Placement of the peritoneal dialysis catheter

INTRODUCTION — The main function of a peritoneal dialysis (PD) catheter is to permit consistent, bidirectional flow of dialysate without extraordinary effort or undue discomfort. The catheter's function depends upon its design, implantation site, and the configuration of the system used to perform dialysis exchanges.

The principles governing the choice, preoperative planning and techniques for placement, and postoperative maintenance of a PD catheter are reviewed here. Other aspects of using a PD catheter are discussed elsewhere including:

●Noninfectious complications of PD catheters, including catheter malfunction, leakage, and cuff extrusion (see "Noninfectious complications of peritoneal dialysis catheters")

●Catheter exit-site infection (see "Peritoneal catheter exit-site and tunnel infections in peritoneal dialysis in adults")

●Urgent-start PD (see "Urgent-start peritoneal dialysis")

●Peritonitis associated with PD (see "Microbiology and therapy of peritonitis in peritoneal dialysis" and "Risk factors and prevention of peritonitis in peritoneal dialysis" and "Fungal peritonitis in peritoneal dialysis")

●Abdominal wall hernias (see "Abdominal wall hernia and dialysate leak in peritoneal dialysis patients")

CLINICAL EVALUATION — A clinical evaluation that includes a targeted history and physical examination is a crucial step in the process of planning placement of a peritoneal dialysis (PD) catheter.

●Focused history – The following aspects of the history are important to elicit during the initial evaluation:

•Preferred sleep position – The patient's preferred sleep position, particularly for side sleepers who prefer one particular side, can help determine the optimal side for PD catheter placement. As an example, if the patient prefers to sleep on their left side, then the catheter should preferentially be placed on the right side of the abdomen.

•Handedness – In the absence of a clear preference for the side of the catheter placement, the handedness of the patient may be helpful in deciding on which side the catheter should be placed. Placing the catheter on the dominant side (ie, right side in those who are right-handed) may allow ease of access to the catheter. However, the catheter does extend approximately 10 to 14 inches from the anterior abdominal wall and can be easily accessed regardless of the side of the exit site.

If a presternal catheter is placed, the nondominant side is typically chosen to minimize discomfort at the catheter insertion site when the patient moves their dominant arm.  

•Bathing practice – Patients who prefer to take baths should have their catheter exit site located on the upper abdomen or chest to prevent submersion. In general, this will require the use of the catheter extension set. Patients who prefer to shower can have an exit site in the lower abdomen. (See 'Extended catheter for some patients' below.)

•History of constipation – It is important to elicit any history of constipation since those patients with chronic constipation need to be on an effective laxative regimen to prevent catheter malfunction immediately prior to and after placement. (See "Noninfectious complications of peritoneal dialysis catheters", section on 'Impaired catheter flow'.)

•History of chronic urinary retention – Patients who have chronic urinary retention, due to conditions such as benign prostate hyperplasia, may benefit from initiating medical management to help promote complete bladder emptying. Chronic urinary retention can also lead to catheter malfunction postoperatively. (See "Noninfectious complications of peritoneal dialysis catheters", section on 'Impaired catheter flow'.)

In the setting of percutaneous PD catheter insertion, placement of a Foley catheter immediately prior to PD catheter placement may be required to reduce the risk of inadvertent urinary bladder injury.

●Focused physical examination – The physical examination is focused on the abdominal region to identify any factors that may complicate PD catheter placement. Examples of such factors include areas where the following might be present (see 'Preoperative mapping' below):

•Skin infection or chronic irritation

•Ostomy, feeding tube, or suprapubic catheter

•Abdominal or inguinal hernia

•Abdominal scarring

•Loose skin or abdominal folds

•Pant or belt line in three positions (ie, lying, sitting, standing)

Placing a PD catheter near areas of skin infection or irritation, near other foreign bodies (eg, feeding tube), or near loose skin or abdominal folds can increase the risk of PD catheter infection. Abdominal scar tissue may correspond to presence of a deeper abdominal wall scar or intraabdominal adhesions [1] and, therefore, placement of the PD catheter in such an area can increase the risk of a leak or malfunctioning catheter. Placing a catheter over a belt or pant line can increase the risk of discomfort and irritation experienced by the patient and increase the risk of catheter exit-site infection. The presence of abdominal or inguinal hernias can increase the risk of catheter malfunction. However, such hernias can be repaired as part of the PD catheter placement procedure or done prior to catheter placement. (See "Abdominal wall hernia and dialysate leak in peritoneal dialysis patients".)

