Last updated: September 26, 2025
Peritoneal dialysis (PD) was introduced nearly a century ago but did not become a primary method for dialysis until 1959. It wasn't until 1968 that the first indwelling PD catheter was developed, initially through an open surgical procedure. Despite significant advancements in PD technology, delivery methods, and cost-effectiveness in countries that produce their own dialysate, PD is still less commonly used than hemodialysis (HD). Comparing surgical techniques to percutaneous fluoroscopic methods shows no significant difference in 1-year catheter survival rates. However, surgical methods can provide additional procedures, like omentopexy or omentectomy, which help manage omental-related issues affecting PD catheters. On the other hand, fluoroscopic techniques offer the benefits of being less invasive and providing precise real-time imaging of catheter placement, along with a lower incidence of infections and mechanical problems.
Presentation
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Anatomy
Placement
Placement
Indications
- End-stage kidney disease (ESKD)
- Acute kidney injury
- Chronic cardiorenal syndrome
Contra Indications
- Unsuitable peritoneal cavity due to extensive adhesions
- Fibrosis
- Irreparable abdominal wall defects
- Active inflammatory or ischemic bowel disease
- Frequent diverticulitis
- Malignancy
Workup
- Exit marking at the dialysis department
- Empty bladder
- 2 g Kefzol
Material
Essentials
- Sterile Draping
- Chlorhexidine 20 mg/ml
- Catheter set
- Titanium connector (available on the dialysis department)
- 5F sheath
- PIER Catheter
- Surgical Suture Set
- Monocryl 4.0 suture
- Scalpel
- 40 ml Lidocaine
- 18G Needle
- 180 cm Hydrophilic Terumo Wire
- 180 cm Amplatz Wire
- 12F Dilator
- 16F Dilator with Peel-Away Sheath
- Three 60 ml Syringes for NaCl
- 10 ml Luer Lock Syringe for Contrast
- Sterile Ultrasound Gel
- Sterile Ultrasound Cover
- 500 ml NaCl
- 50 ml Contrast Medium
- 1 Liter NaCl or PD Fluid for Testing
Non Essentials
Positioning
- Feet first
- Supine
- Arms up
Steps
- Access
- Exit
- Deep cuff
- Subcutaneous cuff
- Tip catheter
- Access
- Exit
- Deep cuff
- Subcutaneous cuff
- Tip catheter
Douglas anteroposteriorly
Douglas anteroposteriorly
Douglas lateral
Douglas lateral
Exit position
Exit position
Final result
Final result
- Place the catheter with the tip below the symphysis and the cuff 2 cm laterally from the umbilicus. The access point is 2 cm above the cuff
- Administer 20-40 ml of 1% Lidocaine for anesthesia
- Make a horizontal incision of 2 cm
- Insert the needle through the rectus abdominis, be carefull not to puncture the epigastric vessel
- Verify intraperitoneal position with contrast under fluoroscopy
- Direct the guide wire towards the small pelvis
- Remove the needle and place a 5F sheath
- Remove the guide wire
- Under fluoroscopic guidance:
- Inject under fluoroscopic guidance alternating 2-3 syringes with 60 ml NaCl and 2-3 syringes with 10 ml of contrast.
- Use a 4F catheter with Terumo wire to reach Douglas.
- Check the catheter's position in the horizontal direction
- Exchange under fluoroscopic guidance the Terumo wire for the Amplatz wire
- Remove the sheath and catheter
- Place under horizontal guidance a 12F dilator
- Dilate further with the 16F dilator only from the peel-away sheath
- Place under guidance the 16F dilator with peel-away sheath
- Remove the dilator from the sheath
- Place the PD catheter
- Use a buddy wire if necessary
- Remove the peel-away sheath while positioning the deep cuff in the muscle
- Bluntly dissect to place the catheter cuff in the rectus abdominis if necessary
- Check for kinking
- Verify functionality with contrast (use the 12F dilator).
- Administer local anesthetic at the exit site
- Make a small incision, as this will not be sutured
- Dissect along the tunnel trajectory.
- Insert the tunneler
- Place the catheter in the tunnel
- Make sure that the subcutaneous cuff is at least 4 cm from the exit
- Verify again for kinking and function with contrast.
- Finish with an intracutaneous soluble suture for insertion site
- The exit is NOT to be sutured
- Attach the transfer set to the catheter, tighten everything
- Perform a final check with 1 liter NaCl or PD fluid
Tips & Tricks
Early
* Bowel perforation
* Bladder perforation
* Hemorrhage (usually puncture of the inferior epigastric vessels)
Late
Flow dysfunction
* Extrinsic compression of the catheter tip
* Internal luminal obstruction
* Poor positioning and/or migration
* Tissue attachment and entrapment
Peritoneal leakage
* Pericatheter leaks
* Abdominal wall hernias
* Pleuroperitoneal connection or fistula development
- Wound control after 10 d (dialysis department)
- No showering 3- 4 w
Folder
Report
Time-out procedure.
Huiddesinfectie en steriel afdekken. Infiltratie lidocaïne. Echografisch punctie buikholte, positie controle met contrast. Over-the-wire plaatsen 5F sheath, en vullen peritoneaalholte met 180 ml NaCl en 30 ml contrast. Over-the-wire positioneren PIER katheter in Douglas. Voerdraad vervangen door Amplatz draad. Verwijderen sheath. Dilateren met 12 en 16F, plaatsen 16F peal-away sheath. Inbrengen PD-catheter, met de diepe cuff in de musculus rectus abdominis. Testen functie en positie catheter. Vervolgens tunnelen cuff naar gewenste uittrede plaats. Afdoppen met titanium dopje. Subcutaan sluiten huid met monocryl. Afplakken met absorberend verband en tape. In- en uitloop 500 ml NaCl, ongecompliceerd.
Sign-out procedure
Time-out procedure.
Skin disinfection and sterile covering. Lidocaine infiltration. Ultrasound-guided puncture of the abdominal cavity, position confirmation with contrast. Over the wire placement of a 5F sheath. Filling the peritoneal cavity with 180 ml of saline and 30 ml of contrast. Over the wire positioning of a PIER catheter in the Douglas. Exchanging the guidewire for an Amplatz wire. Removing the sheath. Dilating with 12F and 16F, placing the 16F peel-away sheath. Inserting the catheter, with the deep cuff in the rectus abdominis muscle. Testing function and position of the catheter. Subsequently, tunneling the cuff to the desired exit site. Capping with a titanium cap. Closing the skin subcutaneously with monocryl. Dressing with absorbent bandage and tape. Inflow and outflow of 500 ml saline, uncomplicated.
Sign-out.
PD Predict studie-parameters:
Baseline catheter characteristics
• Type catheter: straight
• Catheter length: 62 cm
• Tip configuration: colled
Number of cuffs: 2
Baseline operator characteristics
• Speciality of the physician: interventional radiologist
• Main Operator Code (initials): JG
• Experience of operator (number of procedures): 0-10
• Trainer involved: no
Baseline procedure characteristics
• Bowel preparation: yes
• Location: radiology department
• Anaesthesia: local
• Sedation: no
• AB profylaxe: Kefzol
• Fluoroscopy guided: yes
• Ultrasound guidance: yes
• Insertion point into the abdomen: right m rectus abdominis
• Position of the deep cuff: midline
• Exit-site location: right
• Pelvic position of the tip postoperatively by X-ray whenever performed: yes
• Insertion successful: yes
• Procedure time (incision to closure): ... min