Establishment of a secure, properly functioning peritoneal access device is a critical element in the success of any C.A.P.D. program. Implantation of the catherter can be performed surgically under general or regional anesthesia with direct visualization or medically with the help of special trocar at the bedside. Wherever it is done, strict sterile precautions are mondatory.
Presence of possibly complicating factors such as scars from previous surgery, hernia, organo-megalies, bowel distension or ileus should be carefully evaluated by the performing physician prior to implantation. In these situation, heightened precautions are indicated if catheter placement is performed medically without direct visualization.
Prior to catheter placement, proper preparation of the patients is advised. The bladder must be empty and the abdominal wall must be free of infection. The value of prophylactic antibiotic coverage is not established, but is being used commonly.
The site of catheter placement can be either midline through linea alba or lateral through recuts abdominis muscle. Lateral placement is claimed to have lesser
dialysate leakage compared to midline insertion.
In any approach, prior instillation of adequate amount of dialysate into peritoneal cavity is essential for pushing of parietal epithelium against abdominal wall and suspension of intestine in a fluid medium to facilitate good catheter positioning. When double-cuff catheter is used, the exact location of the skin exit site must be determined lest subcutaneous catheter kinking or erosion of the cuff occur.
The external cuff is kept 3 cm deep to the skin exit site to reduce the possibility of extrusion. To minimize the potential for the catheter displacement, the exit site should be placed superior to the fascia insertion site so as the subcutaneous tunnel will tend to direct the catheter into the pelvis.
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