Continuous AmbulatoryContinuous Ambulatory
Peritoneal Dialysis TechniquePeritoneal Dialysis Technique
Dr/Amir SiddigDr/Amir Siddig
Department of SurgeryDepartment of Surgery
Ribat University HospitalRibat University Hospital
• Peritoneal dialysis (PD) as a treatment for
ESRF started in1959 .
• Rigid catheters were used with frequent
• Problem of maintaining access for chronic
• Henry Tenckhoff developed home fluid
production machine and the soft silicone
catheter in 1963.
• Coupling Tenckhoff catheter with the
cycling device made by Norman Lasker
home IPD program started in 1970
• Monchrieff and Popvich developed the
program of Continuous Ambulatory
Peritoneal Dialysis (CAPD) in 1975 in
response to patients with no vascular
1.1. Open MethodOpen Method
• Direct dissection of abdominal layers and
peritoneum under vision .
• Deep cuff secured within rectus sheath
• Limited exposure of peritoneal cavity
2- Blind (subcutaneous) Method2- Blind (subcutaneous) Method
• The catheter is inserted blindly over a
needle ( Seldinger technique)
• Possible risk of perforation of bowel and
mesentery-No visualization of abdominal
cavity (against surgical principles)
• The deep cuff is placed outside
3- Laparoscopy3- Laparoscopy
• Provides excellent visualization of the
entire abdominal cavity
• Proper placement of the catheter tip in
pelvic cavity and the deep cuff within the
• Requires expensive equipment and
advanced training for doctors
Pre-Operative AssessmentPre-Operative Assessment
1. Exclude active skin or systemic infection
2. Inspect for old scars and skin folds
3. Determine the exit site:
-Avoid bony prominences and belt line
-Should be appropriate and accessible for
-Mark the exit site with indelible marker
4-Shave abdominal hair.
5-Empty bladder and bowel.
6-Use prophylactic antibiotics prior to the
• General anaesthesia (GA) is not
recommended and should be avoided
whenever possible -ESRF patients have
altered metabolism and excretion of
• Local anaesthesia(LA) in the form of
Lidocaine 1% or 2% with or without
epinephrine is adequate.
• The maximum recommended dose :
Lidocaine without epinephrine=3mg/Kg
Lidocaine with epinephrine =7mg/Kg
• Gentle handling and retraction is essential to
reduce pain and discomfort .
• The patient should have a venous access , HR
and SPO2 monitoring.
• Resuscitation facilities should be available.
The ProcedureThe Procedure
• Monitor HR and SPO2 and get a peripheral
• Give prophylactic intravenous antibiotic
• Prepare the skin with antiseptic and drape
• Expose prei-umblical area and exit site
• Use LA in adequate dosage –dilute with saline
• Infiltrate LA in the skin and subcutaneous tissue
down to linea alba.
• Wait for 2 minutes for the anaesthesia to be
profound and test for pain.
• Make 2-3 cm longitudinal incision starting 1 cm
below the umbilicus
• Infiltrate more LA for the linea alba as it is
exposed and also infiltrate the recti on each side
of the wound
• After incising the linea alba , gently retract the
recti to expose the posterior rectus sheath and
• Give further doses of LA for the parietal
• Grasp the parietal peritoneum with two
artery forceps after palpation to avoid catching
• Open the peritoneum under direct vision
• Place the catheter tip with the help of a long
artery forceps low in the left side of the pelvic
cavity –warn the patient that this step may cause
• Test the patency of the catheter
• Fix the deep cuff to the posterior rectus sheath
with 2/0 prolene
• Approximate the muscles
• Close the anterior rectus sheath (linea
alba) meticulously with prolene or nylone
• Give LA at the exit site and the tunnel
• Create a subcutaneous tunnel using an
artery forceps or a tunneler.The
recommended subcutaneous tunnel is
slightly arcuate and directed downwards
• Puncture the exit site and pull the catheter by a
forceps inserted through the exit wound so that
the superficial cuff will be placed within the
subcutaneous tissue just deep to the exit wound.
• No need to fix the catheter at the exit site
• Test filling and drainage.
• About 250 ml may be left inside the abdominal
cavity – this may prevent omentum and debris
from blocking the catheter.
Postoperative CarePostoperative Care
1. Dressing is only changed if it becomes
soaked or after one week.
2. Strict aseptic technique in dressing.
3. Shower is allowed after two weeks.
4. Keep the catheter immobilized to the
5. Avoid constipation.
1. Intra-abdominal injuries.
2. Dialysate leaks.
3. Catheter malposition and migration.
4. Catheter obstruction and poor drainage.
5. Incisional and inguinal hernia.
7. Infection –peritonitis.