PREOPERATIVE PREPARATION — The preoperative planning for placement of the peritoneal dialysis (PD) catheter involves adherence to best practices to minimize intraoperative and postoperative complications.

Prophylactic antibiotics — For most patients, we administer 2 grams of intravenous (IV) cefazolin (3 grams for those ≥120 kg) within 60 minutes prior to the procedure for antibiotic prophylaxis against surgical site infection. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'General approach'.)  

For patients allergic to cephalosporins or colonized (or at a high-risk for colonization) with methicillin-resistant staphylococcus aureus (MRSA), we use IV vancomycin for prophylaxis administered within 60 to 120 minutes prior to the procedure (15 mg/kg; not to exceed 2 g). (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'S. aureus' and "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Role of vancomycin'.)

We do not routinely or systematically test for MRSA among all patients scheduled for PD catheter placement but use positive results of available prior tests to identify patients who should be given IV vancomycin rather than cefazolin for preoperative prophylaxis. (See "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Prevention and control", section on 'Clinical approach'.)

The use of antibiotic prophylaxis prior to insertion of the PD catheter is consistent with guidelines from the International Society of Peritoneal Dialysis (ISPD) [2,3], Australasians with Renal Impairment [4], European Renal Best Practice [5], and the UK Renal Association [6]. These guidelines were based upon a 2004 meta-analysis of trials including 335 patients, which showed that antibiotic prophylaxis led to a reduction in the risk of early peritonitis (<1 month after surgery; relative risk [RR] 0.35, 95% CI 0.15-0.80) [7]. Preoperative antibiotics do not reduce the risk of late peritonitis (>1 month after surgery) or exit-site and tunnel infections.

In addition to use of preoperative antibiotics, the ISPD recommends attempting eradication of S. aureus nasal carriage with nasal mupirocin prior to PD catheter placement. However, there are no published trials demonstrating benefit of such a practice on the risk of peritonitis, exit-site or tunnel infection, or catheter loss. In addition, low patient adherence to topical nasal mupirocin limits the utility of this practice.

Bowel regimen — We use laxatives and/or stool softeners preoperatively to reduce the risk of catheter complications that are associated with constipation [2]. Polyethylene glycol (eg, 17 g daily), bisacodyl (eg, 5 mg daily), docusate (eg, 100 mg daily), or a combination of these agents can be used. Typically, the bowel regimen is started three days prior to surgery, held the night before and the day of surgery, and then resumed postoperatively and continued until the risk of constipation (eg, due to postoperative opiate therapy) has resolved. However, patients with chronic constipation should continue to be treated. (See "Management of chronic constipation in adults".)

When a catheter is being inserted for acute PD, there is usually insufficient time to complete an oral bowel regimen; in such cases an enema may be used.

In addition to use of laxatives, we typically instruct patients to hold oral calcium and iron supplements, if applicable, for approximately one week prior to catheter placement, as they can cause or exacerbate constipation. These medications can be restarted one to two days following catheter placement.

The treatment of constipation can be beneficial for the following reasons:

●Reduced risk of catheter nonfunction and malfunction.

●Reduced risk of bowel puncture.

●Easier placement of wires and the catheter into the peritoneal space.

●Reduced risk of straining for a bowel movement postplacement, thereby possibly reducing the risk of strain on the incisions and the risk of dialysate leak.

●Potentially reduced risk of peritonitis by transmural migration of bacteria during management of acute constipation [8].

This recommendation is consistent with the 2019 ISPD guidelines on creating and maintaining optimal PD access [2].

Preoperative mapping — Preoperative mapping of various landmarks on the patient's abdomen can be helpful to ensure optimal catheter placement [2], according to the following principles:

●The catheter placement should not be over belt or pant lines and skin folds, should be visible to the patient, and should be suited to the patient's hand preference. (See 'Clinical evaluation' above.)

●The catheter should be placed in the paramedian left or right side (picture 1).

●When the catheter is in the resting position, the tip should rest in the true pelvis to ensure optimal hydraulic function.

