Peritoneal Dialysis Catheter Insertion

Peritoneal Dialysis
Catheter Insertion 3
GOALS/OBJECTIVES
• BASIC PRINCIPLES
• ANATOMY
• TECHNICAL CONSIDERATIONS
• MANAGEMENT OF COMPLICATIONS
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3-1 PERITONEAL DIALYSIS
Ricardo Correa-Rotter / Alfonso Cueto-Manzano / Ramesh Khanna
From Taal MW, Chertow GM, et al: Brenner and Rector’s The Kidney, 9th edition (Saunders 2011)
PERITONEAL PHYSIOLOGY AND TRANSPORT

During PD, both diffusion and convection are responsible for solute transport. Diffusion results from
a difference in solute concentrations across a membrane, which in turn is governed by Fick’s first law
of diffusion (the rate of transfer of a solute is determined by the diffusive permeability of the membrane
to that solute, the surface area available for transport, and the concentration). Convective transport,
or solute drag, occurs with water transport during ultrafiltration. Determinants of convective transport
include the water flux, the mean solute concentration, and the solute reflection coefficient.1 The reflec-
tion coefficient in semipermeable membranes is related to how such a membrane can prevent solute
particles from passing through. When the value is 0, all particles pass through. When the value is 1,
no particle can pass through.
The effective surface area of the peritoneal membrane and its intrinsic permeability determine the
ability of solutes to be transported. The effective surface area is determined by the number of capil-
laries perfused and the rate of flow within these capillaries.2,3
There are several barriers to the transport of solutes across the peritoneum.4,5 The peritoneal capil-
lary represents the major barrier for peritoneal transport. According to the two-pore theory of capillary
transport, small pores of 40 to 50 Å are abundant, and large pores larger than 150 Å are sparse.6,7
After the demonstration of aquaporin-1–mediated water transport through red blood cells,8,9 these
even smaller pores were also described in endothelial cells of peritoneal capillaries and venules.10,11 To
explain the phenomenon of sieving observed in PD, a three-pore model was proposed.12,13 According
to this model, about half of the transcapillary ultrafiltration occurs through ultra-small pores 3 to 5 Å
in size, and the other half occurs through the small pores.14,15 The mesothelium has been shown not
to be a significant barrier to small solute transport.5 However, the interstitium, despite its meshlike
architecture,16 could be such a barrier.17–19
Changes in solute transport are currently assumed to result from the ultrastructural alteration of
perfused capillaries. The mass transfer of solutes of low and medium molecular weight is dependent
primarily on their size and not on the intrinsic permeability of the peritoneum.20,21 The stagnant blood
in the capillaries and peritoneal cavity could offer some resistance to solute transport.22,23 Macromo-
lecular transport is size selective; therefore, diffusion and convection are limited.12,24 Hence, transport
is dependent primarily both on the effective surface area and permeability of the membrane and on
the molecular size of the solute. In animal models, the negative electric charges at various levels of
peritoneum and microvessels25,54 appear to restrict clearance of macromolecules, but this is not so in
humans.24,26,27 In summary, the transport of solutes of low molecular weight is affected by changes in
effective surface area of the peritoneal membrane, and macromolecule transport is determined mainly
by the structural alteration of the capillary wall or changes in the interstitium, or both.
Several distributed models and solute transport parameters have been proposed18,28–31 to describe
kinetics during a PD exchange. The mass transfer area coefficient (MTAC) is the theoretical instan-
taneous maximal clearance at time 0 without ultrafiltration. Several simple and other more complicated
models have been developed to calculate MTAC.32 In contrast, in clinical practice, relatively simple
measures – such as 24-hour clearance or 4-hour dialysate/plasma (D/P) ratios of low-molecular-weight
solutes – are used to assess the efficacy and adequacy of PD. Studies have shown good correlation
e34
CHAPTER 3-1 ■ Peritoneal Dialysis e35
between D/P ratios and MTAC for all ranges except in the low and high extremes of MTAC.33 During
a dialysis exchange, diffusion accounts for the majority of the mass removal of solutes of lower molecu-
lar weight (e.g., urea or creatinine)34; convective transport is a small fraction of total mass removal.35
Water transport during PD is driven through an osmotic gradient, generated by agents such as
glucose. Under physiologic conditions, the differences among hydrostatic, crystalloid, and colloid
osmotic pressures in the peritoneal capillaries and the peritoneal cavity allow for a small amount of
transcapillary ultrafiltration into the peritoneum to occur continuously. These pressures are exerted
over small pores and through water (aquaporin-1) channels in the endothelium of peritoneal capillaries,
which results in transcapillary ultrafiltration. There is a constant backward absorption of water from
the peritoneal cavity through transcapillary backwards filtration and fluid uptake through peritoneal
lymphatic vessels.36 Therefore, the net amount of ultrafiltration (water removal from the body) during
a PD exchange is a balance between the transcapillary ultrafiltration from the peritoneal capillaries
into the peritoneum and the backwards absorption of fluid from the cavity through capillaries and
lymphatic vessels. Because peritoneal dialysate is devoid of proteins, it exerts only crystalloid osmotic
pressure and hydrostatic pressure in the peritoneal cavity.
The effectiveness of dialysate in inducing ultrafiltration is expressed by the osmotic reflection coef-
ficient. Impermeable solutes such as macromolecular protein exert a reflection coefficient of 1, and
freely permeable solutes exert a reflection coefficient of 0. Therefore, during a PD exchange, the reflec-
tion coefficient for glucose transport through small pores is very low, at 0.02 to 0.05,37–39 and for glucose
transport through aquaporin-1, it is 1. The events of water transport that take place during a PD
exchange with glucose-based dialysate can be summarized as follows36: At the beginning of an exchange
(time 0), the glucose concentration of the dialysate is highest, and therefore, crystalloid osmotic pres-
sure and ultrafiltration rate are both also highest. As glucose is absorbed from the dialysate (approxi-
mately 61% of the total glucose content of a solution over a 4 hour period),40 the crystalloid pressure
and ultrafiltration diminish. Ultrafiltration volume accumulates progressively, and the ultrafiltration
volume peaks before osmotic equilibrium between serum and dialysate is reached; this equilibrium
occurs when the net transcapillary ultrafiltration rate progressively diminishes to equal rates of back-
wards absorption, plus lymphatic absorption. Thereafter, when the back absorption rate exceeds the
net transcapillary ultrafiltration rate, the intraperitoneal volume slowly diminishes. With further exten-
sion of dwell time, additional fluid would be absorbed. Patients deemed “high transporters” experience
rapid transport of small solutes; thus, these patients experience more rapid (and often more extensive)
dialysate glucose absorption and less cumulative transcapillary ultrafiltration. Ultrafiltration fails when
daily reabsorption equals or exceeds daily transcapillary ultrafiltration.
THE PERITONEAL CATHETER AND ACCESS
Key to successful PD therapy is permanent and safe access to the peritoneal cavity. A good catheter
provides obstruction-free access to the peritoneum. In addition, it should not be a source of peritoneal
infection. Catheter-related problems and infections are responsible for approximately 20% of technique
failure.41 Peritoneal catheters in current use have intraperitoneal and extraperitoneal segments.
TABLE 3-1-1 Considerations for

