Peritoneal Dialysis Catheter Insertion

Peritoneal dialysis was first used for the management of end-stage renal disease in 1959. ^[1] In 1968, Henry Tenckhoff developed the indwelling peritoneal catheter, which was placed via an open surgical technique. ^[2] Subsequently, percutaneous and laparoscopic techniques for placement have been utilized.

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

An image depicting peritoneal dialysis catheter insertion can be seen below.

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

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

• Vascular access failure

• Intolerance to hemodialysis

• Congestive heart failure

• Prosthetic valvular disease

• Children aged 0-5 years

• Patient preference

• Distance from a hemodialysis center

• Poor cardiac function

• Peripheral vascular disease

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

• Bleeding diathesis

• Multiple myeloma

• Labile diabetes mellitus

• Chronic infections

• Possibility of renal transplantation in the near future

• Age between 6 and 16 years

• Needle anxiety

• Active lifestyle

Peritoneal dialysis has been utilized infrequently for nonrenal indications with variable benefit in other conditions as follows: ^{[5, 6, 7, 8, 9, 10]}

• Refractory congestive heart failure

• Hepatic failure

• Hypothermia

• Hyperthermia

• Hyponatremia

• Dialysis-associated ascites

• Drug poisonings

• Pancreatitis

• Inherited enzyme deficiencies

The intraperitoneal administration has been used for blood transfusion, chemotherapy, insulin, and nutrition.

Contraindications to peritoneal dialysis include the following: ^[4]

• Documented type II ultrafiltration failure

• Severe inflammatory bowel disease

• Acute active diverticulitis

• Abdominal abscess

• Active ischemic bowel disease

• Severe active psychotic disorder

• Marked intellectual disability

• Women starting third trimester of pregnancy

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

• Severe malnutrition

• Multiple abdominal adhesions

• Ostomy

• Proteinuria >10 g/day

• Upper limb amputation with no help at home

• Poor personal hygiene

• Dementia

• Homelessness

Peritoneal dialysis is not preferred but is possible in select circumstances: ^[4]

• Obesity

• Multiple hernias

• Severe backache

• Multiple abdominal surgeries

• Impaired manual dexterity

• Blindness

• Poor home situation

• Depression

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

Peritoneal dialysis catheters come in various shapes (straight, pigtail-curled, swan-neck), lengths, and numbers of Dacron cuffs. The peritoneal dialysis catheter is composed of a flexible silicone tube with an open-end port and several side holes to provide optimal drainage and absorption of the dialysate.

The extraperitoneal component of the catheter has either one or two Dacron cuffs. The Dacron cuffs are for optimal ingrowth and fixation. In adults, a double cuff catheter is typically used. With the double cuff peritoneal dialysis catheter, the proximal cuff is positioned in the preperitoneal space and the distal cuff in the subcutaneous tissue (see the image below).

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

Placement of the peritoneal dialysis catheter requires that the patient be placed in a supine position.

Peritoneal dialysis catheters may be placed via a percutaneous, a laparoscopic, or an open surgical route. Open surgical and laparoscopic techniques are preferred because of their safety and good initial results. Although less invasive, percutaneous peritoneal dialysis catheter placement has the risks of unsatisfactory placement and bowel injury.

Open surgical technique

The steps in the open surgical technique are as follows:

• The patient is placed in a supine position. General anesthesia is used and intravenous antibiotics are administered.

• An infraumbilical midline incision is made. The subcutaneous layer is dissected down to the sheath of the rectus abdominal muscle. The anterior rectus sheath is opened, and the muscle fibers are bluntly dissected. The posterior sheath is incised, and the abdominal cavity is opened after dissecting the peritoneum. The abdomen is inspected for adhesions, and, if any are present close to the abdominal wall, they are dissected.

• Next, the patient is placed in a Trendelenburg position, and the catheter is placed over a stylet and advanced into the peritoneal cavity. The intraperitoneal portion is slid off the stylet, and the cuff is positioned in the preperitoneal space.

• The peritoneum and posterior and anterior rectus sheaths are closed with absorbable sutures taking care to prevent catheter obstruction and leakage of dialysate. A tunnel is then created to the preferred exit site, which is usually lateral and caudal to the entrance site. The distal cuff is placed subcutaneously, 2 cm from the exit site.

• The incision is closed, and the catheter is tested by filling the abdomen with 100 mL of sterile saline while the entrance site is checked for leakage. The saline is then drained and inspected to ensure no intraperitoneal bleeding or fecal contamination. ^[11]

Laparoscopic technique

The laparoscopic approach to peritoneal dialysis placement is becoming more popular because of to its advantage of being able to perform partial omentectomy or lysis of adhesions if needed during the initial catheter placement.

• The patient is placed in a supine position, and general anesthesia and intravenous antibiotics are administered.

