Peritoneal dialysis catheter insertion

General remarks

• The incidence of peritonitis has been markedly reduced, mainly because of the new connection systems
• Therefore the focus of attention is perceived to be shifting from peritonitis reduction to preventing exit-site infections (ESI)
• Prevention of ESI has 3 prerequisites; optimal catheter design, appropriate implatation technique and post operative care
• The overall survival probability of swan neck missouri catheters at 36 months is double when compared to standard catheters
• Most common cathetes failures are due to obstruction, peritonitis, exit site infection, and leaks (cuff extrusion)
• Double-cuff catheters are preferred over single-cuff catheters
• PD catheters peritoneoscopically placed have less incidence of complications (infection, exit site leak) and longer catheter survival rates than those inserted surgically

Step by step

1. The patient is draped and the abdomen is exposed
2. Draw catheter position and entry site
3. Subumbilical incision, introduction of trocar and establishing pneumoperitoneum
4. Intra abdominal laparoscopic inspection
5. Paramedian incision and opening anterior rectus sheath
6. Exposing posterior rectus sheath
7. Place purse string suture in posterior rectus sheath
8. Insert stilette in catheter and avoid rotation
9. Opening peritoneum
10. Leave about 1cm of catheter beyond tip of stilette to avoid bowel damage during introduction
11. Insert catheter and check position
12. Position catheter in Douglas’s pouch
13. Partially retract stilette and enhance catheter position
14. ntroduce bead into peritoneal cavity (laparoscopic guidance)
15. Place flange flat on posterior rectus sheath
16. Remove stilette
17. Tie purse string securely between bead and flange
18. Anchor flange with 4 sutures
19. Create subcutaneous pocket for bent portion of catheter
20. Tunnel catheter to exit site
21. Suture anterior rectus fascia and avoid constricting catheter
22. Attach connector and infuse sterile saline
23. Final laparoscopic check of catheter position
24. Release pneumoperitoneum and close subumbilical fascia
25. Skin closure and check catheter function

References

Current trends in the use of peritoneal dialysis catheters. Negoi D, Prowant BF, Twardowski ZJ. Adv Perit Dial. 2006;22:147-52 Swan neck presternal ("bath tub") catheter for peritoneal dialysis. Twardowski ZJ, Nichols WK, Nolph KD, Khanna R. Adv Perit Dial. 1992;8:316-24 Design and testing of the Baxter Integrated Disconnect Systems (IDS).Balteau PR, Peluso FP, Coles GA, Michel C, Mignon FM, Tranaeus AP, Verger C, Zaruba K. Perit Dial Int. 1991;11(2):131-6 Long-term experience with Swan Neck Missouri catheters Twardowski ZJ, Prowant BF, Khanna R, Nichols WK, Nolph KD. ASAIO Trans. 1990 Jul-Sep;36(3):M491-4 Peritoneal dialysis catheter insertion. Asif A. Minerva Chir. 2005 Oct;60(5):417-28. Review