Received: 26 October 2021 Revised: 27 April 2022 Accepted: 7 June 2022

DOI: 10.1111/sdi.13118

REVIEW ARTICLE

Peritoneal dialysis catheter insertion techniques by the

nephrologist

Bak Leong Goh1 | Christopher T. S. Lim2

1
Department of Nephrology & Clinical
Research Centre, Hospital Serdang, Kajang, Abstract
Malaysia Peritoneal dialysis (PD) catheter is the lifeline of PD patients, and despite the overall
2
Department of Medicine, Faculty of Medicine
strength of the PD program in many countries, PD catheter survival remains the
and Health Sciences, Universiti Putra Malaysia,
Serdang, Malaysia major weakness of the program. The prompt and effective implantation of the
PD catheter, as well as speedy management of complications arising from catheter
Correspondence
Professor Dr. Bak Leong Goh, Department of insertion, remains crucial for the success of the program.
Nephrology & Clinical Research Centre,
Hospital Serdang, Jalan Puchong, 43000
Kajang, Selangor, Malaysia.
Email: bak.leong@gmail.com

Funding information
No funding was received for this article.

1 | I N T RO DU CT I O N 1.1 | Review of catheter design and option

Traditionally, in many countries, PD catheter was implanted by sur-
geons. This invariably resulted in an inherent delay where potential
patients were exposed to hemodialysis and in the process developed
a loss of interest in PD. Patients who experienced complications such
as catheter malfunction were often forced into long waiting times
1–9
before catheter-related problems can be solved. These factors par-
tially, if not mostly, explained why PD penetration remains low at
around 10% around the world, despite its many advantages such as
preservation of residual renal function,10,11 lessened incidence of left
ventricular hypertrophy,12 cost-effectiveness,13 and reduced cardio-
vascular events.14 While great developments in clinical and basic sci-
ence knowledge have occurred in the field of PD, PD access remains
a challenge and debates remain concerning the preferred access,
implantation technique, exit-site care, and ideal operators. Attempts
and search for evidence-based recommendations usually face with
limitations of a small number of randomized controlled trials (RCT)
and the inadequacy of statistical power of small sample size studies.
Without the purpose of extensively reviewing all the details on PD
access, an update on various commonly available accesses, insertion
techniques especially from a nephrologist perspective will be
presented.
Purpose: To understand what has been tried and what does work.
Long-term PD catheter was made a reality by the development of
the first long-term indwelling catheter (first by Sir Henry Tenckhoff in
1968), created by adding Dacron® cuffs to the earlier silicon-rubber
catheters.15 Until today, modern catheters still use Tenckhoff's design
of variations of it.
1.1.1 | Early designs and concepts
An ideal catheter should be simple, safe, and long-lasting, with a mini-
mal rate of access-related complications while ensuring a rapid dialy-
sate flow rate. Several subcutaneous and intraperitoneal designs were
proposed as better devices subsequently. The catheter may be single-
or double-cuffed with a straight or curled intraperitoneal segment.
1.1.2 | Dr. Henry Tenckhoff's contributions
Since its development in 1968, Tenckhoff catheter is still the most
widely used, either by medical or surgical methods.

24 © 2022 Wiley Periodicals LLC. wileyonlinelibrary.com/journal/sdi Semin Dial. 2024;37:24–35.

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GOH AND LIM 25

Each PD catheter is comprised of three parts:
• Intra-abdominal segment
• Subcutaneous tunnel segment
• External segment
The intra-abdominal segment has multiple small side-holes and an
open terminal end. The subcutaneous segment has two cuffs, the
outer cuff is placed just under the skin (2–3 cm) at the exit site, and
the deep cuff is placed preferably in the rectus sheath just external to
the fascia covering the parietal peritoneum.
1.1.3 | Current variation and alternate option
the internal tip to avoid catheter-tip migration.19 However, these
variations have not shown any consistent advantage in comparison to
standard PD catheters. Therefore, the experience of the center should
dictate the type of catheter used. Table 1 listed the results of the
randomized control trials on the type of catheters.
Some studies, including the International Society for Peritoneal
Dialysis (ISPD) consensus, favored double-cuffed in comparison with
single-cuffed PD catheters in terms of better survival, longer time to
first peritonitis, and fewer exit site infections.27 Theoretically, the
coiled catheter offers less infusion pain, fewer catheter migration, and
omentum wrap. However, the available studies provided inconsistent
results as shown in Table 1. Our center analysis of 126 patients and a
recent Cochrane analysis also failed to show the impact of different
catheter types on peritonitis occurrence and rate.28,29