As described in the ISPD guidelines, preoperative mapping should be performed with the help of a stencil specific to the catheter or free-hand and with the patient in the supine position [2,9-12]. The upper border of the true pelvis is at the upper border of the pubic symphysis. For coiled catheters, the upper end of the coil should be positioned at the upper border of the pubic symphysis (picture 1). For straight catheters, a point 5 cm proximal to the tip of the catheter should be at the upper border of the pubic symphysis (picture 1). The catheter should then be laid on the abdomen in the craniocaudal orientation. The incision site is then mapped at the upper end of the deep cuff (which typically rests within the rectus muscle). After mapping the incision site, the intercuff segment should be bent laterally either following the natural arc of the swan neck catheter or by creating a gentle curve, rather than a steep angle, with the straight catheter. Steep angles can result in superficial cuff extrusion or migration of the catheter tip deeper in the pelvis. Next, the exit site should be marked 2 to 4 cm away from the superficial cuff (which typically rests within the subcutaneous tunnel). Having previously identified and marked the patient's pant or beltline, the exit site can be created superior or inferior to avoid this area.

Patients with obesity or with significant skin folds may benefit from presternal or upper abdominal catheters, and skin marking should be performed while the patient is standing.  

Preoperative medical optimization — Patients who will undergo surgical placement of the PD catheter will need to undergo preoperative testing with anesthesiology to determine the type of anesthesia that would be suitable for the procedure. The perioperative management of anticoagulation and glucose is discussed separately. (See "Preoperative evaluation for anesthesia for noncardiac surgery" and "Perioperative management of patients receiving anticoagulants" and "Perioperative management of blood glucose in adults with diabetes mellitus".)

CATHETER SELECTION — Commercially available peritoneal dialysis (PD) catheters vary by the design of their intraabdominal segment (straight versus coiled), subcutaneous configuration (straight versus swan neck [ie, with a preformed inter-cuff arc bend]), number of cuffs (single versus double), and tip (weighted versus not weighted).

The PD catheters used most commonly are double-cuffed; the subcutaneous segment can be either straight or swan-necked and the intraperitoneal segment can be either straight or coiled-tipped (picture 2). Weighted catheters (ie, tungsten-weighted) are not available in North America [13]. However, the catheter type and configuration chosen for a particular patient depends upon the preference of the proceduralist (surgeon, nephrologist, or radiologist). We agree with the 2019 International Society of Peritoneal Dialysis (ISPD) guidelines on creating and maintaining optimal PD access, which states that there are no high-quality data convincingly demonstrating superiority of any one type of catheter over another [2]. Regardless of the catheter used, successful placement of a PD catheter depends upon the experience and skills of the operator.

All PD catheters are now made with silicone. Polyurethane catheters are no longer in use because they develop multiple stress fractures upon exposure to ethanol- or polyethylene glycol-based topical antibiotics. Most catheters also have a radiopaque strip running longitudinally along the catheter to enable radiographic visualization and to help avoid twisting or kinking of the catheter during insertion and tunneling.

Weighted catheters (also called self-locating catheters) have 12 g of silastic-coated tungsten at the tip. This weighted tip naturally gravitates to the prerectal peritoneal pouch, essentially "self-locating" to the desired position in the peritoneum. Weighted catheters are not used widely because of lack of availability in many parts of the world (eg, North America) and need for special surgical training for placement and removal.

Our preferred catheter for most patients — For most patients, we prefer a double-cuffed catheter with a straight (and less commonly swan-neck) subcutaneous configuration and coiled intraabdominal segment (picture 2). Specific features of, and the rationale for, our choice are as follows:

●Double-cuffed – Double-cuffed catheters have two Dacron velour cuffs, of which the superficial cuff is placed subcutaneously within 2 to 4 cm of the exit site, and the deep cuff is either placed on top of, or preferably embedded into, the rectus abdominis muscle. The main perceived advantages of a catheter with a double cuff over a catheter with a single cuff are that it may reduce the risks of dislodgement, leak, and infection. The presence of two cuffs potentially helps minimize the periluminal migration of bacteria and fluid, although studies thus far have not consistently confirmed these benefits [14,15]. However, in a cohort of over 4000 patients, compared with single-cuffed catheters, double-cuffed catheters reduced the risk of peritonitis caused by gram-positive organisms (rate ratio 0.80, 95% CI 0.69-0.92) [14]. The overall risk of peritonitis from all organisms was reduced (risk ratio 0.82, 95% CI 0.71-0.96) among patients who initiated PD before 2001, but not among those initiating PD thereafter. This was possibly due to improvements in factors other than the PD catheter that occurred around that time (eg, exit-site care incorporating mupirocin, transfer sets incorporating the Y connector), thereby lowering the overall number infections after the year 2000 (regardless of the number of cuffs).

●Straight or swan-neck subcutaneous configuration – We use catheters with a straight subcutaneous segment, but catheters with a swan neck subcutaneous configuration are a reasonable alternative. There are no data favoring one type of subcutaneous segment over another. However, the body habitus of the patient and other factors, such as the patient's preferred belt-line, may impact this choice [16].