Adequate Dialysis
Clinical manifestations
Fluid balance, systemic blood pressure control, and
cardiovascular risk
Renal residual function
Acid-base homeostasis
Nutritional status
Calcium-phosphorous metabolism homeostasis
Inflammation
Small solute clearance
Middle molecule clearance
Psychologic and quality-of-life indicators
e36 SECTION 1 ■ ABDOMEN – GENERAL
FIGURE 3-1-1 Intraperitoneal and extraperitoneal designs of currently available peritoneal catheters.
The extraperitoneal segment passes through a tunnel within the abdominal wall (intramural), exits
through the skin, and has an external (outside the exit site) segment. Figure 3-1-1 shows different
intraperitoneal and extraperitoneal designs of currently available peritoneal catheters.
Globally, the catheter most widely used is the Tenckhoff catheter, followed by the swan-neck cath-
eter.42 More than 90% of the catheters used have two cuffs, and the majority incorporate a coiled
intraperitoneal segment. Tenckhoff catheters are made of silicone rubber tubing with a 2.6-mm inter-
nal diameter and a 5-mm external diameter. The catheter may contain one or two polyester cuffs, 1 cm
long. The straight double-cuff catheter is about 40 cm long with an intraperitoneal segment about
15 cm long, an intramural segment about 5 to 7 cm long, and an external segment about 16 cm long.
The open-ended intraperitoneal segment has multiple 0.5-mm side openings in the terminal 11-cm
segment. The coiled Tenckhoff catheter has a coiled, perforated intraperitoneal end that is 18.5 cm
long. Most Tenckhoff catheters have a barium-impregnated radiopaque stripe throughout the catheter
length to assist in radiologic visualization.
The swan-neck catheter, a modified Tenckhoff catheter, features a molded bend between cuffs.42,43
These catheters can be placed in an arcuate tunnel with both external and internal segments of the
tunnel directed downwards. A long tunnel, downward-directed exit, two intramural cuffs, and an
optimal sinus length tend to reduce exit and tunnel infection rates. The molded bend between cuffs
eliminates the rubber “shape memory” from causing the external cuff extrusion. A downward-directed
peritoneal entrance, aided by a slanted polyester disc, a feature similar to one in the Toronto Western
catheter (described later), tends to keep the internal segment in the true pelvis, reducing its migration.
Insertion of catheters through the rectus muscle decreases pericatheter leaks by promoting fibrous
ingrowth onto the polyester cuff. Finally, swan-neck catheters with a coiled intraperitoneal segment
minimize infusion and pressure pain. The intraperitoneal segment of the swan-neck catheter is identi-
cal to that of the Tenckhoff catheter in that its terminal segment is either straight or coiled.
Presternal catheters were designed to allow for an exit site above the abdomen. The chest is a rather
rigid structure with minimal wall motion; the catheter exit located on the chest wall is subjected to
minimal trauma; therefore, chances of contamination are decreased. Also, in patients with abdominal
ostomies and in children with diapers, a chest exit location reduces the chances of cross contamination.
Implantation directly over the sternum should be avoided, so as to prevent catheter damage during
any cardiac surgery that necessitates sternotomy. A long catheter tunnel, combined with three cuffs,
may reduce pericatheter bacterial contamination of the peritoneal cavity and hence reduce the inci-
dence of peritonitis.44 The presternal catheter is composed of two silicone rubber tubes, cut to an
appropriate length and connected end to end at the time of implantation. The lower tube, including
the internal segment, is identical to that of the swan-neck abdominal catheter. A titanium connector
is used to connect the two components at the time of implantation. The Moncrief-Popovich catheter
is a modified swan-neck coiled catheter with a longer subcutaneous cuff (2.5 cm instead of 1 cm).
This catheter is inserted with the Moncrief–Popovich implantation technique.45 The other catheters
in use are the T-fluted catheter; the self-locating catheter; the Cruz catheter; the Toronto Western
Hospital catheter; the Ash (Life) catheter; the column disc catheter; and the Gore-Tex peritoneal
catheter.46
Rigid catheters for acute dialysis, rarely used in developed nations, are still used in some
countries. Complications of rigid catheter insertion include minor bleeding; leakage of dialysis
solution; extravasation of fluid into the abdominal wall, particularly in patients who have had a previ-
ous abdominal operation or multiple catheter insertions; and inadequate drainage as a result of omental
wrapping, loculation, or misplaced catheter in the upper abdomen. Loss of a part or the entire rigid
catheter after manipulation of a poorly functioning rigid catheter has been reported. The incidence of
peritonitis varies widely with rigid catheters; the rate may be dependent on the duration of dialysis
and catheter manipulation, among other factors.47,48
For long-term use, PD catheters such as the Tenckhoff or swan-neck can be inserted surgically42
at the patient’s bedside by an experienced nephrologist or by a surgeon or through a laparoscopic
insertion, a procedure that has gained favor.46
CATHETER-RELATED COMPLICATIONS
The most common complications of PD catheters include exit and tunnel infection, external cuff
extrusion, poor function, dialysate leaks, peritonitis, and infusion or pressure pain. Several factors
adversely influence the normal healing process and lead to early infections: foreign body-induced tissue
reaction, poor tissue perfusion, mechanical factors, sinus bacterial colonization, delayed epithelializa-
tion, local cleansing agents, exit direction, and several other systemic problems. After the exit site is
well healed, a factor that predisposes to infection is bacterial colonization of the sinus tract in associa-
tion with local trauma.46,49–52
The catheter tip, as it rests against the pelvic wall or intra-abdominal organs,51 may cause localized
pain from irritation. The jet effect of rapidly flowing dialysis solution may also cause abdominal pain.
In some rare instances, compartmentalization from adhesion formation around the catheter may cause
severe abdominal pain.53 Coiled catheters are less likely to induce abdominal pain than are straight
catheters.
The extrusion of the external synthetic cuff can be prevented by creating the tunnel in a shape
similar to the shape of the catheter and placing this cuff approximately 2 to 3 cm beneath the skin.
In the absence of catheter infection, shaving off the extruded external cuff may help prolong the life
of the catheter.50
Entrapment, or “capture,” of the catheter by the active omentum may cause outflow obstruction in
the postimplantation period. Omental “capture” as a late event is rare. From time to time in some
patients, drainage slows as a result of catheter translocation, obstruction by omentum, or fibrin clot
formation. Laxatives or addition of heparin, 500 U per liter of dialysis solution, or both may be suc-
cessful in restoring good dialysate flow. In some patients, catheters have migrated out of the true pelvis.
