caudal to the entrance
site. The distal cuff is placed subcutaneously, 2 cm from the exit site.
 The incision is closed, and the catheter is tested by filling the abdomen with 100 mL of
sterile saline while the entrance site is checked for leakage. The saline is then drained and
inspected to ensure no intraperitoneal bleeding or fecal contamination. [11]

Laparoscopic technique

The laparoscopic approach to peritoneal dialysis placement is becoming more popular because of
to its advantage of being able to perform partial omentectomy or lysis of adhesions if needed
during the initial catheter placement.

 The patient is placed in a supine position, and general anesthesia and intravenous
antibiotics are administered.
 Pneumoperitoneum is typically established via an open technique with a 5-mm access
port in a subumbilical midline position. Diagnostic laparoscopy is performed with a 5-
mm 0-degree lens. An additional 5-mm trocar is placed under direct vision at the site of
the planned exit-site position of the peritoneal dialysis catheter. This is usually
paraumbilical left or right 2-3 cm below the umbilicus.
 The trocar is advanced through the anterior and posterior rectus sheaths, but not through
the peritoneum. Under direct vision, the trocar is directed into the preperitoneal space, 2-
4 cm downwards and to the midline of the abdomen.
  If adhesions are present, the trocar is placed into the abdominal cavity and the adhesions
are lysed. A double-cuffed curled tip peritoneal dialysis catheter is then placed through
the paraumbilical port with the curled tip placed into the pouch of Douglas.
 If no adhesions are present, the second trocar is left in the preperitoneal space. A stiff
stylet is then used to introduce the peritoneal dialysis catheter into the peritoneal cavity.
The distal cuff of the peritoneal dialysis catheter remains outside of the peritoneal cavity
and is positioned either in the preperitoneal space or between the rectus sheaths.
 The paraumbilical trocar is removed, and the catheter is then directed to its exit-site
location. A subcutaneous tunnel is created, and the catheter is brought through the tunnel
with the proximal cuff positioned within the tunnel.
 The catheter is tested, and the abdomen is desufflated. The trocar is removed, and the
rectus sheaths are closed. [11]

Percutaneous placement

Percutaneous placement of peritoneal dialysis catheters with a guidewire and peel-away sheath
uses the Seldinger technique. Percutaneous peritoneal dialysis catheter placement can be
performed under local or general anesthesia with prophylactic antibiotics.

 A small incision is made above the entrance site, usually in the midline with blunt
dissection of the abdominal rectus sheath.
 An 18-gauge needle is placed into the peritoneal cavity. Proper positioning of the needle
is confirmed by filling the peritoneal cavity with air or 500 mL of saline. Absence of pain
or resistance with filling suggests proper needle positioning.
 A 0.035-inch guide wire is then advanced through the needle into the abdomen, and the
needle is removed.
 A dilator and peel-a-way sheath are advanced over the guidewire into the abdominal
cavity. The dilator and wire are then removed, and the peritoneal dialysis catheter is
placed on the stylet and advanced through the sheath. The PD is advanced until the
proximal cuff is in the preperitoneal sheath.
 The peel-a-way sheath and the stylet are removed, and the position of the catheter is
checked.
 A tunnel is created to the selected exit site, with placement of the distal cuff
subcutaneously 2 cm from the exit site. The entrance site is closed. [11]