Straight Easy to place by percutaneous technique

Easy to remove and replace
Outflow problems and rectal discomfort are more
commonly reported
Curled Same as above, but better patency and better outflow
reported
Does not impinge on the rectum
Swan Neck Permanently curve and has less reported migration16
Missouri Combination of Toronto Western and Swan Neck
catheter
Need to be placed and manipulated surgically17,18
PD catheters with different intraperitoneal designs include
Toronto Western (silicon discs perpendicular to the catheter) and
Missouri (Dacron disc and silicon bead) catheters. The purpose of
these designs is to reduce pericatheter leak and migration and at the
same time ensure better flow. Some devices are created to stabilize
the catheter with the intra-peritoneal disk, bead, or flange. There are
also self-locating catheters designed with a tungsten weight added to
1.2 | Review of basic anatomy implementation
sites and catheter function
Purpose: To understand the inter-relationship between anatomy.
There are generally two common approaches in implanting the
PD catheter. The median or infra-umbilical approach is generally
easier to perform. This involves going through the thinnest layer of
abdominal fascias. The subcutaneous layer is dissected down to the
linea alba and implantation is performed. As the catheter is lying
lower, there is a risk that the tip of the PD catheter can be deflected
upwards by pelvic organs during catheter advancement. Moreover,
the low lying catheter can potentially cause pelvic wall irritation.
Furthermore, the inferior gastric arteries, which run at the medial
border of rectus muscles can be lacerated during the tunneling
process (Figure 1). This technique is also inherently flawed by posi-
tioning the deep cuff in the subcutaneous space external to the mus-
cle fascia as they do not provide adequate tissue attachment to the
deep cuff, which can result in leaks, hernias, and superficial cuff

TABLE 1 Randomized controlled trials (RCTs) of PD catheter designs

No of
Author patients Type of catheter Duration Outcomes
20
Akyol et al. 40 Straight versus coiled 23 months No difference in catheter-related infections
21
Eklund et al. 60 Single versus double cuffed 20 months No difference in catheter-related infections and
catheter survival
Eklund et al.22 40 Straight double cuffed versus Swan-neck 12 months No difference in catheter-related infections and
(double cuffed, coiled) catheter survival
Johnson et al.23 132 Straight Swan neck, double cuffed versus double 24 months No difference in catheter-related infections but
cuffed, coiled coiled catheter has higher technique failure
Lye et al.24 40 Straight double cuffed versus Swan-neck 12 months Lower exit-site infection in the Swan-neck
(double cuffed, coiled) group. Peritonitis and catheter survival are
similar.
Nielsen et al.25 72 Straight, single cuffed versus permanent bent 6 months No difference in catheter removed from
Swan-neck (curled, single cuffed) peritonitis. The straight catheter has more
migration.
Scott26 89 Straight, double cuffed versus Toronto Western 12 months No difference in catheter-related peritonitis and
double disk or Oreopoulos standard coiled catheter survival

Abbreviation: PD, peritoneal dialysis.

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26 GOH AND LIM

F I G U R E 1 The relationship
of the inferior gastric arteries
with paramedian versus infra-
umbilical approach

TABLE 2 RCTs of different implantation techniques and outcomes

No of
Author patients Technique Duration Outcomes
31
Gadallah et al. 148 Peritoneoscopic versus mini-laparotomy 16 months Higher infection rate and lower catheter survival in
the laparotomy group
Jwo et al.32 77 Laparoscopic versus mini laparotomy 48 months No difference in catheter survival or infection
Atapour et al.33 64 Surgical versus percutaneous 2 months Higher flow issue and exit site infection in the surgical
group
Voss et al.34 113 Laparoscopic versus percutaneous 12 months Similar catheter survival. The laparoscopic group has
(fluoroscopic) more leaks and peritonitis

Abbreviation: RCT, randomized controlled trial.

