Tenckhoff peritoneal dialysis catheter, made of flexible silicone tubing, is the most commonly used catheter presently. A wide variety of peritoneal dialysis catheters are available and they vary based on the configuration of the extraperitoneal and intraperitoneal catheter segments.

The most commonly used designs of the extraperitoneal catheter segment differ based on the number of cuffs and on the angle of the subcutaneous portion. Peritoneal dialysis catheters are equipped with one or two Dacron cuffs that are located at the proximal catheter end. Majority of surgeons prefer to use double cuffed catheters due to the reported lower risk of infectious complications [23, 24]. The cuff allows for tissue ingrowth, effectively fixing the catheter in place, guarding against leaks and infections. The superficial cuff rests in the subcutaneous tissue, at least 2–3 cm from the exit site; while the distal cuff lays within the rectus muscle (Fig. 6.2). The orientation of the subcutaneous segment can be straight or permanently bent in a swan neck configuration. Some studies show that swan neck catheters have lower rates of mechanical catheter dysfunction from decreased torque on the intraabdominal portion of the catheter, resulting in lower rates of catheter migration [25, 26]. Furthermore, swan neck catheters may lead to lower rates of exit site infections when compared to upward directed straight catheters [24]. In general, catheter exit site should always be directed downward or laterally to minimize infection.

The design of the intraperitoneal segment of the catheter optimizes dialysate exchange, while minimizing the risk of migration and obstruction by peritoneal surfaces, bowel, or omentum. The intraperitoneal design is either straight or coiled, with a number of side openings facilitating easy dialysate exchange [27]. Some studies show that coiled catheters result in less discomfort to the patient during dialysate infusion, which is thought to be due to dispersion of the inflow force. However, current evidence is conflicting in terms of dysfunction rates and catheter survival in regards to intraperitoneal catheter design [24, 26, 28, 29].

Open surgical peritoneal dialysis catheter placement is performed using a mini-laparotomy incision. Historically, patients were placed under general anesthesia for catheter insertion, however in the mid-1980, the trend shifted to the predominant use of local anesthesia and conscious sedation reducing the length of surgical recovery and anesthetic complications [30]. Initially, catheters were placed using a midline infraumbilical vertical or transverse incision, or supraumbilical incision in those patients with prior celiotomy scars and obese abdomen. Although the catheter trajectory was slightly off-midline as it passed through the rectus muscle, the midline insertion technique resulted in high rates of peritoneal fluid leakage, cuff extrusion and herniation [31, 32]. In order to reduce these complications, paramedian incision was adopted as the new standard in adult patient population [32–34]. Currently, midline skin incision with a paramedian trajectory through the rectus muscle is still utilized in the pediatric population due to their smaller size and thinner abdominal wall [35].

Following sterile preparation, the catheter is positioned over the abdomen, preferentially to the left of the midline. Positioning of the peritoneal dialysis catheter on the left side is thought to result in lower incidence of catheter migration due to downward directed peristaltic waves of the left colon [36]. The distal portion of the catheter is positioned over the pubis (Fig. 6.1). The insertion site is planned at the level of the distal Dacron cuff. The exit site is planned 2–3 cm away from the proximal cuff to prevent cuff extrusion and directed downward to minimize the risk of tunnel infection. Once marking is complete, the insertion site is infiltrated with local anesthetic and a 4–5 cm incision is made and carried down to the anterior rectus sheath which is sharply opened. Muscle fibers are split bluntly to expose the posterior rectus sheath and the peritoneum, which are also entered sharply. Patient should be placed in a Trendelenburg position, effectively shifting the bowel cephalad and freeing up the pelvis. The catheter is then inserted with the help of a stylet and blindly directed towards the pelvis. Catheter is secured to the peritoneum using a purse string suture to prevent peritoneal fluid leaks and minimize the risk of peritonitis and tunnel infection. Peritoneal purse string is generally placed just below the distal Dacron cuff when double cuffed catheter is used (Fig. 6.3). The anterior rectus sheath is also tightly closed around the catheter with purse string suture, trapping the distal cuff within the rectus muscle [34]. The extraperitoneal catheter segment is tunneled in the subcutaneous space following the previously marked trajectory towards the exit site. Care is taken to position the proximal Dacron cuff at least 2–3 cm from the exit site to prevent cuff extrusion (Fig. 6.1). Finally, catheter is tested with saline infusion, skin is closed and sterile dressing applied.

