Once a small hole, sized to permit insertion of the CAPD catheter has been created, a purse-string suture of 4-0 absorbable suture is placed in the peritoneum around the opening. The stylet (figure 1) is placed into the catheter, ensuring the end with multiple side holes will be placed within the abdominal cavity. The catheter with stylet is then inserted through the peritoneal opening and the catheter is ideally directed into the pelvis to the right side of the rectum (figure 2a). Care should be taken to limit the force used to insert the catheter to avoid injury to adjacent structures. Avoidance of advancing the stylet tip beyond the end of the catheter tip will also minimize adjacent structure injury. Irrigating the lumen of the catheter with saline prior to stylet insertion will aid in stylet removal and avoidance of altering the catheter position after proper placement within the pelvis. The peritoneal purse-string suture is then cinched around the catheter just below the deep dacron cuff closest to the abdominal cavity (figure 2b). Alternatively, if the catheter has a silastic ball or cuff, the peritoneal purse string is cinched just above this, leaving the silastic attachment within the abdominal cavity. The fascia is closed snuggly around the catheter using a single layer of interrupted #1 nonabsorbable suture immediately above the deep Dacron cuff (midline facial incision figures 2a and 6), or using two layers of #1 nonabsorbable suture for the anterior and posterior rectus sheaths, closed snuggly below and above the deep Dacron cuff (figure 2b), respectively. Saline is injected into the catheter and allowed to drain to verify functionality.
A subcutaneous tunnel is created between the catheter insertion site and the usual right lower quadrant skin exit using a long narrow hemostat (figure 3). A heavy silk suture is grasped in the hemostat and it is secured to the proximal free end of the catheter (figure 4) which is tunneled subcutaneously to the skin exit site leaving the second or superficial Dacron cuff 1 to 2 cm deep to the skin. The catheter is anchored to the skin at the exit site with a 3-0 nonabsorbable monofilament suture placed snuggly around the catheter without constricting the internal lumen (figure 5). The catheter cap adapter and clamp are placed on the exteriorized end of the catheter (figure 5). Cross-sectional views for the final positions of the one and two cuff catheters and their securing sutures are shown in the inset figures 2a,b and 6. The catheter is flushed with heparinized saline (500–1,000 units/cc) to avoid fibrin clot formation within the catheter.