extrusion. On the other hand, overzealous implantation of the deep
cuff will push the cuff deep into the peritoneal cavity. This results in
flow failure secondary to omentum wrap.
The paramedian approach, despite going through a thicker layer
of rectus muscles, has the advantage that it can overcome the above
risks. Thus, it is associated with fewer early postoperative complica-
tions with better PD catheter and overall patient survival.30 For these
reasons, published guidelines have identified the best-demonstrated
practice for insertion of the catheter will be through a paramedian
approach and to implant the deep cuff within the musculature of the
abdominal wall.27
1.3 | Catheter implantation options
Purpose: To be aware of the advantages and disadvantages of the
techniques.
There are four methods of placement of PD catheters:
2. Through peritoneoscopy, in which a small (2-mm) optical instru-
ment is used to choose the optimal location of the catheter within
the peritoneum, and the catheter is advanced into the same
location through the Quill® assembly after the peritoneoscopy.
3. Through open laparotomy, a surgical technique in which layers of
tissue are separated under direct vision.
4. Through laparoscopy where insertion of a peritoneal dialysis cath-
eter is usually performed under general anesthesia (GA). The abdo-
men has to be insufflated and several small incisions are made.
There are not many randomized control trials that compare the
different implantation techniques concerning the outcomes. Gener-
ally, as summarized in Table 2, surgical methods have more complica-
tions as compared to medical methods.
Before insertion of the catheter, the following are to be
recommended.
Patient preparation

1. Through Seldinger's technique where a blind puncture is Cardinal rules

done, then a needle is inserted into the abdomen, a guidewire
placed, a tract dilated, and the catheter inserted through a 1. Each center should have a dedicated team involved in the implan-
sheath. tation and care of peritoneal catheters.

GOH AND LIM
2. PD catheter insertion should not be delegated to inexperienced
unsupervised operators.
Informed consent
Patients should be informed of the potential complications. Dur-
ing this time, the nature, indication, and complications that may arise
from the procedure are explained to the patient. Evaluation of the
patient's coagulation status is also indicated.
Preoperative assessment
This should include thorough examination searching for hernias
that may be repaired at the time of insertion (or before), and scars
from previous abdominal surgery. Selection of the most appropriate
catheter type, marking of the insertion and exit site location should be
performed.
Bowel preparation
Constipation is a known cause of catheter dysfunction.35 There-
fore, preoperative bowel preparation is recommended to optimize
peritoneal access. This can be achieved by the administration of a
stimulant suppository a day before surgery.
Preparation of operation site
The patient is advised to shower on the day of the procedure
with chlorhexidine soap wash of the planned surgical site and removal
of body hair is done in the preoperative holding area, preferably with
electric clippers.
FIGURE 2 Showing combinations of intraperitoneal and extraperitoneal designs and the lateral view in relation to the abdomen wall
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27
Prophylaxis antibiotic
Single preoperative dose of prophylactic antibiotic to provide
anti-staphylococcal coverage will be administered immediately before
the PD catheter implantation.
Anesthesia, analgesia, and conscious sedation
Patients with end-stage kidney disease generally have multiple
co-morbidities leading to increased risk of GA.36 Laparoscopic inser-
tion of a PD catheter requires GA for the creation of CO2 pneumoper-
itoneum and visualization of the abdomen. Even though laparoscopic
insertion of PD catheter by creating nitrous oxide pneumoperitoneum
under local anesthesia has been described, the vast majority of cases
using laparoscope will need GA.37 In patients who are not suitable for
GA, peritoneoscope or percutaneous technique, performed under
local anesthesia with analgesia and sedation, should be preferred.
Analgesia and sedative agents frequently used during peritoneoscope
technique are lignocaine 2% (10 ml), fentanyl (10 mcg and titrate up
to100 mcg), and midazolam (1-mg titrate up to 5 mg). They are
favored due to their anxiolytic and amnesic effects.
A. Medical
1. Seldinger technique
The procedure can be carried out in the treatment room (with full
sterile precautions). After the patient has voided urine, the appropriate
site for the primary incision is selected; ideally, a paramedian
approaches for reasons outlined earlier (Figure 2). A 2- to 3-cm long
incision is made and the subcutaneous tissue is dissected down to the

