Steps for Peritoneal Dialysis Catheter Placement
The preferred approach for peritoneal dialysis catheter placement is ultrasound-guided insertion with fluoroscopic confirmation of catheter position, as this technique minimizes complications while ensuring proper catheter function. 1
Pre-Procedure Assessment
- Review patient's medical history for contraindications
- Evaluate for previous abdominal surgeries (may influence placement technique)
- Assess patient's suitability for PD (absence of significant adhesions, hernias)
- Explain procedure and obtain informed consent
Equipment Needed
- Sterile field setup
- Peritoneal dialysis catheter (typically Tenckhoff catheter)
- Ultrasound machine with sterile probe cover
- Fluoroscopy equipment
- Local anesthetic
- Surgical instruments for dissection and catheter tunneling
Step-by-Step Procedure
1. Patient Positioning and Preparation
- Position patient supine
- Perform surgical site preparation and draping
- Administer prophylactic antibiotics as per institutional protocol
2. Ultrasound Assessment
- Use ultrasound to identify anatomy of insertion site 1
- Locate and mark the entry point (typically 2-3 cm below umbilicus in midline)
- Identify and avoid blood vessels and bowel loops
- Confirm patency of veins if using a vascular approach 1
3. Anesthesia
- Administer local anesthesia at insertion site and along planned tunnel tract
- Allow sufficient time for anesthetic effect
4. Catheter Insertion
- Make a small incision at the marked entry site
- Use blunt dissection to reach the peritoneum
- Under ultrasound guidance, puncture the peritoneum
- Confirm entry into peritoneal cavity with saline injection or guidewire placement
- Use real-time ultrasound guidance for puncture of the vein if using a vascular approach 1
5. Catheter Placement and Tunneling
- Create exit site for catheter (typically lateral to entry site)
- Tunnel the catheter subcutaneously from entry site to exit site
- Advance catheter into peritoneal cavity with tip directed toward the pelvis
- Confirm catheter position using fluoroscopy 1
- Secure the deep cuff in the rectus muscle and the superficial cuff in the subcutaneous tissue
6. Verification and Testing
- Confirm catheter position in the peritoneum using fluoroscopy 1
- Test catheter function by instilling and draining small volume of dialysate
- Ensure no leakage around insertion site
- Verify outflow is adequate without obstruction
7. Closure and Dressing
- Close the incision sites with sutures
- Apply sterile dressing to catheter exit site
- Secure catheter to prevent displacement
Post-Procedure Care
- If possible, wait 10-14 days after catheter placement before starting regular PD 1
- If PD must be started earlier, use low-volume, supine dialysis 1
- Monitor for early complications (bleeding, leakage, infection)
- Perform baseline 24-hour urine collection for clearance calculations 1
Potential Complications and Management
- Bleeding: Apply pressure; may require surgical exploration if severe
- Bowel perforation: Surgical consultation for repair
- Catheter malposition: Fluoroscopic or surgical repositioning
- Leakage: Low-volume exchanges or temporary cessation of PD
- Infection: Appropriate antibiotics; may require catheter removal in severe cases
Follow-up
- First dressing change typically 5-7 days post-procedure
- Regular monitoring of catheter function
- Training for PD should begin after adequate healing (typically 2 weeks)
- Adjust dialysis prescription based on patient's residual kidney function 1
The evidence suggests that percutaneous placement with imaging guidance may result in fewer complications such as tunnel/exit-site infections and catheter migration compared to surgical placement 2. However, the direct visualization provided by open or laparoscopic methods may provide more reliable access, particularly in patients with previous abdominal surgeries 3.