If the catheter continues to function appropriately, it is not necessary to reposition it. If the catheter
fails to function after simple maneuvers are implemented, more aggressive measures (e.g., laxatives,
forced flushing) may be tried. When these measures fail, laparoscopic repositioning of the catheter tip
back to the true pelvis and anchoring may be necessary. The Toronto Western catheter has two silicone
discs in the intraperitoneal segment of the catheter that hinder the free movement of catheter tip out
of the pelvis after placement.46
Insertion of the deep cuff into the center of the rectus muscle, as opposed to midline placement,
has significantly reduced the incidence of early leakage of pericatheter dialysis solution.46,51 Pericatheter
leaks are rare with catheters that have a bead and polyester flange at the deep cuff (Toronto Western
Hospital catheter, swan neck Missouri catheter, swan neck presternal peritoneal catheter). In contrast
to the early leaks, which are usually external, the late leaks infiltrate the abdominal wall through prior
healed incisions. PD catheters may cause hemoperitoneum by causing minor tears of small vessels. On
occasion, a peritoneal catheter erodes into the mesenteric vessels, leading to hemoperitoneum. In rare
cases, a peritoneal catheter damages the internal organs, which leads to intra-abdominal bleeding.
Transvaginal leakage of peritoneal fluid is rare, but the possibility should be considered in an appropri-
ate clinical setting.46,51
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15. Smit W, Struijk DG, Ho-dac-Pannekeet MM, Krediet RT. Quantification of free water transport in peritoneal dialysis.
Kidney Int. 2004;66:849–854.
16. Levick JR. Flow through interstitium and fibrous matrices. Q J Exp Physiol. 1987;72:409–438.
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gradients. Am J Physiol. 1985;248:F425–F435.
19. Wiig H, DeCarlo M, Sibley L, et al. Interstitial exclusion of albumin in rat tissues measured by a continuous infusion
method. Am J Physiol. 1992;263:H1222–H1233.
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1987;110:207–216.
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22. McGary TJ, Nolph KD, Rubin J. In vitro simulations of peritoneal dialysis. J Lab Clin Med. 1980;96:148–157.
23. Levitt MD, Kneip JM, Overdahl MC. Influence of shaking on peritoneal transport. Kidney Int. 1989;35:1145–1150.
24. Krediet RT, Koomen GCM, Koopman MG, et al. The peritoneal transport of serum proteins and neutral dextran in CAPD
patients. Kidney Int. 1989;35:1064–1072.
25. Galdi P, Shostak A, Jaichenko J, et al. Protamine sulfate induces enhanced peritoneal permeability to proteins. Nephron.
1991;57:45–51.
26. Krediet RT, Struijk DG, Koomen GCM, et al. The peritoneal transport of macromolecules in CAPD patients. Contrib
Nephrol. 1991;89:161–174.
27. Krediet RT, Zemel D, Struijk DG, et al. Individual characterization of the peritoneal restriction barrier to macromolecules.
Adv Perit Dial. 1991;7:16–20.
28. Flessner MF, Dedrick RL, Schultz JS. A distributed model of peritoneal plasma transport: theoretical considerations. Am
J Physiol. 1984;246:R597–R607.
29. Seasmes El, Moncrief JW, Popovich RP. A distributed model of fluid and mass transfer in peritoneal dialysis. Am J Physiol.
1990;258:958–972.
30. Smeby LC, Wideroe T-E, Jorstad S. Individual differences in water transport during continuous peritoneal dialysis.
ASAIO J. 1981;4:17–27.
31. Waniewski J, Werynski A, Heimbürger O, et al. Simple membrane models for peritoneal dialysis: evaluation of diffusive
and convective solute transport. ASAIO J. 1992;38:788–796.
32. Lysaght MJ, Farrell PC. Membrane phenomena and mass transfer kinetics in peritoneal dialysis. J Membrane Sci.
1984;44:5–53.
33. Heimbürger O, Waniewski J, Werynski A, Park MS, et al. Dialysate to plasma solute concentration (D/P) versus peritoneal
transport parameters in CAPD. Nephrol Dial Transplant. 1994;9:47–59.
34. Twardowski ZJ, Nolph KD, Khanna R, et al. Peritoneal equilibration test. Perit Dial Bull. 1987;7:138–147.
35. Smit W, Langeijk M, Schouten N, et al. Peritoneal function and assessment of reference values using a 3.86% glucose
solution. Perit Dial Int. 2003;23:440–449.
36. Mactier RA, Khanna R, Twardowski ZJ, et al. Contribution of lymphatic absorption to loss of ultrafiltration and solute
clearances in continuous ambulatory peritoneal dialysis. J Clin Invest. 1987;80:1311–1316.
37. Krediet RT, Imholz ALT, Struijk DG, et al. Ultrafiltration failure in continuous ambulatory peritoneal dialysis. Perit Dial
Int. 1993;13(suppl 2):S59–S66.
38. Imholz ALT, Koomen GCM, Struijk DG, et al. Fluid and solute transport in CAPD patients using ultralow sodium
dialysate. Kidney Int. 1994;46:333–340.
39. Leypoldt JK. Interpreting peritoneal osmotic reflection coefficients using a distributed model of peritoneal transport. Adv
Perit Dial. 1993;9:3–7.
40. Pannekeet MM, Imholz ALT, Struijk DG, et al. The standard peritoneal permeability analysis: a tool for the assessment
of peritoneal permeability characteristics in CAPD patients. Kidney Int. 1995;48:866–875.
41. Flanigan M, Gokal R. Peritoneal catheters and exit-site practices toward optimum peritoneal access: A review of current
developments. Perit Dial Int. 2005;25:132–139.
42. Negoi D, Prowant BF, Twardowski ZJ. Current trends in the use of peritoneal dialysis catheters. Adv Perit Dial.
2006;22:147–152.
43. Twardowski ZJ, Nolph KD, Khanna R, et al. The need for a “Swan Neck” permanently bent, arcuate peritoneal dialysis
catheter. Perit Dial Bull. 1985;5:219–223.
44. Twardowski ZJ, Prowant BF, Pickett B, et al. Four-year experience with swan neck presternal peritoneal dialysis catheter.
Am J Kidney Dis. 1996;27:99–105.
45. Dasgupta MK. Moncrief-Popovich catheter and implantation technique: the AV fistula of peritoneal dialysis. Adv Ren
Replace Ther. 2002;9:116–124.
46. Kathuria P, Twardowski ZJ, Nichols WK. Peritoneal dialysis access and exitsite care including surgical aspects. In: Khanna
R, Krediet R, eds. Nolph and Gokal’s textbook of peritoneal dialysis. 3rd ed. New York: Springer; 2009:371–446.
47. Chitalia VC, Almeida AF, Rai H, et al. Is peritoneal dialysis adequate for hypercatabolic acute renal failure in developing
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48. Phu NH, Hein TT, Mai NT, et al. Hemofiltration and peritoneal dialysis in infection associated acute renal failure in
Vietnam. N Engl J Med. 2002;347:895–902.
49. Werner S, Grose R. Regulation of wound healing by growth factors and cytokines. Physiol Rev. 2003;83:835–870.
50. Khanna R, Twardowski ZJ. Peritoneal catheter exit site. Perit Dial Int. 1988;8:119–123.
51. Diaz-Buxo JA. Complications of peritoneal dialysis catheters: early and late. Int J Artif Organs. 2006;29(1):50–58.
52. Crabtree JH, Fishman A, Siddiqi RA, et al. The risk of infection and peritoneal catheter loss from implant procedure exit-
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53. Diaz-Buxo JA. Peritoneal dialysis catheter malfunction due to compartmentalization. Perit Dial Int. 1997;17:209–210.
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Nephron. 1987;47:22–28.
PERITONEAL DIALYSIS
3-2 CATHETER PLACEMENT