28
anterior rectus sheath. The patient is instructed to take a deep breath,
hold it, and tense the anterior abdominal wall. An 18G
7-cm intro-
ducer needle is inserted through the fascia and into the peritoneal cav-
ity. When this is accomplished, the patient is allowed to breathe
normally. Once the presence of the needle in the peritoneal cavity is
ensured, the cavity is sometimes filled with about 1–2 L of dialysate.
A guidewire is fed through the needle, and the needle is then with-
drawn once the guidewire is in position in the peritoneal cavity, leav-
ing the guidewire through the entry point. The patient is again asked
to tense the abdominal muscles and a dilator with a peel-apart sheath
is introduced over the guidewire to dilate the insertion hole. The dila-
tor is then removed, leaving the peel-apart sheath in the cavity. The
appropriate catheter is soaked in sterile saline, all the air is squeezed
out from the cuff (air has an anti-fibroblast effect) and the catheter is
rinsed with saline. The PD catheter is threaded over the stylet, leaving
about 1 cm of the distal end empty. The catheter is then advanced
through the sheath (directed posteriorly), and slowly and gently angled
about 20 caudally. The stylet is removed, and the catheter is checked
for free flow of dialysate. If the flow is not smooth, the catheter must
be repositioned. Once the catheter is positioned in the desired place,
the sheath is peeled away. A curved tunnel is created and the main
incision closed. A tunneling tool is inserted through the exit site and
advanced to the main incision, carefully tracking it to fit the shape of
the desired tunnel. The catheter is attached to the tunneling device
and pulled out through the exit site until the cuff sits snugly under the
skin, 2 cm away from the exit site. Some centers routinely use fluoros-
copy to assist in catheter placement as a modification.
2. Peritoneoscopic (one puncture technique designed for nephrolo-
gists with local anesthesia)
This procedure provides endoscopic instrumentation with direct
visualization of the peritoneal cavity for nephrologists and is especially
useful if adhesions are suspected. A trocar inside a metal cannula that
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GOH AND LIM
is coiled around by a plastic Quill guide is advanced into the peritoneal
cavity at 45 angles from the horizontal, directing toward the coccyx.
The trocar is removed, and the abdomen is filled with about 600 ml of
filtered air via a separate air insufflation set. The patient is placed in a
typical Trendelenbugh position. The peritoneoscope is then inserted
through the metal cannula coiled around by the plastic Quill guide,
and the whole assembly is locked and advanced under direct vision
(Figure 3). The distal end of the scope is directed parallelly with the
anterior abdomen to ensure it enters the air pocket. Once the position
is confirmed by noting the smooth surface of the bowel moving with
respiration, omentum and anterior abdominal wall, the scope is
removed together with the metal cannula leaving the plastic Quill
guide in place. The plastic guide is dilated and the PD catheter on its
stylet is advanced through the guide (Figure 4). The guide is removed
carefully, ensuring that the catheter does not come out together when
the guide is removed. The stylet is then removed from the catheter.
Tunnel creation and skin closure are then performed.
B. Surgical
1. Cut-down
A horizontal incision of the skin is made over the lateral border of
the rectus sheath (lateral approach) or at the medial border of the rec-
tus muscle (paramedian approach) and the subcutaneous tissue and
the rectus are dissected to expose the peritoneal membrane. A 1- to
2-cm-long incision is made in the peritoneum and the bowel loops,
omentum, and the peritoneal cavity are identified. The catheter is
then placed into the peritoneal cavity, either between the anterior
abdominal wall and the omentum, with the tip of the catheter in the
pelvis space just anterior to the rectum. The peritoneum is closed
around the catheter, using non-absorbable purse-string sutures. The
deep cuff sits just external to the entry point through the peritoneum.
Interrupted sutures are used to close the muscle and subcutaneous
F I G U R E 3 A illustration of
components of Quill assembly