A swan-neck configuration may be more beneficial when the available abdominal surface area is limited (eg, among patients with smaller body habitus). This is because the arc bend of a swan neck catheter allows the subcutaneous segment to be accommodated in a smaller space. In addition, the swan-neck configuration may also be helpful among patients who choose to have their belt-line above the umbilicus [17]. In such patients, a swan neck catheter with a downwardly directed external limb and exit-site may limit its overlap and interference with the belt-line. Conversely, among patients who prefer their belt-line to be below the umbilicus, a catheter with a straight subcutaneous segment and laterally directed tunnel and exit-site may be preferred.

●Coiled intraabdominal segment – We prefer catheters with a coiled intraabdominal segment because, in our experience, these are associated with a lower frequency of drain pain. Others prefer a straight intraabdominal segment due to its perceived lower risk of catheter dysfunction and longer catheter survival. However, in a 2019 meta-analysis, the choice between straight and coiled catheters made little or no difference in terms of the risk of peritonitis, exit-site infection, catheter survival, or patient mortality [16]. In a subsequent small trial, compared with coiled catheters, straight catheters had a lower rate of catheter dysfunction (0.7 versus 5.8 percent) [18]. However, due to low number of events, our confidence in these findings is limited.

Extended catheter for some patients — There are patients for whom having the PD catheter exit-site over the lower abdomen can increase the risk for some complications, such as peritonitis. For such patients, the exit-site can be placed over the upper abdomen, presternal area, or back (figure 1 and picture 3). However, this requires a longer catheter, such as an extended catheter, to ensure that the intraabdominal portion remains in the pelvis without strain or tugging [19]. The extended catheter is a two-piece catheter; it consists of a single-cuffed intraabdominal piece that attaches to an extended subcutaneous piece.

The following groups of patients may benefit from placement of an extended rather than a standard-sized PD catheter:

●Patients who are obese and have a large pannus or skin folds that interfere with fully visualizing an abdominal exit-site [20,21]. Such patients should have the exit-site placed over the upper abdomen or presternal region for better visualization of the exit-site. The upper abdomen and presternal region have a relatively thinner layer of subcutaneous fat, even among patients who are obese, and this can potentially help reduce the risk of shear stress on the catheter from movement of the subcutaneous fat [2].

●Patients with ostomies who may be at risk for peritonitis due to proximity to the exit-site [20-22]. Such patients should have the exit-site placed over the presternal region.

●Patients who have cognitive impairment and who are at risk for pulling their catheter out from an accessible area, such as the abdomen. Such patients may benefit from having their exit-site placed on the back [23].

●Patients with incontinence [2]. Placing the exit-site higher may reduce the risk of contamination from bodily fluids.

●Patients who prefer to take baths. Submersion of the lower abdominal area during the bath may increase the risk of peritonitis. Such patients should have their exit-site placed on the presternal region, which should not be submerged in a bath [24].

●Toddlers who crawl may benefit from a presternal catheter.

CATHETER INSERTION — A peritoneal dialysis (PD) catheter can be inserted using laparoscopic (basic or advanced), open surgical, or percutaneous techniques (with or without imaging guidance).  

Open surgical dissection remains the most common insertion technique used globally. However, in the United States, laparoscopic methods are the most common insertion techniques. As an example, in 2018, 60 percent of catheters inserted in the United States were placed by laparoscopic, 30 percent by image-guided percutaneous, and 10 percent by open surgical techniques [25].

General principles — Regardless of technique of PD catheter insertion, the following general measures should be used in all patients:

●Catheter placement should be a paramedian approach and not midline, with rectus sheath tunneling to avoid catheter migration. The deep cuff should be positioned in the rectus muscle and if possible, secured with a purse string suture to reduce the risk of early leaks and later development of hernias.

●Once the PD catheter is placed correctly in the peritoneal cavity, the end of the catheter should be connected to a tunneling tool that is advanced subcutaneously along the premarked path to the exit site.

●The exit site should be created in a downwardly or laterally directed tunnel. This reduces the risk of pooling of fluids (eg, sweat, dialysate) or collection of debris when the patient is supine and is associated with fewer catheter-related infectious complications [9,10,26].

●The exit site should be sized for a snug fit around the catheter to limit its movement and possibly lower the risk of infection [27]. No catheter anchoring sutures should be placed as they can serve as a nidus of infection. We usually secure the catheter in place using bandages.