William P. Robinson III / Matthew T. Menard
From Vernon AH, Ashley SW: Atlas of Minimally Invasive Surgical Techniques,
1st edition (Saunders 2012)
FIGURE 3-2-1 Trocar insertion sites and placement of catheter.
e40
CHAPTER 3-2 ■ Peritoneal Dialysis Catheter Placement e41
FIGURE 3-2-2 Note the equipment used for the insertion of a coiled peritoneal dialysis catheter through a laparoscopically
guided percutaneous insertion technique.
FIGURE 3-2-3 Note position of catheter cuffs.
FIGURE 3-2-4 Positioning of the catheter at Douglas Pouch is confirmed with the camera before desufflation of the abdomen.
ADVANCED LAPAROSCOPIC
TECHNIQUES SIGNIFICANTLY
IMPROVE FUNCTION OF
3-3 PERITONEAL DIALYSIS
CATHETERS
Vikram Attaluri / Christopher Lebeis /
Stacy Brethauer / Steven Rosenblatt
From Advanced laparoscopic techniques significantly improve function of
peritoneal dialysis catheters. JACS 2010;211:699–704
BACKGROUND: Continuous ambulatory peritoneal dialysis (CAPD) catheters provide

a preferred alternative to hemodialysis in a growing population with
chronic kidney disease. However, CAPD catheters traditionally have
been associated with a high rate of nonfunction with both open and
laparoscopic procedures. New advanced laparoscopic techniques
using rectus sheath tunneling and omentopexy have been reported to
improve catheter function.
STUDY DESIGN: This study retrospectively reports the Cleveland Clinic experience
during the transition from basic to advanced laparoscopic techniques
from June 2002 to July 2008. A total of 197 patients were identified:
68 who underwent insertion with basic techniques and 129 who
received catheters with advanced techniques. Primary nonfunction,
procedural complications, and overall nonfunction rate were analyzed
using the most recent follow-up to June 2008.
RESULTS: Primary nonfunction occurred in 25 of 68 (36.7%) patients in the
basic group; this occurred in only 6 of 129 patients (4.6%) in the
advanced group (p < 0.0001). The overall rate of complications
including nonfunction from primary and secondary sources, perito-
neal leak, peritonitis, port-site hernia, and bleeding occurred in 31 of
68 (45.6%) patients in the basic group and 21 of 129 (16.28%)
patients in the advanced group (p < 0.0001).
CONCLUSIONS: These data clearly show a significant improvement in CAPD catheter
function using omentopexy and rectus sheath tunneling. These
advanced laparoscopic techniques should become the preferred
method of CAPD catheter insertion. ( J Am Coll Surg 2010;211:699–
704. © 2010 by the American College of Surgeons)
Dialysis is becoming more common as the number of patients with end-stage renal disease (ESRD)
increases and the number of available donor kidneys fails to keep up with the demand. There are
approximately half a million patients in the United States with ESRD, and the incidence of this disease
is around 330 per million people per year. The need for dialysis has increased as the waiting list for
kidney transplantation has doubled, even with a rise in the number of kidneys available for
transplantation.1,2
The two main modalities for dialysis are hemodialysis (HD) and peritoneal dialysis (PD), with the
majority of patients on HD.3,4 Continuous ambulatory peritoneal dialysis (CAPD) has been used as
a major renal replacement therapy since the early 1980s.5 Although the results comparing PD and
e42
CHAPTER 3-3 ■ Peritoneal Dialysis Catheters e43
HD have been conflicting, several studies have shown short-term benefit in survival with PD.6 Com-
pared with HD, PD has shown improved preservation of residual kidney function, improving initial
survival.7 Additional advantages of PD include increased patient mobility and independence, fewer
dietary restrictions, and no required systemic anticoagulation.
However, CAPD catheters have historically been associated with high complication rates. Tradi-
tionally, CAPD catheters have been inserted using a small laparotomy and blind placement of the
catheter in the pelvis. This technique has been associated with catheter obstruction rates as high as
36%. Other techniques have since been described that use fluoroscopy, percutaneous puncture using
laparoscopy, and straight laparoscopy. However, there is a lack of consensus in the literature as to the
preferred operation. Most importantly, the rate of catheter obstruction has been reported to vary
between 2% and 36%.8–11 This malfunction is often the result of outflow obstruction, usually related
to a mechanical problem, such as catheter tip migration and/or omental wrapping.12 Additionally, other
complications also vary widely, including pericatheter leaks (1% to 27%) and superficial cuff extrusion
(4% to 10%). The absence of a standard procedure using best surgical practice may help to explain
this wide variation.
Rectus sheath/extraperitoneal tunneling and omentopexy in CAPD catheter placement have shown
a vast decrease in catheter malfunction.8,13 We review our experience as we transitioned between
laparoscopic CAPD catheters without rectus sheath tunneling to the implementation of rectus sheath
tunneling and selective omentopexy.
METHODS
A retrospective review of all patients undergoing CAPD catheter placement at the Cleveland Clinic
from June 2002 through July 2008 was completed. This time period was divided into 2 groups encom-
passing patients who underwent CAPD catheter placement without rectus sheath tunneling ( June
2002 to December 2004) and patients who underwent CAPD catheter placement using rectus sheath
tunneling and selective omentopexy (December 2004 through July 2008).
All patients were evaluated by the Cleveland Clinic Nephrology Department and deemed eligible
for PD. The nonrectus tunneling group consisted of 68 patients with laparoscopic placement. The
rectus tunneling group contained 129 patients who had laparoscopic implantation using advanced
methods that included rectus sheath tunneling and selective prophylactic omentopexy. Both groups
also had selective adhesiolysis. All patients had a traditional pelvic catheter placement with a Tenckhoff
style catheter. The primary endpoint was nonfunction of the catheter. Secondary endpoints included
pericannicular leak, peritonitis, port-site hernia, and bleeding.
Surgical Technique
All patients underwent consultation before surgery, and the exit site was planned with the patient in
a seated position to ensure the catheter would not fall below the belt line, below a skin crease, or into
a skin fold and was easily visible for the patient. We used a standard Tenckhoff style catheter with a
deep cuff to be placed into the rectus sheath and a superficial cuff meant to be placed in the subcu-
taneous tissue.
All catheters were placed under general endotracheal anesthesia, and patients were given a dose of
preoperative prophylactic antibiotics before incision in the operating room.14,15 For placement of the
deep cuff, we begin by planning out the course that the catheter will run by positioning the coiled tip
of the catheter on the patient’s pubic symphysis and marking the location where the deep cuff will sit
in the rectus abdominis muscle that will maintain the position of the catheter. The incision is made
at the paramedian location and is about 3 cm from the midline; this location allows the catheter to
travel through the rectus sheath and avoid the epigastric vasculature.
A 2-port technique is used for laparoscopic CAPD catheter placement, with an additional
port as needed for selective omentopexy. Pneumoperitoneum and laparoscopic access is gained
via a 5-mm paramedian incision far enough away so as not to interfere with the catheter insertion
site. We insert a 0-degree scope and an Endopath (Ethicon Endosurgical) trocar under direct
visualization, and we then insufflate with CO2. A 30-degree scope is then inserted and the
abdomen is visualized for adhesions that could cause compartmentalization of the abdomen,
undiagnosed abdominal wall hernias, and a redundant omentum. The patient is put into steep reverse
Trendelenburg position to see if the omentum falls into the pelvis and therefore requires
an omentopexy.
A bladeless trocar port system is used to perform rectus sheath tunneling (7/8-mm Auto
Suture Mini Step, Covidien AG). The rectus sheath tunnel is started by a small 3-cm paramedian
incision over the rectus muscle and dissected down to the level of the anterior fascia, which is then
incised using electrocautery. A Veress needle with an expandable plastic sheath is then used to
create the rectus sheath tunnel under direct laparoscopic visualization. A 4- to 6-cm intramuscular
tract is created before entering the peritoneal cavity. After retracting the Veress needle, a 7/8-mm-
dilator-cannula assembly is used to expand the plastic sleeve to a size large enough for catheter inser-
tion. This allows for catheter placement within the rectus sheath through a smaller hole than a cutting
trocar would allow, which may reduce the incidence of pericannular hernias, leaks, and bleeding of the
rectus muscle.
The CAPD catheter is soaked in saline before implantation and is placed over a straight stylet to
assist in its passage into the abdomen. The catheter is then inserted through the port into the abdomen
until the deep cuff is visualized, ensuring its passage through the anterior sheath, and the stylet is
withdrawn while the catheter is being inserted. The coiled tip is placed in the retrovesical space. Under
laparoscopic visualization, the catheter is withdrawn until the distal cuff is placed within the rectus
muscle.
The pneumoperitoneum is released so that the subcutaneous tract can be created with the abdomen
in normal contour without the distortion that occurs with insufflation. After placing the catheter in
the abdominal wall and the coiled tip sits in the retrovesical space, the remaining catheter is tunneled
subcutaneously using a Faller stylet (Covidien AG) to the planned exit site. This stylet is smaller in
diameter than the catheter so that the tunnel and exit site are snug around it and it can be advanced
through the skin without an incision.
The patient is placed in steep reverse Trendelenburg position, and the catheter is then tested for
flow obstruction by infusion of 500 mL of isotonic saline through the catheter and return of this fluid
by gravity. With completion of this test we again insufflate the patient with CO2 to confirm placement
of the catheter tip and check for bleeding and then we remove the trocars. The exit site is not sutured
and is covered with a dressing to prevent infection as it heals around the catheter. The catheter is
flushed with 50 mL of heparinized saline to prevent clot formation and closed with a Betadine (Purdue
Pharma) cap.
We recommend that our patients wait at least 2 weeks before using their catheter for PD to allow
their wounds to heal and avoid the risk of early leaks.8,16
Selective Omentopexy
Because the omentum is a common cause of flow obstruction, its placement and size should always
be observed when placing a CAPD catheter. Crabtree and Fishman17 described a similar technique
for performing the omentopexy. If the omentum is redundant and falls into the pelvis, an omentopexy
is performed. The omentopexy is carried out using a suture passer with #0 Prolene (Ethicon) suture
through a stab incision located in the upper abdominal quadrant lateral to the rectus sheath and a
5-mm laparoscopic grasper inserted through an additional port. The grasper directs the multiple folds
of the omentum through the Prolene suture with care to avoid the omental vessels. After securing the
omentum to the abdominal wall, the patient is put into steep reverse Trendelenburg position to ensure
that the omentum does not fall into the pelvis.
Subcutaneous Catheter Tunneling

