The best placement of the catheter within the abdominal wall was thoroughly studied by Tenckhoff, who included himself among the study subjects1. The dacron cuffs are placed within the rectus muscle and in the subcutaneous tissue of the anterior abdominal wall. The cuff induces a classic inflammatory reaction characterized by formation of fibrin clots, ingrowth of granulocytes and fibroblasts and granulomata with giant cells. The resulting fibrous plug represents a curious case of beneficial bioincompatibility. It prevents bacteria from entering the subcutaneous space from the skin surface into the peritoneum. At the skin exit site, stratified squamous epithelium grows along the surface of the catheter ending in granulation tissue near the pre-peritoneal cuff. At the peritoneal surface, simple squamous epithelium grows around the catheter, penetrating the abdominal wall and ending at the deep cuff, resulting in a smooth surface surrounding the catheter2.
Optimal Catheter Placement
Used with permission from reference 2.
The midline penetration through the linea alba was commonly used in the past due to fewer vascular structures; however, it is now mostly reserved for acute catheters and as a last resource only. The preferred primary penetration sites for chronic catheters are the lateral or paramedian insertions through the rectus muscle since they are associated with better outcomes and a lower rate of complications3-5.
The exit site placement is critical for good outcomes. An arcuate subcutaneous tunnel and a downward exit site for the catheter was first proposed by Tenckhoff in 1968 to maintain the internal and external portions of the catheter in a caudad direction and to foster drainage from the subcutaneous tunnel and prevent infection1. The advantages of this practice in reducing the number and severity of infections has been reported by several author6-9. The exit site should precisely fit the catheter diameter in order to avoid extrusion of the external cuff if it is too large, or pressure necrosis if too tight. This can be easily accomplished using a commercially available perforator or by a single pass with a Parker blade # 11. The subcutaneous cuff should be 1-2 cm from the skin after healing.
Methods of Implantation
The principal methods are generally classified as surgical and percutaneous. The selection is ultimately the responsibility of the operator and is often influenced by their experience and training. The success rate mostly depends on the operators proficiency rather than the technique.
Percutaneous Placement. The earliest clinically successful percutaneous placement required the use of a large bore trochar developed by Tenckhoff.
Courtesy of Dr. J.A. Diaz-Buxo.
This method is simple and can be performed at the bedside under local anesthesia. The disadvantages with this method relate to the diameter of the penetration site and that it is a blind procedure.
The percutaneous implantation has been further simplified with a modified Selding technique similar to that used for insertion of vascular catheters10. Although this is a blind procedure, the risk of perforation is relatively low since it uses a simple needle for penetration followed by dilatation with a blunt plastic dilator. The location of the catheter can be further improved with the use of imaging assistance, if available.
Seldinger Technique Disposables
Courtesy of Dr. J.A. Diaz-Buxo.
Peritoneoscopic implantation has become increasingly popular and offers good visualization of peritoneal structures and allows early diagnosis to impediments to good function and of complications.
Laparoscopic/mini-laparoscopic implantation with or without omentopexy11 is a minimally invasive approach requiring smaller incisions and usually associated with less pain and quicker return to full activities, especially in obese patients. It offers complete visualization of the catheter insertion process and permits selective proactive intervention for catheter migration, omental entrapment and obstructive adhesions. It also allows the diagnosis and treatment of previously unsuspected herniae.
Surgical Placement. The traditional surgical implantation is perhaps the most common method. It requires light general or extensive anesthesia. The principal advantages are good and extensive visualization of the peritoneal cavity, precise placement of the catheter tip, optional fixation, lysis of adhesions and omenentectomy, if required. It has been reported to have a higher incidence of leaks compared to percutaneous implantation methods.
Alternative Placement Techniques.
Moncrief-Popovich catheter and technique. Subcutaneous burial of the external segment of the catheter to prevent colonization of the catheter by skin bacteria and promote attachment of the cuff to the tissue prior to exteriorization has been described and recently tested by several experienced clinicians with encouraging results12. The initial reports by the developers claimed a reduction in the rate of peritonitis and colonization of bacterial biofilms in the catheter segments between the two cuffs13. However, a controlled randomized study failed to confirm these claims14. A possible reason for the failure to reduce the incidence of infectious complications may be the inability of the body to provide an effective “seal” around the external cuff. Therefore, upon exteriorization of the catheter, the process of healing starts all over again. Prischl et al. have also reported a high incidence of seromas, subcutaneous hematomas and fibrin thrombi postoperatively with this technique15.
Extended Dialysis Catheters. Extended dialysis catheters have been developed to allow placement of the exit site in remote places and preferably in the presternal area16. This is particularly useful for obese patients, the rare patient with a stoma and those with other sources of potential contamination in the anterior abdominal wall. The commercially available kits contain catheters of various configurations, a presternal extension tube and a titanium connector to join the aforementioned parts.
The main advantages of these catheters are better wound healing and immobilization, decreased pressure by garments, increased distance from ostomy sites, easier exit site care, lower frequency of exit site infections and peritonitis in selected cases. The main disadvantage is the possibility of disconnection inside the subcutaneous tunnel. Body image is thought to be improved by some patients but definitely worse by others.
A six year non-randomized prospective study comparing swan-neck presternal catheters with swan-neck abdominal catheters showed good tolerance of the presternal catheters but not significant differences in survival or peritonitis rates17. Similarly, a retrospective comparison by a single surgeon comparing a standard, double-cuff Tenckhoff catheter (n=46) or a swan-neck presternal catheter (n=14) reported a lower, but non significant difference in the rate of exit site infections18.