In patients who are found to have a large omentum, a partial omental resection (omentectomy) can be performed through the mini-laparotomy incision. Alternatively and to avoid the risk of bleeding complications with omentectomy, “omental hitch” (omentopexy) has been described with open peritoneal dialysis catheter placement. During omentopexy, the bulky omentum is displaced from the pelvis and anchored to the anterior abdominal wall in the epigastric region [37], which may necessitate a larger incision.

According to the International Society for Peritoneal Dialysis Clinical Practice Guidelines, catheter insertion should be planned at least 2 weeks before peritoneal dialysis start, to allow for tissue healing, catheter incorporation, as well as patient training [38]. In cases when earlier start is necessary, peritoneal dialysis can be initiated with small dialysate volumes in the supine position [39]. However, catheter-related mechanical complications may be higher with earlier peritoneal dialysis start following open insertion technique [40].

The most common complications of open peritoneal dialysis catheter placement technique include infections, peri-catheter dialysate leakage, and mechanical catheter dysfunction. Infectious complications related to the catheter placement are defined as occurring within 2 weeks of surgery and include peritonitis and tunnel infections. Technique-related mechanical catheter problems include (1) catheter inflow and outflow obstruction due to omental entrapment, adhesions and fibrin plugs, (2) catheter migration into the upper abdomen, often resulting in pain with dialysate infusion and possible obstruction, (3) peritoneal fluid leakage around the catheter, which may predispose to infectious complications. Rare intraoperative complications include bowel or bladder perforation and bleeding from inadvertent vascular injury, requiring extension of the laparotomy incision for management and abandonment of the peritoneal dialysis catheter placement due to excessive risk of peritonitis.

One benefit of open peritoneal dialysis catheter insertion is the ability to perform the operation under local anesthesia and conscious sedation with faster recovery and lesser risk to the patient. Compared to blind percutaneous insertion, placement of the catheter under direct surgical vision permits limited intra-operative peritoneal assessment, lowering rates of undiagnosed bowel injury.

Traditional open peritoneal dialysis catheter insertion techniques as described above, have been historically associated with high catheter dysfunction rates up to 38% due to the blind placement of the catheter towards the pelvis and the inability to perform complete lysis of adhesions. These catheter problems include mechanical issues, such as obstruction to dialysate flow due to catheter entrapment in the omentum or adhesions, pain and flow obstruction related to catheter migration, and peri-catheter fluid leakage.

When compared to blind percutaneous bedside peritoneal dialysis catheter insertion using Seldinger technique, open technique results in similar or improved catheter outcomes, depending on the series being reviewed. Nicholson et al. published the results of their large cohort comparing percutaneous to open midline peritoneal dialysis catheter insertion, showing a significant improvement in catheter survival with the use of open technique [41]. Blind percutaneous technique has been historically associated with highest rates of catheter malposition and failure rates up to 65%, as well as increased risks of hemorrhage and injury to the bowel [5]. However, others show acceptable rates of dysfunction and low rates of bowel injury, comparable to open technique [42–46]. Percutaneous technique benefits include faster recovery and ambulation, less delays associated with scheduling of an operation, as well as cost saving benefits. It has been recommended for low risk patients in developing countries with poor resources [47].

Fluoroscopic-guided peritoneal dialysis catheter placement method also utilizes Seldinger technique, with the peritoneal entry of the access needle confirmed by instillation of contrast under fluoroscopy, as well as confirmation of guide wire location in the pelvis. Ultrasound guidance is often used as an adjunct to avoid injury to the inferior epigastric vessels. Catheter-related outcomes appear to be similar to those with open peritoneal dialysis catheter insertion method, depending on the series being reviewed [48–51]. Additionally, hollow viscous perforation rates range from 0% to 4.4% [48, 52].

The use of basic laparoscopy was incorporated to visualize the peritoneum, perform lysis of adhesions when necessary, and direct the catheter tip towards the pelvis under direct vision. Basic laparoscopy, as will be seen in later chapters, is associated with slightly lower catheter dysfunction rates, up to 14% [53, 54]. In order to further lower catheter dysfunction rates and thus improve peritoneal dialysis failure rates, additional laparoscopic maneuvers such as catheter fixation, rectus sheath tunnel and omentopexy have been used, either alone or in combination, collectively called the advanced laparoscopic technique. Utilization of the advanced laparoscopic technique has been shown to result in even lower rates of catheter dysfunction. This is especially true when combination of these techniques is used, with dysfunction rates of 4.7% [55, 56]. Nonetheless, the available data comparing these modalities in terms of catheter dysfunction is sparse, conflicting and difficult to compare between studies because of lack of standardization and large heterogeneity of the insertion techniques used.