An algorithm described by Crabtree18 assists in the location of the exit site for the catheter and loca-
tion of the deep cuff. Briefly, it is done by keeping pressure on the deep cuff location and using the
catheter like a compass from a point 2 cm beyond the superficial cuff and swinging it around, creating
a 90-degree arc. A point is selected on the arc approximately 30 degrees above the horizontal plane
to roughly indicate the exit site location. A point on the catheter 4 cm external to the superficial cuff
is then bent over to the selected exit site to produce a gentle tubing arc that is directed both laterally
and slightly downward. This process helps to avoid excessive bending of the catheter in its subcutane-
ous tunnel that could lead to kinking or shape memory stress, producing tube straightening and
superficial cuff extrusion through the exit site. At the time of catheter insertion, the superficial cuff
will rest 4 cm from the exit wound. In the event that some tube straightening occurs over time, the
described algorithm prevents the superficial cuff from coming closer than 2 cm to the exit site. This
site will vary from patient to patient depending on body habitus and previous abdominal surgical scars.
The subcutaneous tunnel configuration produced by the algorithm avoids pooling of water and/or
sweat in the skin exit sinus.
Statistical Analysis
Chi-square and Fischer’s exact t-test were used for nominal variables. A Student t-test was used for
continuous variables.
RESULTS
During our implantation of all 197 catheters, there were no deaths, and no operations in either group
were converted to open procedures. Demographics for both groups can be seen in Table 3-3-1. There
was no statistical difference between the age, sex, or previous abdominal surgery of the patients in
either group. There was a statistical difference in length of follow-up, which was expected because the
groups were defined by chronologic order.
Patients in the rectus sheath tunneling group underwent a prophylactic omentopexy when the
omentum was found to lie within the pelvis/retrovesical space. Sixty-nine (53.5%) patients had an
omentopexy performed during the catheter implantation procedure. Adhesiolysis was performed in 21
patients (16.3%), 12 of whom also had an omentopexy, to prevent compartmentalization or to clear
the area in the abdominal wall for catheter implantation. Five patients (3.9%) had intraoperative
umbilical herniorrhaphy to prevent worsening of the hernia from PD.
Mechanical flow obstruction occurred in 6 of the 129 CAPD catheter implantations that involved
the rectus sheath tunneling (Table 3-3-2). The low rate (4.6%) of catheter dysfunction was significantly
better (p < 0.0001) than the rate in the non-rectus sheath tunneling group (36.8%). Three of the
patients with flow obstruction had blockage due to a large amount of sigmoid epiploic fat. Two patients
had dysfunction caused by postoperative adhesions, and all had previous abdominal surgery and
underwent adhesiolysis. One patient’s catheter tip became entangled in a rent of the median umbilical
ligament. Of these 6 patients who had mechanical obstruction, only 2 were not amendable to
revision.
The overall rate of complications, including nonfunction, peritoneal leak, peritonitis, port-site
hernia, and bleeding, occurred in 31 of 68 (45.6%) patients in the basic group and 21 of 129 (16.28%)
patients in the advanced group (p < 0.001) (Table 3-3-2). All identifiable umbilical, ventral, and
inguinal hernias were repaired at the time of catheter implantation, and this occurred in 5 (3.9%)
patients in the advanced group and only 1 (1.5%) in the basic group. There was only 1 case (0.51%
overall) of a pericannular leak in all of our patients and we believe this low rate of occurrence is attrib-
utable to our paramedian implantation and rectus sheath tunneling. Port-site hernias did not occur in
TABLE 3-3-1 Patient Characteristics Between the Non-Rectus Sheath