Self-Locating or Front Loading Catheters. Several European reports describing a PD catheter with either a 12 g tungsten cylinder embedded in the silicone or stainless steel weights attached to the distal end of the catheter suggest better catheter survival and less migration as compared to standard catheters19-22. Although the data from clinical trials are limited, the results are consistently positive. Further evaluation of this simple modification to the peritoneal catheter is warranted.
While the implantation technique may offer some benefits under specific circumstances, there is no evidence that insertion technique per se or time of first use influence clinical outcomes.
- Tenckhoff H, Schechter H. A bacteriologically safe peritoneal access device. Trans Am Soc Artif Intern Organs 14:181-186, 1968
- Ash SR, Carr DJ, Diaz-Buxo JA, Crabtree JH. Peritoneal access devices: Design, function and placement techniques, in Nissenson AR and Fine RN (eds): Clinical Dialysis, Fourth Edition, McGraw Hill, New York, 2005, pp 309-356
- Helfrich BG, Pechan WB, Alijani MR, Barnard WF, Rakowski TA, Winchester JF. Reduction of catheter complications with lateral placement. Perit Dial Bull 3(Suppl 4):S2-S4, 1983
- Stegmayr BG, Wikdahl AM, Arnerlöv C, Petersen E. A modified lateral technique for the insertion of peritoneal dialysis catheters enabling immediate start of dialysis. Perit Dial Int 18:329-331, 1998
- Wikdahl AM, Granbom L, Stegmayr BG. Lower catheter-related peritonitis rates with catheter insertion through the rectus muscle, and the internal cuff between the peritoneum and the inner fascia. Perit Dial Int 18:331-334, 1998
- Twardowski ZJ, Nolph KD, Khanna R, Prowant B, Ryan LP, Nichols WK. The need for a "swan neck" permanently bent, arcuate peritoneal dialysis catheter. Perit Dial Bull 5:219-225, 1985
- Khanna R, Oreopoulos DG: Peritoneal catheters. In: Bengmark S., ed. The peritoneum and peritoneal access. London: Wright, 1989:220-229
- Copley JB. Prevention of peritoneal dialysis catheter infections. Am J Kidney Dis 10:401-407, 1987
- Favazza A, Petri R, Montanaro D, Boscutti G, Bresadola F, Mioni G. Insertion of straight peritoneal catheter in an arcuate subcutaneous tunnel by tunneler: A long-term experience. Perit Dial Int 15:357-362, 1995
- Seldinger I. Catheter replacement of the needle in percutaneous arteriography, a new technique. Acta Radiol 39:368, 1953
- Ogunc G: Minilaparoscopic extraperitoneal tunneling iwth omentopexy: A new technique for CAPD catheter placement. Perit Dial Int 25:551-555, 2005
- Moncrieff JW, Popovich RP, Broadrich LJ, He ZZ, Simmons EE, Tate RA: The Moncrieff-Popovich Catheter. A new peritoneal access technique for patients on peritoneal dialusis. ASAIO J 39:62-65, 1993
- Moncrief JW, Popovich RP, Dasgupta M, Costeerton JW, Simmons E, Moncrief V. Reduction in peritonitis incidence in continuous ambulatory peritoneal dialysis with a new catheter and implantation technique. Perit Dial Int 13:S329-S331, 1993
- Danielsson A, Blohme L, Tranaeus A, Hylander B. A prospective randomized study of the effect of a subcutaneously "buried" peritoneal dialysis catheter technique versus standard technique on the incidence of peritonitis and exit-site infection. Perit Dial Int 22:211-219, 2002
- Prischl FC, Wallner M, Kalchmair H, Povacz F, Kramar R. Initial subcutaneous embedding of the peritoneal dialysis catheter--a critical appraisal of this new implantation technique. Nephrol Dial Transplant 12:1661-1667, 1997
- Crabtree JH: Extended peritoneal dialysis catheters for upper abdominal wall exit sites. Perit Dial Int 24:292-294, 2004
- Twardowski ZJ, Prowant BF, Nichols WK, Nolph KD, Khanna R. Six-year experience with Swan neck presternal peritoneal dialysis catheter. Perit Dial Int 18:598-602, 1998
- Warchol S, Ziolkowska H, Roszkowska-Blaim M. Exit-site infection in children on peritoneal dialysis: comparison of two types of peritoneal catheters. Perit Dial Int 23:169-173, 2003
- Di Paolo N, Petrini G, Garosi G, Buoncristiani U, Brardi S, and Monaci G. A new self-locating peritoneal catheter. Perit Dial Int 16:623-627, 1996
- Cavagna R, Tessarin C, Tarroni G, Casol D, De Silvestro L, Fabbian F. The self-locating catheter: Clinical evaluation and comparison with the Tenckhoff catheter. Perit Dial Int 19: 540-543, 1999
- Dantoine T, Benevent D, Boudet R, Lagarde C, Charmes JP, Leroux-Robert C. Front-loading a peritoneal dialysis catheter prevents its migration in elderly patients. Perit Dial Int 22:528-531, 2002
- Minguela I, Lanuza M, de Gauna R, Rodado R, Alegria S. Andreu AJ, Gonzalez MJ, Rodriguez B, Vitores JM, Castellanos T, Martinez C, Aurrekoetxea B, Chena A. Lower malfunction rate with self-locating catheters. Perit Dial Int 21 Suppl 3:S209-S212, 2001