GOH AND LIM
FIGURE 4 Some of the essential steps of peritoneoscopic peritoneal dialysis (PD) catheter insertion
tissue around the deep cuff. The catheter is then laid over the skin in
a curved orientation so that the external segment points lateral and
downwards at the exit.
2. Laparoscopic (two puncture techniques designed for surgeons with
general anesthesia)
Laparoscopy provides a minimally invasive approach with
complete visualization of the peritoneal cavity during the catheter
implantation procedure. Laparoscopic procedures are performed
under GA in an operating room environment. Surgical laparoscopy
uses either a basic or advanced approach to providing PD access.
This technique needs a specially trained laparoscopic surgeon.
Advanced laparoscopic catheter placement employs proactive adjunc-
tive techniques (such as omentectomy, omentopexy, rectus sheath
tunneling, and immobilization of the catheter) that significantly
improve catheter outcomes.
1.4 | Detailed presentation of Y-TEC ®
peritoneoscopic procedure with laparoscopic
variations
Purpose: To learn the basic peritoneoscopic technique.
This procedure is carried out in a day-care or operating theater.
Patients are admitted a day earlier and are given a chlorhexidine bath
the evening before the procedure. On the day of the procedure, they
are asked to empty their bladders and prophylactic antibiotic
cefuroxime 1.5 g IV will be given. The procedures are performed
under local anesthesia and sedation. A combination of intravenous
midazolam and fentanyl are used. The level of sedation is titrated to
achieve moderate sedation, where the patient is still able to respond
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29
and cooperate with the nephrologist performing the procedure. The
procedure is carried out using Y-Tec® peritoneoscope (Medigroup, Illi-
nois, USA) with the use of a VP-210STD disposable pack (Medigroup).
Preferred catheters used are double cuffed coiled PD catheters of
either 57- or 62-cm length depending on the patient's body habitus.
Skin preparation for the operation is performed using povidone-
iodine, and the abdomen is draped as per the usual surgical procedure.
Lignocaine 2% is infiltrated into the skin as local anesthesia, and the
procedure is performed as described above. The standard chronic
catheter care with povidone-iodine is employed. Patients are routinely
put on a few cycles of manual PD immediately post-op until the PD
fluid is clear and discharged home the same evening or the next morn-
ing in the absence of complications. Catheter break-in for initiation of
treatment is usually performed within 2 weeks after insertion of the
catheter. If the training of patients and caregivers are delayed,
patients will be placed on PD cyclers weekly aiming for a weekly cre-
atinine clearance of 40–60 L/week/1.73 m2 while waiting for training,
which was usually performed within 2–4 weeks.
It was not our original intention to promote the peritoneoscope
technique alone, but by adopting this technique of PD catheter inser-
tion, we noted several advantages, including its simplicity, which
shortens the learning curve for new operators to master the tech-
nique. Also, the technical knowledge of this technique is transferable
through well-conducted workshops and thus will ultimately provide
positive, reproducible outcomes and enhance PD penetration.38
1.4.1 | Comparison of the three (medical, surgical,
and peritoneoscope) techniques
The major advantage of the percutaneous method is that it does not
require highly skilled surgeons and operating room with its inherence
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30 GOH AND LIM

long waiting time and needs for GA. The procedure is quick, relatively TABLE 3 Advantages and disadvantages of different implantation
inexpensive and with an experienced operator, the risk of complica- techniques

tion is low. The incidence of the fluid leak around the catheter is par- Advantages Disadvantages
ticularly low with this technique, even when a catheter is used Peritoneoscopy Can be done under Learning curve exists
immediately, as long as the infusion volumes are low.39 The disadvan- local anesthesia Require specialized
tage of the blind method is the potential for complications (including Able to visualize the equipment (Y TEC)
peritoneal cavity Blind puncture
injury to the viscera or bleeding).
Deep cuff secured at Require disposable
Safety is the major advantage of surgical procedures. It is carried rectus muscles VP-210STD pack
out under direct vision and omentum related procedures (if necessary) Can be done by the and air insufflation
and correct positioning of the catheter is possible. This procedure can nephrologist kit
also place any type of catheter. Medical Can be done under Blind puncture
The advantages of peritoneoscope are that it is mainly nephrolo- (Seldinger) local anesthesia Unable to visualize
Can be done at the peritoneal cavity
gist operated and that catheter can be placed in the most suitable
bedside Deep cuff rests on
position under direct vision, while the cost of the surgical technique Low cost rectus muscle
(theater, disposable VP-210STD pack, and air insufflation kit) and the Familiarity with Low pericatheter leaks
initial expense of the peritoneoscope form the major barriers. Fluid procedures