Tunneling and Rectus Sheath Tunneling Groups
Non-Rectus Sheath Rectus Sheath
Tunneling, June Tunneling, December
Parameter 2002–December 2004 2004–June 2008
n 68 129
Age, y, mean ± SD 48.6 ± 15.7 51.4 ± 14.8
Male, n (%) 38 (55.9) 72 (55.8)
Postoperative follow-up, mo* 19.9 15.1
Previous abdominal surgery, n (%) 45 (66.2) 79 (61.2)
Selective prophylactic omentopexy, n (%)* 3 (4.4) 69 (53.5)
Selective prophylactic omentectomy, n (%) 1 (1.5) 0
Selective prophylactic adhesiolysis, n (%) 9 (13.2) 21 (16.3)
Intraoperative umbilical hernia repair, n (%) 1 (1.5) 5 (3.9)
*p < 0.05.
TABLE 3-3-2 Breakdown of Specific Complications Between the

Non-Rectus Sheath Tunneling and Rectus Sheath Tunneling Groups
Non-Rectus Sheath Rectus Sheath
Tunneling Tunneling
Procedural Complication n % n %
Catheter flow obstruction 25 36.8 6 4.6
Omentum 11 44 0 0
Adhesions 3 12 2 33
Catheter migration 3 12 0 0
Cuff erosion 2 08 0 0
Sigmoid epiploics 0 0 3 50
Subcutaneous kink 1 4 0 0
Caught in median umbilical ligament 0 0 1 17
Unknown (drainage issues) 5 20 0 0
either group, possibly due to the use of 5-mm ports. In addition, there was 1 instance of postoperative
hemorrhage in the basic group and none in the advanced group. There were no cases of superficial
cuff extrusion in the advanced group and 4 (5.9%) in the basic group, the absences of extrusions being
attributed to the use of a subcutaneous tunneling algorithm that minimized tubing shape memory
forces and assured proper positioning of the subcutaneous cuff.
DISCUSSION
PD has continued to undergo technical improvement to become a common, and increasingly preferred,
treatment for patients with ESRD. One of the groundbreaking advancements in PD was the invention
of the catheter cuff by Tenckhoff in 1968. The resulting fibrosis around the cuff helps create a seal
against leaks and a barrier against infection.19 This seal allows PD to be used for long-term cases and
for acute kidney failure. Intermittent PD was used for ESRD until 1977, when Popovich and col-
leagues20 developed CAPD. Others further perfected CAPD and it became very popular due to its
low cost, simplicity of technique, and ease of use for the patient.21,22
The addition of laparoscopic surgery and best surgical practice has only continued to improve these
results. Crabtree and colleagues8 have built upon the early success of surgeons such as McIntosh and
associates23 in 1985, who performed omentopexy by using an open incision through which the
omentum was gathered, pleated, and then secured to the abdominal wall: the “omental hitch,” which
improved their catheter dysfunction rate from 67% to 17%. Gajjar and coworkers11 showed improve-
ment in functional success and a lower incidence of PD catheter revision in the group that underwent
laparoscopic-assisted CAPD catheter placement compared with the traditional “blind” technique
through a small lower abdominal incision using a malleable catheter guide. Additionally, Crabtree and
colleagues24,25 showed that laparoscopic procedures are more cost-effective.
Our data with the addition of rectus sheath tunneling, selective omentopexy, and proper subcutane-
ous catheter tunneling have greatly reduced the most common complications of CAPD catheters.
Looking at the causes of nonfunction between the 2 groups, it is evident there are entirely different
causes. Omentum used to be the single largest cause of our catheter nonfunction, but it was nonexist-
ent with the new techniques. Similarly, we no longer had a problem with cuff extrusion. These data
support the view that it is not necessary to insert an additional trocar and complete an omentopexy
in all patients. Rather, clinical judgment at the time of operation saved almost half the patients from
undergoing this additional technique. The effect of selective omentopexy could be greater than directly
noted by the data. A significant group of patients used to have unknown drainage issues causing
obstruction (20% in the non-rectus sheath tunneling group). It is possible that temporary blockage by
the omentum could have caused these drainage issues. However, we are unable to provide a certain
answer for the lack of these problems in the rectus sheath tunneling group.
Alternative methods have been described to laparoscopically guide placement of a catheter into a
rectus sheath tunnel; however, these techniques either use more than 1 port in the tunneling process13,26
or subject the peritoneal catheter to potential damage by forcefully pulling it through the abdominal
wall, the latter resulting in imprecise positioning of the catheter cuffs.27 Another approach has been
to anchor the catheter in the pelvis with a stitch. The problem with this approach is that extra laparo-
scopic ports are required to place the stitch, and the suture sometimes fails by pulling out of the tissues,
but at other times, its secure hold complicates catheter removal.28 Rectus sheath tunneling, as described
in this report, using an expandable sleeve as a conduit for placement of a nonbladed laparoscopic port,
is a simple, safe, accurate, and reproducible method for immobilization of the catheter tip in the pelvis,
and it prevents migration.
It is important to note that the improved results in this study are not due to a single new interven-
tion but rather a collection of improvements. An advancement that is particularly important in the
growing obese patient population is the use of an extended catheter, allowing placement of exit sites
in a more manageable position above abdominal skin folds. This allows better care of catheters, leads
to decreased complication rates, and extends CAPD to those previously troubled by body habitus,
presence of stomas, or urinary-fecal incontinence.24
CONCLUSIONS
Laparoscopic placement of CAPD catheters using rectus sheath tunneling, selective omentopexy, and
proper subcutaneous catheter tunneling is clearly advantageous to other techniques reported in the
literature and should be strongly encouraged.
References
1. Liu KD, Chertow GM. Dialysis in the treatment of renal failure. In: Kasper DL, Fauci AS, Longo DL, et al. Harrison’s
Principles of Internal Medicine. 17th ed New York, NY: McGraw-Hill;2008.
2. Carpenter CB, Milford EL, Sayegh MH. Transplantation in the treatment of renal failure. In: Kasper DL, Fauci AS, Longo
DL, et al. Harrison’s Principles of Internal Medicine. 17th ed New York, NY: McGraw-Hill;2008.
3. Grassmann A, Gioberge S, Moeller S, Brown G. ESRD patients in 2004: global overview of patient numbers, treatment
modalities and associated trends. Nephrol Dial Transplant 2005;20:2587–2593.
4. Miskulin DC, Athienites NV, Yan G, et al. Comorbidity assessment using the Index of Coexistent Diseases in a multicenter
clinical trial. Kidney Int 2001;60:1498–1510.
5. Sharma A, Blake PG. Peritoneal dialysis. In: Brenner B, ed. Brenner and Rector’s The Kidney. 8th ed. Philadelphia, PA:
Saunders Elsevier;2007.
6. Schaubel DE, Morrison HI, Fenton SS. Comparing mortality rates on CAPD/CCPD and hemodialysis. The Canadian
experience: fact or fiction? Perit Dial Int 1998;18:478–484.
7. Heaf JG, Løkkegaard H, Madsen M. Initial survival advantage of peritoneal dialysis relative to haemodialysis. Nephrol
Dial Transplant 2002;17:112–117.