●The patency of the catheter should be assured before concluding the procedure. This is usually accomplished by infusing 1 liter of peritoneal dialysate or saline over a few minutes via the catheter into the peritoneal cavity. Once the catheter has been placed, and the titanium adapters have been secured, the rubber end of sterile cystoscopy tubing can be attached to the titanium adapter and the other end, with the drip chamber, can be inserted into the bag of saline or dialysate. The fluid is then allowed to flow from the bag into the abdomen. When complete, the bag is placed onto the floor to allow the fluid to drain out. The drip chamber allows the operator to appreciate the flow dynamics both of the fluid going in and draining out. The fluid should then be allowed to drain; we consider a catheter well-functioning if at least 50 percent of the instilled volume drains. To ensure proper function postoperatively, catheters should be repositioned or exchanged if they fail to drain adequately.

Choice between insertion techniques — The choice between the various catheter insertion techniques largely depends upon local procedural expertise, availability of resources (eg, operating room, laparoscopy, fluoroscopy), whether or not the patient can tolerate general anesthesia, and whether or not additional procedures (eg, hernia repair) need to be performed at the time of catheter insertion.

In resource-rich settings that have ample availability of broad procedural expertise, the preferred procedure is an advanced laparoscopic insertion if the patient has a history of major abdominal surgery (or suspected intraabdominal adhesions). This is due to the lowest risk of complications associated with this technique [2]. Patients who do not have such a history could undergo a PD catheter placement either by advanced laparoscopic insertion or the image-guided percutaneous technique, depending upon the available procedural expertise relative to the urgency of initiating dialysis. Patients who need urgent dialysis can have the catheter placed using the image-guided percutaneous technique. (See "Use of peritoneal dialysis (PD) for the treatment of acute kidney injury (AKI) in adults".)

Percutaneous insertion should not be performed for patients who are obese, have a history of multiple abdominal surgeries, have had peritonitis, are unable to lay flat, or have poor tolerance to procedures under local anesthesia.

In resource-limited settings, the PD catheter procedure is entirely dependent upon local expertise and availability of resources.

Patients who need extended catheters should have them placed under general anesthesia preferably with advanced laparoscopic catheter insertion.

Laparoscopic techniques — Laparoscopy is a minimally invasive approach that allows complete visualization of the peritoneal cavity for PD catheter insertion [28]. The basic laparoscopic insertion begins with gaining access to the peritoneal cavity in a variety of ways at the discretion of the operating surgeon. Once pneumoperitoneum is achieved, inspection of the abdomen allows for precise placement of the additional port(s) for peritoneal catheter insertion and advancement. It is useful to place the initial port remote from prior surgical incisions to reduce the risk of poor visualization or inadvertent bowel injury.

The advanced laparoscopic technique combines the basic laparoscopic insertion technique with additional preemptive procedures to reduce the risk of mechanical complications [29]. Not all of these procedures are required in every patient. The need for any or all of these additional procedures is determined intraoperatively based upon an individual patient's anatomy. The ultimate goal is to identify any potential anatomic issues that may contribute to future catheter malfunction.

●Omentopexy – An omentopexy is the most common adjunct procedure performed at the time of PD catheter placement. As opposed to an omentectomy, which is the surgical removal of the omentum, an omentopexy involves tacking the omentum to the anterior abdominal wall, to the falciform ligament, or folded upon itself. An omentopexy should be performed when the omentum extends into the pelvis because, in this position, it can juxtapose the PD catheter and hinder its function.

●Adhesiolysis – Adhesiolysis involves removing or compartmentalizing adhesions that might create intraperitoneal pockets and interfere with complete drainage of the dialysate.

●Colopexy – Colopexy, which involves tacking or suspending the colon from the lateral abdominal wall, may be required in patients who have a redundant and bulky rectosigmoid colon that blocks the pelvic inlet.

●Rectus sheath tunneling – Rectus sheath tunneling involves penetrating the anterior rectus fascia and then bluntly creating a tunnel through the rectus muscle, in the caudal direction, for several centimeters before penetrating the posterior rectus sheath and entering the peritoneal space. This method prevents catheter tip migration and reduces the risk of pericatheter leak and pericatheter hernia. [30].