leaks are also more common and healing takes longer following surgi- Open Does not require any Require GA and
laparotomy specialized operating theater
cal technique than after the other procedures.
equipment Limited visualization of
The advantages and disadvantages and their unique characteris-
the peritoneal cavity
tics are summarized below in Tables 3 and 4. Higher postoperative
pain
More pericatheter
leaking
1.4.2 | Recommended technique
Laparoscopy Able to visualize the Require GA and
peritoneal cavity operating theater
We do not favor one technique over the others for the insertion of a Able to perform Learning curve exists
PD catheter. The decision to use any of the techniques outlined above intervention for, for Pain by CO2
depends on a variety of important factors such as familiarity with the example, insufflation
adhesiolysis Higher post-operative
technique, available budget, accessibility of the operating theater/day-
Minimizes the need for pain
care/procedure room, and the existing equipment. From a practical multiple procedures Only limited for use by
perspective, Seldinger's technique is most suitable for a new set-up the surgeon
PD center that has limited resources. Furthermore, most physicians or More pericatheter
leaking
nephrologists are familiar with Seldinger's technique, which makes the
learning curve relatively shorter. On the other hand, if a patient has a Abbreviation: GA, general anesthesia.
previous history of PD peritonitis, a peritoneoscope can be used to
visualize the suitability of peritoneal space before implantation is car-
ried out. Finally, if a patient has previous abdomen surgery in which (tPA) or urokinase may be used to dissolve a fibrin plug. Urokinase
adhesion is deemed to be highly possible, the laparoscopic method 5000 IU diluted with 0.9% saline solution to 40 ml is infused into the
will be preferred as adhesiolysis could be performed at the same set- catheter, and the catheter is clamped for 30–90 min. If required, the
ting if needed. procedure can be repeated with a higher dose of urokinase (10,000 IU
diluted to 40 ml with 0.9% saline). tPA is more expensive (used in a
dilution of 1 mg/ml), and the volume instilled is dependent on the cal-
1.5 | Catheter complications, causes and cures culated volume of the catheter assembly.41 The recovery of flow post
tPA has been reported to be near 100%.42 If the outflow problem is
Purpose: To be aware of possible complications and to avoid and/or due to migration of the PD catheter, it may have to be salvaged, repo-
resolve them. sitioned or replaced.
The usual non-infectious and infectious complications are dis-
cussed below: • Leakage around the catheter

• Outflow problem: Early leaks are usually related to catheter implantation tech-
nique, the timing of PD initiation, dialysate volumes used, and the
Laxative agents are useful to treat constipation related flow strength of abdominal wall tissues. The incidence of pericatheter
issues. If fibrin or clot is observed, heparin 100–500 units/L can be leaks is higher with a midline than with a paramedian site.43 Dialy-
40
added to the dialysate. If that fails, tissue plasminogen activator sate volume should be reduced, or the procedure stopped
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GOH AND LIM 31

T A B L E 4 Characteristics of
Peritoneoscope versus laparoscope versus open
peritoneoscope versus laparoscope
versus open technique Peritoneoscope Laparoscope Open surgical
Diameter (mm) 2.2 3.10 -
Operator Physician/surgeon Surgeon Surgeon/physician
OT room Yes Definite Yes
Procedure room Yes No Possible
Anesthesia LA GA LA/GA
Poor GA risk Yes No Possible
Anesthetist No Yes No/Yes
Incision/puncture 1 (1–3 cm) 2–3 (1–3 cm) 2 (5 cm)
Operating time (min) 20–30 45 30–45
Insufflation Air CO2 -
Tissue manipulation Minimal More Most
Direct visualization Yes Yes No
Immediate use Yes Maybe No
Leak Minimal Minimal More
Pain ## # Most
Complexity Simple Complex Mix
Length of stay <24 h >24 h 2–3 days
Break-in time ≤1 week ≥2 weeks ≥2 weeks
Previous surgery Yes/no Yes Yes
Obese Yes Yes Yes
Catheter salvage Possible Yes No

Abbreviation: GA, general anesthesia; LA, local anesthesia.

temporarily to allow sufficient time for healing to occur. If the
patient is receiving CAPD, a temporary switch to APD in a supine
position is recommended.
• Exit site infection
• Cuff erosion
This tends to be the result of a tunnel being too short for the tun-
nel segment of the catheter, which over time forces the superficial
cuff out. The extruded cuff can be carefully shaved off.

