What are the different methods of PD catheter placement?
There are currently three techniques for catheter placement:
- 1. The dissective technique involves surgical placement of the catheter by mini-laparotomy. This is typically done under general anesthesia.
- 2. The modified Seldinger technique involves “blind” insertion of a needle into the abdomen, placement of a guidewire, dilation of a tract, and insertion of the catheter through a sheath, all without visualization of the peritoneal cavity.
- 3. Laparoscopic insertion using a small optical peritoneoscope for direct inspection of the peritoneal cavity. The latter can be performed as an outpatient procedure under local anesthesia with gas insufflation.
The advantage of the Seldinger approach is that it can be placed acutely at the bedside or in the interventional radiology/nephrology suite without the need for general anesthesia. Conversely, superior results have been demonstrated using the advanced laparoscopic technique. Though some of the success may be operator dependent, the technique benefits from:
• Rectus sheath tunneling, during which the transmural segment of the catheter is obliquely placed through a long musculofascial tunnel in the abdominal wall. This effectively maintains pelvic orientation of the catheter tip and reduces the risk of both exit site leak and hernia.
• Direct visualization of the PD catheter into the pelvic cavity
• Ability to address other abdominal peritoneal issues such as occult hernias, adhesions, redundant omentum, and epiploic appendices that may influence short- and long-term catheter success
The insertion technique used is determined by availability of expertise and economics. Success of the catheter after implantation is driven by the following of best demonstrated practices (BDPs), operator expertise, and patient comorbidities. To ensure the best patient outcomes, there needs to be cooperation among surgeons, radiologists, and nephrologists, irrespective of who places the PD catheter. These operators need to work collaboratively to develop common pathways and techniques to provide timely peritoneal access and resolve complications.