For patients with a history of multiple abdominal surgeries, patients who are obese, or patients who require other simultaneous procedures such as hernia repair, we suggest an advanced laparoscopic catheter placement rather than another technique. In a 2018 meta-analysis of observational studies involving over 1000 patients that compared advanced laparoscopy, basic laparoscopy, and open surgery, advanced laparoscopy was associated with the lowest risk of catheter-associated complications [31]. Compared with open surgery, advanced laparoscopy was associated with reduction in catheter obstruction (odds ratio [OR] 0.14, 95% CI 0.03-0.63), catheter migration (OR 0.12, 95% CI 0.06-0.26), pericatheter leak (OR 0.27, 95% CI 0.11-0.64), pericatheter and incisional hernias (OR 0.29, 95% CI 0.09-0.94), and an improved two-year catheter survival (OR 0.50, 95% CI 0.28-0.92). Compared with basic laparoscopy, advanced laparoscopy was associated with a reduced risk of catheter obstruction (OR 0.11, 95% CI 0.05-0.21) and catheter migration (OR 0.07, 95% 0.01-0.51).  

Percutaneous techniques — Image-guided percutaneous (Seldinger) technique of catheter insertion is typically performed by radiologists or interventional nephrologists and is the second most common technique used in the United States [32]. The procedure usually uses abdominal ultrasound to better visualize the underlying rectus muscle, loops of bowel, and blood vessels. Using a paramedian approach, a blunt needle, such as an Atkins Hawkins needle or a spring-loaded Veress needle, is used to access the peritoneum. Contrast is then injected to identify and confirm position of the needle and to rule out any bowel or bladder perforation. A wire is then advanced through the needle into the lower part of the peritoneal cavity under fluoroscopic guidance. The needle is then removed, and the tract is dilated over the wire using progressively bigger dilators, up to 16 French size. The PD catheter is then placed over the wire into the peritoneum. Alternatively, a stiff stylet can be placed through the PD catheter and advanced through a peel-away sheath under fluoroscopic guidance.

For uncomplicated patients and those unable to tolerate general anesthesia, there are no true outcome differences among the individual techniques (eg, percutaneous insertion), and therefore, the choice should be based on local expertise. In one trial of 113 patients, compared with basic laparoscopic insertion of the PD catheter (ie, without advanced techniques), image-guided placement led to a higher rate of catheter survival at one year (84 versus 74 percent). In addition, the risk of catheter complications, such as peritonitis, dialysate leaks, and umbilical hernia, was lower in the image-guided insertion group (18 versus 43 percent) [33]. Another subsequent observational study reported similarly fewer catheter-related complications in the group who received image-guided compared with laparoscopic insertion of the catheter [34].

In general, percutaneous insertion without image guidance should be avoided due to the risk of bladder or bowel perforation, especially among patients with a history of prior abdominal surgery. However, it may be the only option in some resource-limited settings and may be associated with fewer complications when performed by experienced operators [35]. The procedure involves blind cannulation into the peritoneum using a 16- or 18-gauge needle at the midline or a paramedian location. Approximately 0.5 to 2 L dialysate or saline is usually infused into the peritoneum to expand the area and to reduce the risk of bowel perforation. The remainder of this technique is similar to the image-guided percutaneous technique. (See "Use of peritoneal dialysis (PD) for the treatment of acute kidney injury (AKI) in adults", section on 'Alternate access in resource-limited settings'.)

Open surgical technique — Open surgical insertion remains the most common technique used for placing PD catheters worldwide because it is economical (relative to laparoscopic insertion), does not require special equipment, and can be performed under local anesthesia or conscious sedation. In many instances, however, it is performed under general anesthesia [36].

The procedure is performed by making a paramedian incision, opening the anterior rectus fascia, spreading the rectus muscle, and dissecting down to and then through the posterior rectus fascia to the level of the peritoneum. The peritoneum is then opened sharply, and the PD catheter is then inserted into the peritoneal space and directed toward the pelvis. A purse string suture is then used to close the anterior and posterior rectus fascia around the deep cuff to reduce the risk of leakage.

Compared with laparoscopic insertion, open insertion has limited visibility and poor surgical exposure. As such, the adjunctive maneuvers, with the exception of rectus sheath tunneling, are more difficult to perform. Consequently, PD catheters placed with the open surgical approach have a higher incidence of catheter obstruction, pericatheter leak, and overall catheter malfunction compared with those placed laparoscopically at one and two years [31].

Compared with the Seldinger techniques, open surgical insertion has some advantages, such as some ability to perform adhesiolysis and omentopexies, a reduced risk of bowel puncture due to direction visualization, and the ability to perform hernia repair. However, it requires a larger incision, which needs a longer time to heal and is at a higher risk for dialysate leaks.

POSTPLACEMENT CARE — The care of a peritoneal dialysis (PD) catheter after placement is performed to ensure adequate healing of the surgical wound and continued patency of the catheter for eventual initiation of regular peritoneal dialysis.

