Peritoneal Dialysis Catheter Insertion

Overview

Peritoneal dialysis was first used for the management of end-stage

renal disease in 1959. [1] In 1968, Henry Tenckhoff developed the
indwelling peritoneal catheter, which was placed via an open surgical
technique. [2] Subsequently, percutaneous and laparoscopic techniques for
placement have been utilized.

Peritoneal dialysis has several advantages over hemodialysis

including quality of life due to its ability to provide better patient mobility
and independence, the simplicity of use, as well as the clinical advantages
of maintaining residual renal function and lower mortality in the first years
after starting peritoneal dialysis. A disadvantage of peritoneal dialysis is
the poor blood pressure control due to fluid overload as well as the risk of
peritonitis. [3]

An image depicting peritoneal dialysis catheter insertion can be seen

below.

Peritoneal dialysis catheter showing the double cuff catheter.

Indications

Chronic peritoneal dialysis is an option for many patients with end-stage

renal disease.

Strong indications for peritoneal dialysis include the following: [4]

Vascular access failure

Intolerance to hemodialysis
Congestive heart failure
Prosthetic valvular disease
Children aged 0-5 years
 Patient preference
Distance from a hemodialysis center
Poor cardiac function
Peripheral vascular disease

Peritoneal dialysis is preferred in patients with the following conditions: [4]

Bleeding diathesis
Multiple myeloma
Labile diabetes mellitus
Chronic infections
Possibility of renal transplantation in the near future
Age between 6 and 16 years
Needle anxiety
Active lifestyle

Peritoneal dialysis has been utilized infrequently for nonrenal indications

with variable benefit in other conditions as follows: [5, 6, 7, 8, 9, 10]

Refractory congestive heart failure

Hepatic failure
Hypothermia
Hyperthermia
Hyponatremia
Dialysis-associated ascites
Drug poisonings
Pancreatitis
Inherited enzyme deficiencies

The intraperitoneal administration has been used for blood transfusion,

chemotherapy, insulin, and nutrition.

Contraindications

Contraindications to peritoneal dialysis include the following: [4]

Documented type II ultrafiltration failure

Severe inflammatory bowel disease
Acute active diverticulitis
Abdominal abscess
 Active ischemic bowel disease
Severe active psychotic disorder
Marked intellectual disability
Women starting third trimester of pregnancy

Relative contraindications to peritoneal dialysis include the following: [4]

Severe malnutrition
Multiple abdominal adhesions
Ostomy
Proteinuria >10 g/day
Upper limb amputation with no help at home
Poor personal hygiene
Dementia
Homelessness

Peritoneal dialysis is not preferred but is possible in select circumstances:

[4]

Obesity
Multiple hernias
Severe backache
Multiple abdominal surgeries
Impaired manual dexterity
Blindness
Poor home situation
Depression

Anesthesia

Peritoneal dialysis catheters may be placed percutaneously,

laparoscopically, or via an open surgical route. The anesthetic used will
vary with the method selected. Percutaneous placement can be performed
at the bedside with local anesthesia, whereas the laparoscopic or open
route will require general anesthesia.

Equipment

Peritoneal dialysis catheters come in various shapes (straight,

pigtail-curled, swan-neck), lengths, and numbers of Dacron cuffs. The
peritoneal dialysis catheter is composed of a flexible silicone tube with an
open-end port and several side holes to provide optimal drainage and
absorption of the dialysate.
 The extraperitoneal component of the catheter has either one or
two Dacron cuffs. The Dacron cuffs are for optimal ingrowth and fixation.
In adults, a double cuff catheter is typically used. With the double cuff
peritoneal dialysis catheter, the proximal cuff is positioned in the
preperitoneal space and the distal cuff in the subcutaneous tissue (see the
image below).

Peritoneal dialysis catheter showing the double cuff catheter.

The proximal cuff holds the catheter in place while the distal cuff acts as a
barrier to infection. The type of catheter selected is usually surgeon
dependent.

Positioning

Placement of the peritoneal dialysis catheter requires that the patient be

placed in a supine position.