• Pneumoperitoneum is typically established via an open technique with a 5-mm access port in a subumbilical midline position. Diagnostic laparoscopy is performed with a 5-mm 0-degree lens. An additional 5-mm trocar is placed under direct vision at the site of the planned exit-site position of the peritoneal dialysis catheter. This is usually paraumbilical left or right 2-3 cm below the umbilicus.

• The trocar is advanced through the anterior and posterior rectus sheaths, but not through the peritoneum. Under direct vision, the trocar is directed into the preperitoneal space, 2-4 cm downwards and to the midline of the abdomen.

• If adhesions are present, the trocar is placed into the abdominal cavity and the adhesions are lysed. A double-cuffed curled tip peritoneal dialysis catheter is then placed through the paraumbilical port with the curled tip placed into the pouch of Douglas.

• If no adhesions are present, the second trocar is left in the preperitoneal space. A stiff stylet is then used to introduce the peritoneal dialysis catheter into the peritoneal cavity. The distal cuff of the peritoneal dialysis catheter remains outside of the peritoneal cavity and is positioned either in the preperitoneal space or between the rectus sheaths.

• The paraumbilical trocar is removed, and the catheter is then directed to its exit-site location. A subcutaneous tunnel is created, and the catheter is brought through the tunnel with the proximal cuff positioned within the tunnel.

• The catheter is tested, and the abdomen is desufflated. The trocar is removed, and the rectus sheaths are closed. ^[11]

Percutaneous placement

Percutaneous placement of peritoneal dialysis catheters with a guidewire and peel-away sheath uses the Seldinger technique. Percutaneous peritoneal dialysis catheter placement can be performed under local or general anesthesia with prophylactic antibiotics.

• A small incision is made above the entrance site, usually in the midline with blunt dissection of the abdominal rectus sheath.

• An 18-gauge needle is placed into the peritoneal cavity. Proper positioning of the needle is confirmed by filling the peritoneal cavity with air or 500 mL of saline. Absence of pain or resistance with filling suggests proper needle positioning.

• A 0.035-inch guide wire is then advanced through the needle into the abdomen, and the needle is removed.

• A dilator and peel-a-way sheath are advanced over the guidewire into the abdominal cavity. The dilator and wire are then removed, and the peritoneal dialysis catheter is placed on the stylet and advanced through the sheath. The PD is advanced until the proximal cuff is in the preperitoneal sheath.

• The peel-a-way sheath and the stylet are removed, and the position of the catheter is checked.

• A tunnel is created to the selected exit site, with placement of the distal cuff subcutaneously 2 cm from the exit site. The entrance site is closed. ^[11]

Alternative placement techniques

The Moncrief-Popovich catheter and technique involves subcutaneous burial of the external segment of the peritoneal dialysis catheter to prevent colonization of the catheter by skin bacteria and to promote attachment of the cuff to the tissue prior to exteriorization.

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

Extended dialysis catheters

Longer dialysis catheters have been developed to allow placement of the exit site in remote places such as the presternal area. ^[14] Such extended catheters may be useful in obese patients and in those with an abdominal stoma.

Results

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

Fixation of the catheter downwards in the peritoneal cavity using the conventional placement technique may lengthen the time to dislocation of the catheter. ^[16]

Complications after peritoneal dialysis catheter placement may be early (occurring < 30 days post placement) or late (>30 days post placement). ^[11]

Early complications

Bowel perforation

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

Bleeding

Bleeding is rarely a significant problem after peritoneal dialysis catheter placement. When bleeding occurs, it is usually at the exit site.

Wound infection

Wound infection is uncommon and often can be treated with antibiotics when it is superficial. If the wound is deeper, then it may need to be drained.

Other early complications

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

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

Peritonitis may occur early and manifests as abdominal pain associated with cloudy peritoneal fluid. The fluid should be cultured, and appropriate antibiotics should be administered.

Late complications

Late complications include exit-site infection, tunnel infection, cuff protrusion, outflow failure and dialysate leaks, or hernias. ^[11]

Cuff extrusion or infection

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

Outflow failure

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

Peritonitis

Peritonitis is often the result of contamination with skin bacteria, but it may also be due to gram-negative bacteria associated with diarrhea or diverticulitis. Systemic or intraperitoneal antibiotics are administered, and the exchange volumes are decreased. Usually, a peritoneal dialysis catheter-related peritonitis will resolve with proper antibiotic therapy. If the infection persists, catheter removal and use of hemodialysis for 4-6 weeks is sufficient for resolution of the peritonitis. ^[21]

There is a strong association between exit-site infections and subsequent peritonitis, with an increased risk up to 60 days after initial diagnosis. ^[22]  Lower serum albumin concentrations have also been associated with an increased risk of peritonitis in patients undergoing peritoneal dialysis. ^[23]