Dressing change — Peritoneal dialysis programs vary in their protocols for wound dressing and flushing of new catheters. In our program, we use nonocclusive dressings over the exit and incision sites because it helps immobilize the catheter and allows for drainage of blood or dialysate without pooling. The transfer set is secured on top and covered separately to allow easy access for flushing (picture 4). The dressings are changed on a weekly basis at the dialysis unit by trained PD nurses until the patient initiates PD. For the initial two weeks after catheter placement, the wound is only cleaned with normal saline before the dressing is applied. After the initial two weeks, the wound is cleaned with normal saline and mupirocin cream is applied before dressing the wound.

Catheter flushing — Along with change of dressings, the PD nurses also flush new PD catheters, though programs vary in the volume used and frequency. In fact, some programs do not perform flushing at all unless blood is present in the effluent after catheter placement [13,37]. At present, there are no trials evaluating the impact of flushing, although putative benefits include prevention of catheter obstruction by blood or fibrin and identification of catheters that may require intervention due to nonfunction.

Our program follows the 2019 guidelines outlined by the International Society for Peritoneal Dialysis (ISPD) [2]. The catheter flushing procedure is performed by infusing 500 to 1000 mL of saline into the peritoneal cavity and draining it back out until the effluent is clear. There should be unimpeded inflow and outflow. At the end of the flushing procedure as the infusate flows out, a 100 to 200 mL residual volume should be left behind in the abdomen to avoid siphoning of peritoneal structures up into the side apertures of the catheter. The assessment and management of PD catheters that do not function as described is presented elsewhere. (See "Noninfectious complications of peritoneal dialysis catheters", section on 'Impaired catheter flow'.)

The timing and frequency of flushes are tailored to the individual patient depending upon the presence or absence of blood in the returned irrigant at the time of catheter placement and persistence of blood-tinged fluid at the time of postoperative flushes. Flushing helps clear any clots from the lumen of the new PD catheter, which is crucial for patients with a bloody fluid return.

Among patients who have blood in the returned irrigant at the time of placement, especially patients who required adhesiolysis, we flush the catheter within 24 hours of placement and continue flushing every 24 hours until the returned irrigant is clear. Five hundred to 1000 units of heparin may be added to each liter of dialysate when bleeding is present or if fibrin or clots are evident in the fluid returned from flushing. The catheter is then capped, and a dressing is applied to the site. Once the return is cleared of blood, the frequency of flushing can be extended to weekly until PD is initiated.

If the catheter is not used during the first month, and it is not clear when the patient will initiate dialysis, flushing can be converted to two- to four-week intervals.

Catheter embedding for delayed PD initiation — Catheter embedding (Moncrief-Popovich technique) is an adjunct method by which the external limb of the PD catheter is tunneled and embedded under the skin in the subcutaneous space. The catheter is then exteriorized through a small skin incision at a later time when the patient needs dialysis. This technique can be combined with any of the other catheter insertion techniques above. Exteriorization is a simple procedure and can be performed in the office.

●Ideal patients – It is suitable for patients who do not need to start dialysis immediately but also want to avoid the possibility of needing placement of a hemodialysis catheter for urgent initiation of dialysis.

●Additional benefits of catheter embedding – In addition to avoiding the need for a temporary hemodialysis catheter for urgent initiation of dialysis, there are additional advantages of catheter embedding:

•PD catheter placement can be planned far in advance and performed when the patient is likely to be more clinically stable and not uremic, rather than when the need for dialysis is imminent.

•PD can be initiated at full volumes rather than at low volumes since surgical wounds (exit-site and incision sites) would have already healed while the catheter was embedded.

●Success rate – Some [38,39], but not all, studies [40-43] have raised the concern that embedded catheters may be at a high risk for nonfunction upon exteriorization compared with non-embedded catheters. Success rates in terms of having a functioning catheter have ranged from 72 to 99 percent, with some catheters requiring additional procedures to enable function upon exteriorization [38-43]. Time to exteriorization ranged from four weeks to over two years across these studies.

●Relative contraindications – The placement of an embedded catheter should be avoided among patients with a high probability of intraabdominal adhesions (from prior intraabdominal operations) that may require extensive adhesiolysis for successful catheter placement. Adhesiolysis may result in periprocedural bleeding, which, in turn, can promote the development of fibrinous material settling in the catheter and impeding function upon exteriorization.

Patient restrictions — To ensure optimal healing of the surgical wounds, we generally advise against bathing, showering, or swimming for two to four weeks and strenuous exercise for four weeks after PD catheter placement.