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]

Alternative placement techniques

The Moncrief-Popovich catheter and technique involves

subcutaneous burial of the external segment of the peritoneal dialysis
catheter to prevent colonization of the catheter by skin bacteria and to
promote attachment of the cuff to the tissue prior to exteriorization.

Results with this technique have been conflicting. The developers noted a
reduction in the rate of peritonitis and colonization of bacterial biofilms in
the catheter segments between the 2 cuffs; [12] however, a controlled
randomized study failed to confirm these results. [13]

Extended dialysis catheters

Longer dialysis catheters have been developed to allow placement of the

exit site in remote places such as the presternal area. [14] Such extended
catheters may be useful in obese patients and in those with an abdominal
stoma.

Results

A review of the outcomes of percutaneous versus open placement of

peritoneal dialysis catheters demonstrated that the placement modality
did not affect catheter survival. However, early mechanical complications,
including technical failures, occurred more frequently in the percutaneous
group. [15]

Complications

Complications after peritoneal dialysis catheter placement may be early

(occurring < 30 days post placement) or late (>30 days post placement).
[11]

Early complications

Bowel perforation

The risk of bowel perforation is less than 1%, and it usually occurs during
entry into the abdominal cavity or when the catheter and stylet are
advanced into the abdomen. Surgical exploration is necessary with repair
of the perforation and removal of the catheter. [11]

Bleeding

Bleeding is rarely a significant problem after peritoneal dialysis catheter

placement. When bleeding occurs, it is usually at the exit site.
Wound infection

Wound infection is uncommon and often can be treated with antibiotics

when it is superficial. If the wound is deeper, then it may need to be
drained.

Other early complications

Outflow failure may be due to several causes including clots or fibrin

in the catheter, a kink in the subcutaneous tunnel, placement of the
catheter in the omentum, occlusion from omentum, or adhesions. An
attempt to irrigate the catheter forcefully with saline or urokinase can be
tried, or a stiff wire can be inserted into the catheter under fluoroscopy. If
there is a kink in the subcutaneous tunnel, then an incision is made
directly over the kink and the catheter is repositioned. Laparoscopy is
useful for identification and treatment of obstruction due to omentum or
adhesions. [17] Outflow obstruction may also occur from malpositioning of
the catheter into the upper abdomen. The position of the catheter may be
identified on plain film or under fluoroscopy with the injection of contrast
into the catheter. The catheter may be repositioned with a stiff guidewire
or forceps. [18] Laparoscopic repositioning and fixation is an alternative.

Leakage of the dialysate may be identified by the presence of

drainage at the exit site or the appearance of a bulge underneath the
entrance site. Leaks may occur due to a hernia at the entrance site,
positioning of the proximal cuff on the rectus muscle, and trauma.
Withholding use of the peritoneal dialysis catheter for several weeks may
solve the problem. [11] A study performed on 19 children by Hisamatsu et
al reported that a modified technique of peritoneal dialysis catheter
insertion with fibrin glue prevented pericatheter leakage. [19, 20]

Peritonitis may occur early and manifests as abdominal pain

associated with cloudy peritoneal fluid. The fluid should be cultured, and
appropriate antibiotics should be administered.

Late complications

Late complications include exit-site infection, tunnel infection, cuff

protrusion, outflow failure and dialysate leaks, or hernias. [11]
Cuff extrusion or infection

Cuff extrusion or infection can occur when the exit site is placed directly
beneath the belt line. Superficial cuffs placed close to the skin may
extrude or become infected. In such situations, the catheter should be
exchanged and a new exit site selected. [11]

Outflow failure

Outflow failure beyond 30 days may occur due to constipation and can be
treated with laxatives.

Peritonitis

Peritonitis is often the result of contamination with skin bacteria, but it

may also be due to gram-negative bacteria associated with diarrhea or
diverticulitis. Systemic or intraperitoneal antibiotics are administered, and
the exchange volumes are decreased. Usually, a peritoneal dialysis
catheter-related peritonitis will resolve with proper antibiotic therapy. If
the infection persists, catheter removal and use of hemodialysis for 4-6
weeks is sufficient for resolution of the peritonitis. [21] There is a strong
association between exit-site infections and subsequent peritonitis, with
an increased risk up to 60 days after initial diagnosis. [22]

References

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