Open surgical placement of peritoneal dialysis catheters should begin with standing evaluation of the patient noting the belt line as well as marking with indelible ink identification of this landmark, which is not obvious when the patient is supine on the operating room table. We also advocate supine examination with the patient lifting his or her head off the table. This maneuver, much like in preoperative marking for ostomy sites, allows easier identification of the rectus musculature. Proper identification of the rectus ensures that the incision will allow transrectus placement of the catheter. This has been shown to decrease not only pericatheter site leakage, but also catheter tract infections which can predispose toward peritonitis by allowing better tissue ingrowth into the cuffs [7].

The patient is positioned supine. Arm positioning is surgeon dependent, however, we find it easier to perform the presternal tunneling and chest incision with the patient’s arms tucked into the side and padded. After induction of appropriate anesthesia, a 3–5 cm incision is marked, usually lateral to the approximate location of inferior epigastric vessels, and the incision made. Electrocautery is used to deepen the incision and self-retaining retractors (such as a Weitlaner retractor) are used to facilitate exposure. Care should be taken to have meticulous hemostasis, as postoperative hematoma can be a source of catheter infection. The incision is deepened to the anterior rectus sheath, which is opened transversely.

Once encountered, rectus fibers are separated with a muscle-sparing technique by spreading a hemostat in a cephalad-caudad direction. This exposure is maintained by a self-retaining retractor. Once the posterior sheath is encountered, a small incision is then made through the posterior sheath/peritoneum and a purse-string suture of approximately 1.5 cm diameter is placed. Elevation of this incision with forceps grasping the edges allows air to enter the abdomen creating pneumoperitoneum and separates the viscera from the anterior abdominal wall.

The catheter of choice is then prepared on the back table by soaking the Dacron cuffs in saline and then flushing the catheter. At this point, a stiffening stylet is placed into the catheter. This provides extra support in a straight catheter to facilitate positioning and straightens the coiled catheter so that it may be placed in the pelvis more easily. Care should be taken in both the straight and coiled catheter to leave approximately 1 cm of soft catheter beyond the stylet to make the placement more atraumatic to the viscera during placement.

The catheter with a stiffening stylet is then guided carefully, by feel, into the pelvis. This is accomplished by elevation of the posterior sheath/peritoneum and by directing the stylet anteriorly and caudally until the area of the pubis is reached and then allowing it to fall posteriorly into the pelvis. If any resistance is felt, the catheter should be pulled back and redirected. Once placed, the catheter is held in place and the stylet removed. Each catheter variation is then placed to its appropriate level (e.g., Missouri catheter placed so that the purse string can be tied above the bead, or Lifecath disk folded and placed with disks beneath the peritoneum and one on the anterior sheath) (Fig. 40.2). Once the defect is closed in the posterior sheath, a short (approximately 1.5 cm) tunnel is created in the cephalad direction through the anterior sheath and the catheter pulled through the sheath into the subcutaneous space. At this point, a tunneling trocar can be used to facilitate externalization of the tubing. One liter of saline is then allowed to infuse via gravity, and bag is then placed on the floor to allow drainage. Once good flow is confirmed, the anterior rectus is closed as well as subcutaneous tissue and skin with absorbable sutures in multiple layers.

If one desires to place a Missouri Swan-Neck Presternal Peritoneal Dialysis Catheter (Fig. 40.3), the steps of placement are unchanged until after the small tunnel through the anterior rectus is created. At this point, creation of a small pocket on the chest wall is accomplished using a vertical incision to the left of the sternum/manubrium. This pocket needs to be wide enough to allow the preformed curve to again lay flat on the chest wall. At this point, the presternal catheter containing two further Dacron cuffs is tunneled subcutaneously down to the previous incision. These catheters are then connected using a supplied titanium connector (Fig. 40.4). At this point, a 0 Ethibond suture is hand-tied around the connector on each end and then tied together. This creates a reinforced connection that is sturdy enough so that we have never seen separation of the catheters in the tract. Once satisfied with the catheter length and flow, the chest wall catheter should be externalized approximately 3 cm below the superficial cuff using a sharp trocar attached to the PD tubing. At this point, we recommend closing all incisions with absorbable suture in multiple layers.

Placement can also occur in a “blind” fashion using either a Tenckhoff trocar or percutaneous technique. Each method requires a 2–3 cm skin incision that allows introduction of a trocar or large bore needle. Once access to the abdomen is confirmed, dialysate or saline is allowed to infuse in the abdomen and the tract dilated until it will accept the Tenckhoff style of catheter. This catheter is then advanced through the sheath until the first cuff can be placed at the level of the abdominal musculature. A tunneling trocar is then used to place the second cuff approximately 2 cm from the decided exit site.

The advent and growth of laparoscopic surgery has also become of use to dialysis access surgeons. The ability to obtain minimally invasive access has had an increasing role in both the initial placement of peritoneal dialysis catheters as well as in revisions. The discussion of optimal method of abdominal entry technique is beyond the scope of this chapter; however, we suggest each surgeon use the technique he or she is most comfortable using. Advances with the laparoscopic approach now allow patients who may have previously been turned down as PD candidates the ability to dialyze at home.

Generally, for laparoscopic placement, a double-cuff coiled Tenckhoff catheter is chosen. The patient is positioned supine and is used after a probable catheter site is marked preoperatively on the abdomen. Arms can be positioned either extended or to the sides. Generally, a supraumbilical 5 millimeter (mm) incision is made and blunt dissection carried down to the level of the anterior sheath. A Veress needle is then introduced into the abdomen and insufflation of CO2 is begun after confirmation of intra-abdominal placement. Once the abdomen is insufflated a pressure to 15 mmHg, a 5 mm trocar is introduced through this tract and camera placed. Visual inspection of the abdomen is then carried out. Upon determination that access to the pelvis is possible, placement of two additional 5 mm trocars under direct visualization into the right lower quadrant and the left lower quadrant (avoiding inferior epigastric vessels) is performed. A blunt grasper is then placed through the site of eventual catheter placement and brought through the opposite trocar. The portion of the catheter to be externalized is then given to the grasper, which is now through and through, and withdrawn carefully until the coiled portion of the catheter is in the abdominal cavity, and the catheter exits the trocar on the opposite side from where it was introduced. At this point, another blunt grasper can be introduced through the free trocar to facilitate placement in the true pelvis.

Once the coiled catheter is satisfactorily positioned in the pelvis, the trocar with the external catheter is withdrawn until the deep cuff proximal to the coil is just above the level of the peritoneal opening. The trocar is completely withdrawn and the incision widened. A tunneling trocar is attached to the end of the catheter now protruding from the wound and used to tunnel the catheter to the previously marked external site for the peritoneal dialysis catheter being careful to not kink or twist the tubing during tunneling. Once this is done, the abdomen can be decompressed and saline instilled into the abdomen and then subsequently be allowed to drain. After a functioning catheter is confirmed, heparin lock is placed into the tubing and all incisions are closed in layers. Sterile dressings are applied to each site as well as to the PD catheter site. One should avoid placement of sutures at the exit site for the catheter due to potential compromise of the tube lumen, direct catheter damage, or promotion of exit site infection (i.e., stitch abscess).