8. Crabtree J, Fishman A. A laparoscopic method for optimal peritoneal dialysis access. Am Surg 2005;71:135–143.
9. Draganic B, James A, Booth M, Gani JS. Comparative experience of a simple technique for laparoscopic chronic ambula-
tory peritoneal dialysis catheter placement. ANZ J Surg 1998;68:735–739.
10. Ogünç G. Videolaparoscopy with omentopexy: a new technique to allow placement of a catheter for continuous ambulatory
peritoneal dialysis. Surg Today 2001;31:942–944.
11. Gajjar A, Rhoden D, Kathuria P, et al. Peritoneal dialysis catheters: laparoscopic versus traditional placement techniques
and outcomes. Am J Surg 2007;194:872–876.
12. Yilmazlar T, Yavuz M, Ceylan H. Laparoscopic management of malfunctioning peritoneal dialysis catheters. Surg Endosc
2001; 15:820–822.
13. Ogünç G. Minilaparoscopic extraperitoneal tunneling with omentopexy: a new technique for CAPD catheter placement.
Peritoneal Dialysis International: J Int Soc Peritoneal Dialysis 2005;25:551–555.
14. Strippoli GF, Tong A, Johnson D, et al. Antimicrobial agents to prevent peritonitis in peritoneal dialysis: a systematic review
of randomized controlled trials. Am J Kidney Dis 2004;44:591–603.
15. Gadallah MF, Ramdeen G, Mignone J, et al. Role of preoperative antibiotic prophylaxis in preventing postoperative peri-
tonitis in newly placed peritoneal dialysis catheters. Am J Kidney Dis 2000;36:1014–1019.
16. Del Peso G, Bajo MA, Costero O, et al. Risk factors for abdominal wall complications in peritoneal dialysis patients.
Peritoneal Dialysis International: J Int Soc Peritoneal Dialysis 2003;23:249–254.
17. Crabtree J, Fishman A. Selective performance of prophylactic omentopexy during laparoscopic implantation of peritoneal
dialysis catheters. Surg Laparosc Endosc Percutaneous Tech 2003;13:180–184.
18. Crabtree J. Construction and use of stencils in planning for peritoneal dialysis catheter implantation. Peritoneal Dialysis
International: J Int Soc Peritoneal Dialysis 2003;23:395–398.
19. Tenckhoff H, Schechter H. A bacteriologically safe peritoneal access device. Trans Am Soc Artif Intern Organs
1968;14:181–187.
20. Popovich RP, Moncrief JW, Decherd JF. The definition of a novel portable-wearable equilibrium peritoneal technique. Am
Soc Artif Intern Org 1976;5:64 (abstract).
21. Popovich RP, Moncrief JW, Nolph KD, et al. Continuous ambulatory peritoneal dialysis. Ann Intern Med
1978;88:449–456.
22. Oreopoulos DG, Robson M, Izatt S, et al. A simple and safe technique for continuous ambulatory peritoneal dialysis
(CAPD). Trans Am Soc Artif Intern Organs 1978;24:484–489.
23. McIntosh G, Hurst PA, Young AE. The ‘omental hitch’ for the prevention of obstruction to peritoneal dialysis catheters.
Br J Surg 1985;72:880.
24. Crabtree J, Fishman A. Laparoscopic implantation of swan neck presternal peritoneal dialysis catheters. J Laparoendoscop
Advanced Surg Tech Part A 2003;13:131–137.
25. Crabtree JH, Kaiser KE, Huen IT, Fishman A. Costeffectiveness of peritoneal dialysis catheter implantation by laparoscopy
versus by open dissection. Adv Perit Dial 2001; 17:88–92.
26. Comert M, Borazan A, Kulah E, Uçan BH. A new laparoscopic technique for the placement of a permanent peritoneal
dialysis catheter: the preperitoneal tunneling method. Surg Endosc 2005;19:245–248.
27. Schmidt S, Pohle C, Langrehr J, et al. Laparoscopic-assisted placement of peritoneal dialysis catheters: implantation tech-
nique and results. J Laparoendoscop Advanced Surg Tech Part A 2007;17:596–599.
28. Lu CT, Watson DI, Elias TJ, et al. Laparoscopic placement of peritoneal dialysis catheters: 7 years experience. ANZ J Surg
2003;73:109–111.
PERITONEAL DIALYSIS
CATHETER PLACEMENT
William P. Robinson III / Matthew T. Menard
From Vernon AH, Ashley SW: Atlas of Minimally Invasive Surgical Techniques,
1st edition (Saunders 2012)
3-4
The video for this procedure can be accessed here
Further Reading
Hagen SM, Lafranca JA, Steyerberg EW, IJzermans JN, Dor FJ. Laparoscopic versus open peritoneal dialysis catheter insertion:
a meta-analysis. PLoS ONE. 2013; 8(2); e56351.
Gajjar AH, Rhoden DH, Kathuria P, Kaul R, Udupa AD, Jennings WC. Peritoneal dialysis catheters: laparoscopic versus
traditional placement techniques and outcomes. Am J Surg. 2007; 194: 872–876.
e49
SELF ASSESSMENT
3-5 Michelle A. Kominiarek / Edward F. Hollinger
From Velasco J: Rush University Medical Center Review of Surgery, 5th edition (Saunders 2011)
1. A 62-year-old woman with long-standing end-stage renal disease who is being maintained
on peritoneal dialysis (PD) has had several months of intermittent abdominal pain and
difficulty obtaining normal dwell volumes for her peritoneal catheter. She goes to the emergency
department because she was unable to adequately drain her peritoneal fluid. Review of her
medical records reveals that her creatinine level has slowly been increasing for the last several
months without any change in her dialysis regimen. Abdominal CT shows ascites; shortened,
thickened small bowel mesentery; and diffusely thickened small bowel with areas of luminal nar-
rowing. There are punctuate calcifications throughout the peritoneum. Which of the following is
least appropriate?
A. Trial of tamoxifen therapy
B. Oral steroid pulse
C. Replacement of the PD catheter
D. Immunosuppressive therapy with azathioprine
E. Exploratory laparoscopy and enterolysis
Ref.: 1, 2
COMMENTS: Encapsulating peritoneal sclerosis (EPS, sclerosing peritonitis) is one of the most
feared complications of peritoneal dialysis. EPS is characterized by a decrease in the efficacy of PD
and the development of extensive intraperitoneal fibrosis, mesenteric shortening, and encasement of
the bowel. It can progress to bowel obstruction. Radiologic features include mesenteric, bowel, and
peritoneal thickening, often with calcifications. Loculated ascites, adherent bowel loops, and luminal
narrowing of the bowel may also be visualized. The etiology of EPS is not well understood. Risk factors
include the duration of PD therapy, episodes of peritonitis, and acetate dialysis. Treatment is often
unsuccessful. Most patients with EPS are switched to hemodialysis (although such a switch can some-
times precipitate EPS). Steroid therapy, tamoxifen, and immunosuppressive regimens, including aza-
thioprine or cyclosporine, have all been used to treat EPS. When bowel obstruction is present, total
parenteral nutrition may be required. The role of surgical therapy for EPS remains controversial. Early
results with enterectomy and anastomosis have shown high mortality rates, but more recent studies
suggest a role for early enterolysis.
ANSWER: C
2. A 54-year-old woman with end-stage renal disease treated by PD complains of abdominal pain
and fever. When performing her exchanges she has noted turbid fluid for the last several days. She
has been undergoing PD for 3 years and has never had any complications. Which of the following
statements is correct?
A. She should undergo immediate peritoneal exploration with removal of the dialysis catheter.
B. Fungal peritonitis requires long-term antifungal therapy through the PD catheter.
e50
CHAPTER 3-5 ■ Self Assessment e51
C. PD-associated peritonitis from coagulase-negative staphylococci can be cured with antibiotics