The presence of redness, pain, swelling, or discharge at the exit
site should be treated as infection, and any discharge should be cul-
tured. First, the area must be cleaned thoroughly, and a local anti-
bacterial agent (such as povidone-iodine) applied daily. Local
treatment alone may not be effective, systemic antibiotics should be
added. If the cuff is not involved (the skin over the cuff is not
inflamed, squeezing on the cuff produces no discharge or pus) exit
site infection can be treated successfully without removal of the
catheter.44
• Bowel or visceral perforation
Accidental perforations into the bowel and bladder have been
recognized. Many of these perforations are asymptomatic due to the
small puncturing needle/scope. A majority of these patients can be
treated medically. Clinical deterioration or increasing peritoneal irrita-
tion will require surgical intervention.45
• Bleeding

• Tunnel infection A common cause of bleeding is laceration of inferior epigastric

Redness, pain, swelling, and induration over the tunnel are signs
of tunnel infection. These do not usually respond to therapy and the
risk of recurrent peritonitis is high. If the infection does not respond
to treatment, the catheter should be removed or replaced through a
newly created tunnel and antibiotic therapy should be continued for
at least 2 weeks.44
arteries. An arterial laceration may occur from needle insertion into
the blood vessels, which can be easily detected. In such cases, remov-
ing the needle or other offending agents may be sufficient to control
bleeding. Bleeding can also occur from puncture of intra-abdominal
vessels, though it occurs less frequently. Prompt intervention is
needed and may require surgical ligation through laparoscopy or
laparotomy of the affected vessels.46

32
• Hernias
Increased intra-abdominal pressure can cause abdominal
hernia and hemorrhoids. Decreasing the intra-abdominal pressure
by decreasing volume in a nightly dialysis program may be
helpful.47
• Pain during dialysate flow:
 At the beginning of inflow improving later:
Usually, this is due to hypersensitivity to acidic pH. Measures to
raise the pH of dialysate and ensure the fluid is at a suitable tempera-
ture will be useful.48
 At the end of inflow and outflow:
Hydraulic suction of the omentum and a long intraperitoneal
segment of the PD catheter due to low implantation can result in
pelvic wall irritation. Tidal PD or changing to a shorter length of the
tube have been proven to be able to lessen the pain.49
• Back pain
This is seen frequently in patients undergoing continuous ambula-
tory peritoneal dialysis and requires that the patient be evaluated for
other medical problems affecting the back. Changing to night-time
50
(supine) dialysis may relieve symptoms in some.
• Peritonitis:
If peritonitis presents as an early complication, it should raise the
possibility of intraoperative contamination. Polymicrobial peritonitis
with gram-negative organisms and/or yeasts is most suggestive of
colonic perforation. If bowel perforation is suspected, the diagnosis
should be confirmed and appropriate surgical intervention with
removal of the infected catheter is recommended.51
1.6 | Repositioning of catheter
Purpose: To be aware of aspects of catheter salvage or replacement.
When extrinsic compression of the catheter tip by distended
intraabdominal structures and intraluminal blockage by fibrin/clots
have been excluded, the flow failure can be attributed to either cathe-
ter tip migration to a location of poor drainage function or obstruction
by adherent intraperitoneal tissues. Both conditions may have the
radiologic appearance of a catheter tip displaced from the pelvis while
the latter can also occur with a normal pelvic position. Options for
restoring catheter flow function include radiologically guided manipu-
lation, laparoscopically-directed interventions, and simultaneous cath-
eter replacement.
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GOH AND LIM
1.6.1 | Radiological manipulation
Fluoroscopic-guidewire, stiff rod, and aluminum bar manipulations
have been used to resolve catheter tip migration and extraluminal and
intraluminal obstructions. The procedures are minimally invasive, do
not require anesthesia, and allow PD to be resumed immediately if
technically successful.52,53
1.6.2 | Exchange via the percutaneous method
We have demonstrated successful simultaneous removal and reinser-
tion by PD catheter via a stylet or guidewire, which can be completed
in less than 30 min.54
Stylet method
A 70-cm stylet is inserted through the old PD catheter into the
peritoneal cavity before the catheter was removed, leaving the end
stylet still within the peritoneal cavity. A new PD catheter is then
threaded through the stylet (with the curved end straightened) and
then placed into the peritoneal cavity. The internal cuff of the
catheter was then placed within the rectus sheath and the external
cuff implanted within the subcutaneous tissue, at least 2 cm away
from the new exit site.
Guidewire method
A 70-cm guidewire is inserted through the old PD catheter before the
old catheter is removed. Subsequent steps were similar to PD cathe-
ter insertion via Seldinger's method. A dilator and a pull-apart sheath
as a single unit were advanced along the guidewire into the peritoneal
cavity. The new PD catheter is inserted through a pull-apart sheath
with the guidance of a stylet and placed into its proper position. The
internal cuff was placed just above the anterior rectus sheath and the
external cuff was implanted within the subcutaneous tissue in the
normal fashion.
The caveat for guidewire guided exchange is that it may not be
able to bypass complete intraluminal blockage from thrombus or
omentum wrap. In such cases, the old PD catheter will not be able to
be retracted while keeping the guidewire stationary.
1.6.3 | Surgical manipulation
Direct visualization with endoscopic instrumentation has the advan-
tage of allowing identification of the underlying condition producing
catheter flow dysfunction and permits diagnosis-specific manage-
ment. The details of the technique are beyond the scope of the article.
However, those who are interested in more detailed descriptions can
refer to the article by Crabtree et al.27
We have outlined the PD catheter malfunction algorithm in
Figure 5.

