All catheters used for acute peritoneal dialysis are straight or slightly curved, relatively rigid tubing with numerous side holes at the distal end without any protective cuff. The implantation can be carried out with Seldinger percutaneous, open or laparoscopic insertion techniques. Acute peritoneal dialysis is still used in the management of acute and chronic renal failure in many developing countries [4, 5], where costs are a major limitation. In this setting, it is usually placed at the bedside under local anaesthesia, and catheters are used immediately after implantation. The absence of cuffs, a protection against bacterial migration, makes the incidence of peritonitis prohibitively high beyond 3 days of use; if extended dialysis is necessary the acute catheters are periodically replaced.

There are several types of catheters for chronic peritoneal dialysis; the basic structure is the same with an intraperitoneal portion, one or two cuffs, an inter-cuff segment and an external portion (Table 5.1). They are constructed from silicone rubber or polyurethane and are flexible, and atraumatic to the bowel. Catheters are available with barium impregnated either throughout or as a radiopaque stripe to assist in the radiologic localization of the intra-abdominal section. The silicone rubber or polyurethane surface promotes development of squamous epithelium in the subcutaneous tunnel around the catheter, at the exit site and within the abdominal wall. The presence of this epithelium increases resistance to bacterial penetration of the tissue near the skin exit and peritoneal entry sites. The Dacron cuffs provoke a local inflammatory response with fibrosis, which gives stability to the catheter and prevents bacterial migration from the skin surface into the subcutaneous tunnel and peritoneal cavity.

The intraperitoneal segment has multiple 0.5 mm perforations in the terminal part. Several modifications have been made to the intraperitoneal portion and to the tip of the catheters, with the aim of obtaining an unrestricted flow of dialysate to and from the peritoneal cavity. This flow is most efficient if the catheter tip lies deep within the pelvis (also changes for dislocation/migration are less when placed deep in the pelvis). Catheter design and insertion techniques aim at the prevention of one- or two-way obstruction, tip displacement from the pelvis, common causes of catheter malfunction. Different catheter lengths are available for every patient size.

Despite all the different options, most programs limit their experience with one or two catheter types, making difficult a critical comparison. For simplicity and based on studies present in literature, the discussion on which catheter type offers better results focused mainly on the number of cuffs, single versus double, the configuration of the intraperitoneal portion, straight versus coiled, and of the inter-cuff shape, straight versus Swan-Neck. Lewis and coll. carried out a prospective randomized controlled study that favoured the double cuff over the single cuff Tenckhoff catheters, in terms of survival, time to the first peritonitis episode, and number of exit site infections [27]. Previous ISPD consensus opinion also supported the choice of double cuff Tenckhoff catheters [28]. However, Eklund and coll. in a prospective randomized controlled study found no differences in the number of peritonitis episodes, exit site infections, or in catheter survival between single and double cuff Tenckhoff catheters [29]. As mentioned earlier in the chapter, coiled catheters (intra-peritoneal segment) have been developed in order to achieve less infusion/pressure pain (“jet effect”), better flow, less catheter-related complications such as migration and omental wrapping. These theoretical advantages have been substantiated by some authors in randomised controlled trials [30–32], but not confirmed in two more recent meta-analyses [33, 34]. The meta-analysis conducted by Xie J and coll. suggested that coiled catheters might be more prone to migration and resultant dysfunction [33]. A more recent meta-analysis by Hagen and coll., including more studies and with the following outcomes of interest (catheter survival, drainage dysfunction, migration, leakage, exit-site infections, peritonitis, and catheter removal), found no differences when comparing straight versus swan neck and single versus double-cuffed catheters. Comparison of straight versus coiled-tip catheters demonstrated that survival was significantly different in favour of straight catheters (hazard ratio 2.05; confidence interval 1.10–3.79, P = 0.02). The conclusion of the authors was that for surgically inserted (open and laparoscopic) catheters, the removal rate and survival at 1 year were significantly in favour of straight catheters [34].

In our experience we primarily use double cuff Tenckhoff catheters, both straight and coiled (intraperitoneal portion) and with straight inter-cuff shape. When critically comparing the different catheters we have to bear in mind that the most important aspect of preventing mechanical complications is probably attention to detail and the operative insertion technique used [35].

Peritoneal dialysis catheters may be placed via a percutaneous, a laparoscopic, or an open surgical route. Open surgical and laparoscopic techniques are the most commonly performed worldwide. According to American data, the laparoscopic technique is now the most commonly used, compared to all other techniques [36].

It is reported the original technique described by Crabtree of laparoscopic dialysis catheter implantation using a two-port technique [104]. The infiltration with local anaesthetic of all abdominal wall layers until the peritoneum, for complete pain control, helium insufflation is used to create pneumoperitoneum; Keshvari and coll. described the technique using nitrous oxide (NO₂) [64]. Few characteristics make helium ideal in this setting: it is painless, thereby allowing the laparoscopic procedure to be performed under local anaesthesia [104]; non-flammable, thereby safe when using electrosurgical devices [105, 106]; inert, thereby increasingly utilized in high-risk patients [107, 108]. Contrary to paralyzed patients under general anaesthesia, patients under local anesthesia benefit from lower gas insufflation pressure (between 8 and 10 mmHg) and rates (0.5–2.0 L/min.). The peritoneal catheter is inserted through a para-median port site while continuously monitoring the implant procedure with a laparoscope from a second port location. The catheter–stylet assembly is then inserted and placed deep in the pelvis. The rectus sheath tunnelling technique is applied. The deep Dacron cuff is withdrawn until disappears above the peritoneum in the anterior rectus sheath. The stylet is removed from the catheter, the pneumoperitoneum is allowed to deflate, and the laparoscope is removed. The catheter is tested with the patient in reverse Trendelemburg position; a standard 1-L bag of normal saline is observed for unimpeded inflow and drainage by gravity. A residual of 250–300 mL is left in the abdomen to reduce the likelihood of intraperitoneal structures sucking up against the catheter toward the end of the drainage process. At the conclusion of a successful irrigation, the entire system is flushed with 20 mL of heparin (100 U/mL) (Table 5.6).