Before getting the wound wet for the first time, we require examination of the exit site by an experienced PD nurse to look for signs of infection, including drainage, erythema, or crusting. The nurse also examines for signs of healing, particularly appropriate approximation of the edges of the skin and healing around the catheter. The dressing should be removed before entering the water and antibiotic cream such as mupirocin or gentamicin followed by a new dressing should be applied after exit from the water. In addition, for swimming, patients should be advised to keep the exit-site covered with an occlusive bandage or an ostomy bag for the duration of swimming (picture 5). After swimming, the exit-site should be cleaned with soap and water before applying the antibiotic cream and new dressing.

We encourage all types of exercise four weeks after PD catheter placement and beyond, including weight-lifting. However, exercise should be performed with a dry abdomen (ie, with no dwell left in the peritoneal cavity). Some clinicians ask the patient to wear a wet suit during vigorous exercise or water sports to protect the catheter and the exit site.

Nonfunctioning catheter — PD catheters can be nonfunctioning in some patients, and this usually occurs one to two months after catheter placement. Nonfunctioning catheters account for up to 15 percent of patients transitioning to hemodialysis from PD [44-47]. Nonfunction of the catheter can result from dysfunctional inflow, outflow, or both. The details regarding such nonfunction of the catheter are discussed elsewhere. (See "Noninfectious complications of peritoneal dialysis catheters", section on 'Impaired catheter flow'.)

SUMMARY AND RECOMMENDATIONS

●Clinical evaluation – All patients should be assessed prior to peritoneal dialysis (PD) catheter placement with special attention placed on underlying medical history, body habitus, patient placement preference, bowel and bladder function, and candidacy for suggested placement technique. (See 'Clinical evaluation' above.)

●Prophylactic antibiotics – Prior to PD catheter placement, we suggest intravenous antibiotics rather than no antibiotics (Grade 1B). We usually give cefazolin 2 g (3 g for ≥120 kg), or vancomycin (15 mg/kg up to 2 g) for those with a penicillin allergy or methicillin-resistant staphylococcus aureus (MRSA) colonization within 60 minutes (for cefazolin) or 60 to 120 minutes (for vancomycin) before incision time. (See 'Prophylactic antibiotics' above.)

●Preoperative mapping – PD catheters should be premapped out with the patient in the lying, sitting, and standing (if possible) position to best mark out the catheter exit site. The exit site should avoid areas of skin folds or ostomies, pant or belt lines, and be visible to the patient. (See 'Preoperative mapping' above.)

●Catheter selection – There are no catheters available that have demonstrated superiority over others. Several different designs and lengths should be available to best meets a patient's needs.

•For most patients, we suggest a double-cuffed catheter with a straight (and less commonly swan-neck) subcutaneous configuration and coiled intraabdominal segment (Grade 2C). (See 'Our preferred catheter for most patients' above.)

•For patients whose abdomen should be avoided for exit sites or have preference for bathing, we suggest a two-piece or extended catheter (Grade 2C). (See 'Extended catheter for some patients' above.)

●Catheter insertion:

•General principles – Catheter placement should be with a paramedian approach and not midline, with rectus sheath tunneling to avoid catheter migration. The deep cuff should be positioned in the rectus muscle and if possible, secured with a purse string suture to reduce the risk of early leaks and later development of hernias.

•Insertion techniques

-For patients with a history of multiple abdominal surgeries, patients who are obese, or patients who require other simultaneous procedures such as hernia repair, we suggest an advanced laparoscopic catheter placement rather than another technique (Grade 2C). (See 'Laparoscopic techniques' above.)

-For uncomplicated patients and those unable to tolerate general anesthesia, there are no true outcome differences among the individual techniques, and therefore, the choice should be based on local expertise. (See 'Percutaneous techniques' above.)

-Open surgical insertion remains the most common technique used for placing PD catheters worldwide because it is economical (relative to laparoscopic insertion), does not require special equipment, and can be performed under local anesthesia or conscious sedation. (See 'Open surgical technique' above.)

●Postplacement care – Post catheter placement, we keep the catheter and transfer set covered separately with nonocclusive dressing for one week without access. Thereafter, the catheter should be flushed and redressed weekly by a trained PD health care professional until used. Antibiotic cream should be applied to the exit site after the first week, with weekly flushing and redressing. However, patients with bloody returned irrigant in the operating room require earlier catheter flushing daily until the return clears, then flushing weekly until PD. (See 'Postplacement care' above.)