GOH AND LIM
F I G U R E 5 Peritoneal dialysis (PD) catheter malfunction algorithm. *, endoscopic salvage via laparoscope or peritoneoscope depending on
available expertise
1.7 | Continuous Quality Improvement and
monitoring tools
PD catheter insertion success rate is known to vary among different
operators and demands mastery of a steep learning curve. Defining a
learning curve using a continuous monitoring tool such as a Cumula-
tive Summation (CUSUM) chart is useful for planning training pro-
grams. The evaluation of technical proficiency in a specific operation
is a difficult and complex task. CUSUM is a type of monitoring tool
that has gained acceptance in the medical field. The basic point of the
analysis is to plot the sequential difference of a set of measured
values and to define a target level for those values. With the
establishment of the learning curve, nephrologists, and surgeons can
be objectively evaluated for this approach. We applied CUSUM chart-
ing to assess the doctor's performance of peritoneoscopic PD cathe-
ter insertion. CUSUM chart is a graphical representation of the trend
in the outcome of a series of consecutive procedures.55,56
At acceptable levels of performance, the CUSUM curve is flat,
while at unacceptable levels of performance, the curve slopes upward
and eventually crosses a decision interval, h. When this occurs, the
CUSUM chart indicates unsatisfactory performance. When this hap-
pens, the doctor being monitored is required to determine and correct
the cause of unacceptable performance. The CUSUM monitoring
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33
scheme is then restarted. Restart should theoretically be at 0, but one
often restarts at h as the new x axis, so the raising CUSUM chart can
be obtained to represent the learning curve that is typically seen for
trainees.55,56 We defined the acceptable level of performance as a pri-
mary failure rate of <15% (defined as catheter malfunction within
3 months of insertion) and an unacceptable level of performance as a
primary failure rate of >30%.
1.7.1 | Proposed key performance index (KPI)
We recommend the multidisciplinary PD team should meet regularly
to review and audit the center performance. We suggest the audit
show peg to the following KPIs to ensure the delivery of a
high-quality PD program:
1. Catheter patency—more than 80% of catheters should be patent
at 1 year (censor for death and elective modality changes)
2. Complications following PD catheter insertion -
• Bowel perforation <1%
• Significant hemorrhage <1%
• Exit site infection within 2 weeks of catheter insertion <5%

34
• Peritonitis within 2 weeks of catheter insertion <5%
• Functional catheter problem requiring manipulation or replacement
or leading to technique failure <20%
2 | C O N CL U S I O N
We have summarized and updated here the catheter types, pre-
procedure work-up, various catheter placement techniques with
their advantages and disadvantages, post-procedure care, and com-
plications. We advocate that nephrologists should play a vital role in
the placement of PD catheters. Patients with anticipated problems
with PD implantation should be referred for laparoscopic
intervention.
ACKNOWLEDGEMEN TS
We would like to acknowledge and thank all the staff who have con-
tributed to the peritoneal dialysis program and the team that cared for
PD patients in Hospital Serdang Malaysia.
CONF LICT OF IN TE RE ST
All the authors declared no competing interest.
ORCID
Bak Leong Goh https://orcid.org/0000-0002-4644-7743
Christopher T. S. Lim https://orcid.org/0000-0003-3623-0484
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How to cite this article: Goh BL, Lim CTS. Peritoneal dialysis
catheter insertion techniques by the nephrologist. Semin Dial.
2024;37(1):24‐35. doi:10.1111/sdi.13118