alone in more than 80% of cases.
D. She will need to resume hemodialysis while the infection is treated.
E. Broad-spectrum empirical antibiotic therapy is required because peritoneal fluid cultures have
little value.
Ref.: 3
COMMENTS: Peritonitis is a common complication of peritoneal dialysis and occurs about 1.4
times per patient-year of PD. It is one of the most important reasons for failure of PD and accounts
for nearly one half of all technical failures. Typically, patients have abdominal pain and tenderness
(75%), fever (33%), and cloudy dialysate. The diagnosis is confirmed by a fluid leukocyte count of
greater than 100/mL with more than one half of the cells being neutrophils. Most infections are caused
by gram-positive organisms, but gram-negative bacilli and fungi can also be responsible. Initial treat-
ment should consist of intraperitoneal antibiotics, most commonly vancomycin or a first-generation
cephalosporin. About 75% of infections are cured with culture-directed antibiotic therapy without
discontinuation of PD. Persistent or recurrent infection may require removal of the PD catheter and
a switch to hemodialysis. Cure rates with antibiotics alone are best for coagulase-negative staphylococci
(90%) and less for Staphylococcus aureus (66%) or gram-negative bacilli (56%). Fungal infections require
prompt removal of the catheter. Prompt treatment of peritoneal infections is important to reduce the
formation of adhesions and the loss of peritoneal area, which can limit the patient’s ability to continue
with PD.
ANSWER: C
References
1. Blake PG, Sharma A: Peritoneal dialysis. In Brenner BM, editor: Brenner & Rector’s the kidney, ed 8, Philadelphia, 2008,
WB Saunders.
2. Kawaguchi Y, Tranaeus A: A historical review of encapsulating peritoneal sclerosis, Perit Dial Int 25(S4):S7–13, 2005.
3. Li BD, McDonald JC, Richardson KA, et al: Abdominal wall, umbilicus, peritoneum, mesenteries, omentum, and retroperi-
toneum. In Townsend CM, Beauchamp RD, Evers BM, et al, editor: Sabiston textbook of surgery: the biological basis of
modern surgical practice, ed 18, Philadelphia, 2008, WB Saunders.

Peritoneal Dialysis Catheter Insertion

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Peritoneal Dialysis

PERITONEAL PHYSIOLOGY AND TRANSPORT

THE PERITONEAL CATHETER AND ACCESS

TABLE 3-1-1 Considerations for

3-2 CATHETER PLACEMENT

FIGURE 3-2-1 Trocar insertion sites and placement of catheter.

FIGURE 3-2-3 Note position of catheter cuffs.

BACKGROUND: Continuous ambulatory peritoneal dialysis (CAPD) catheters provide

Subcutaneous Catheter Tunneling

TABLE 3-3-1 Patient Characteristics Between the Non-Rectus Sheath

TABLE 3-3-2 Breakdown of Specific Complications Between the

The video for this procedure can be accessed here

C. PD-associated peritonitis from coagulase-negative staphylococci can be cured with antibiotics

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