Selected best demonstrated practices in peritoneal dialysis access J.H. Crabtree  Kidney International  Volume 70, Pages S27-S37 (November 2006) DOI: 10.1038/sj.ki.5001913 Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 1 Embedded catheter procedure. (a) External limb of catheter is buried under the skin at the time of implantation. (b) External limb is exteriorized when dialysis is needed. Kidney International 2006 70, S27-S37DOI: (10.1038/sj.ki.5001913) Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 2 (a) Plastic tunneling stylet. (b) Close-up of barbed end. (c) Catheter plugged with barbed end and secured with suture. (d) Plugging process completed by snapping off barbed end from stylet. Kidney International 2006 70, S27-S37DOI: (10.1038/sj.ki.5001913) Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 3 Laparoscopic non-bladed trocar port system includes, from top to bottom, Veress-type pneumoperitoneum needle, radially expandable plastic sleeve, 7/8-mm dilator–cannula assembly, and 5-mm reducer cap for the 7/8-mm cannula. The reducer cap is modified (inset) to permit passage of the cuff of the dialysis catheter. Kidney International 2006 70, S27-S37DOI: (10.1038/sj.ki.5001913) Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 4 Steps of rectus sheath tunneling of dialysis catheter. (a) Veress needle–expandable sleeve assembly is inserted through skin incision and anterior rectus sheath. (b) The needle–sleeve assembly is angled toward the pelvis, advanced down the rectus sheath and pushed through into the peritoneal cavity at the indicated site. (c) The needle is removed and the expandable sleeve serves as a conduit for insertion of the dilator–cannula. (d) The dialysis catheter over a stylet is advanced into the peritoneal cavity until the deep cuff is visible. The cannula and stylet are withdrawn and the catheter is retracted until the deep cuff is just below the anterior rectus sheath. Kidney International 2006 70, S27-S37DOI: (10.1038/sj.ki.5001913) Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 5 Laparoscopic photograph shows catheter obstruction at the pelvic tack-up site from adherent omentum and visceral adhesions. The potential risk for bowel incarceration through a ‘window’ created by a tube fixed at two points within the abdominal cavity can be seen. Kidney International 2006 70, S27-S37DOI: (10.1038/sj.ki.5001913) Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 6 Method of omentopexy. (a) Needle device with suture is introduced through the abdominal wall. (b) Needle and suture are passed through one or more folds of omentum and a grasping forceps retrieves the suture from the device. (c) The needle is removed and reinserted through the same skin incision but different abdominal wall location to retrieve and withdraw the suture from the abdominal wall. (d) The suture is tied to fix the omentum to the abdominal wall. Kidney International 2006 70, S27-S37DOI: (10.1038/sj.ki.5001913) Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 7 Laparoscopic photograph of a redundant epiploic appendage of the sigmoid colon that was discovered during a catheter implantation procedure after a failed test of flow function. Kidney International 2006 70, S27-S37DOI: (10.1038/sj.ki.5001913) Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 8 Tenckhoff catheter modifications that provide for a variety of exit site locations based upon patient-specific characteristics. Kidney International 2006 70, S27-S37DOI: (10.1038/sj.ki.5001913) Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 9 Schematic drawing indicating the manner in which the catheter insertion site and deep cuff location are selected in order to achieve proper pelvic position of the coiled catheter tip. Kidney International 2006 70, S27-S37DOI: (10.1038/sj.ki.5001913) Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 10 Three-step algorithm for lateral tunnel tract and exit site design. Step 1: scribe arc from vertical to lateral plane using catheter as compass from point 2cm external of superficial cuff. Step 2: mark exit site at junction of medial 2/3rd and lateral 1/3rd of arc. Step 3: indicate tunnel tract shape by bending catheter over from point 4cm external of superficial cuff to exit site. Kidney International 2006 70, S27-S37DOI: (10.1038/sj.ki.5001913) Copyright © 2006 International Society of Nephrology Terms and Conditions