4 test. Once identiﬁed the oﬀending epiploic (seen blocking the catheter during an outﬂow check) appendages indicate a laparoscopic resection [66]. 3.16. Adhesiolysis. Adhesions play a signiﬁcant role in catheter displacement, thus dysfunction. Extensive dissection is neither necessary nor desirable to mobilise and divide every single adhesion. Abdominal wall adhesion above the level of the pelvis will not interfere and is best left alone. Laparoscopic dissection can be carried out using either scissor with diathermy, hook diathermy or ultrasonic shears. Limiting adhesiolysis to that necessary avoids visceral injury, haemorrhage, and reformation of adhesions which will eventually compromise the peritoneal cavity [10]. 3.17. A Trained Surgeon. Surgical outcomes strongly corelate with training during residency [67]. RA/PAG PD6.1 [12] recommend that PD catheter insertion training should be available to all trainees with an interest [68]. Placement of a PDC by an experienced surgeon is strongly recommended to reduce complications [69]. Repetition of the procedure is needed for surgical proﬁciency [67, 70] and the number quoted is 20–40 procedures before an acceptable level of skill can be obtained [70, 71]. RA/PAG PD6.2 [12] recommend that PD catheter insertion should not be delegated to inexperienced unsupervised operators [13]. 3.18. Patient Selection. Surgical placement of PDC should be the standard for complicated patients such as PDC revisions and patients with hernias and redo abdominal surgery. The procedure should be carried out as a laparoscopic placement (direct visualisation; ISPD guideline 4.1) under a general anaesthesia as problems such as adhesions and hernias can be dealt with at the time of surgery [10, 15, 28, 61, 65]. The anaesthetic requirement depends on the technique selected, which is inﬂuenced by the patients characteristics (ISPD: 5.1) [14] and thus for complicated patients general anaesthesia is preferred. ISPD guideline 4.1 recommend that local expertise at individual centres should govern the choice of method of PDC placement, with timely surgical support available for the review of PD patients (ISPD: 4.4) [14]. There is no RCT evidence to support one method of insertion over another; however, the method needs be determined by patient characteristics (ISPD: 4.4) [14]. Indeed, some data show that laparoscopic PDC implantation may be superior to other methods in patients with pervious operation [58, 72], though results of the RCT LOCI trial are awaited [73]. 3.19. Perioperative Catheter Care Protocol. RA/PAG PD 3.1 and ISPD 3.1 recommend that renal units should have clear protocols for perioperative catheter care addressing the following [12, 15]: (a) Preoperatively—check for hernias, screen for MRSA, and nasal carriage of Staphylococcus aureus, identi- fying a catheter of a suitable length, and mark the appropriate exit-site sitting and standing. International Journal of Nephrology (b) Before-implantation—bowel preparation with laxa- tives, ensuring bladder emptying, administration of prophylactic antibiotics, and surgical site preparation according to NICE guidance [18]. (c) Aftert-procedure—catheter ﬂush and cap oﬀ using suitable dialysate, exit-site covered with a suitable nonocclusive dressing and if possible not disturbed for 5–10 days, immobilisation of the catheter, patient discharged home with supply of aperients with advice as how to recognise potential complications. Intraperitoneal administration of heparin catheter ﬂushes prevents ﬁbrin formation in CAPD patients and may have added beneﬁts [74]. Once the catheter is placed and until healing is completed, the dressing changes should be addressed by a dialysis follow- up nurse using sterile technique. 3.20. Contraindications for PDC (http://www.kidney.org/pro- fessionals/kdoqi/guidelines/). Absolute contraindications for PD include (guideline 30: NKF KDOQI guidelines for peritoneal dialysis adequacy) (a) documented loss of peritoneal function or extensive abdominal adhesions that limit dialysate ﬂow, (b) uncorrectable mechanical defects that prevent eﬀec- tive PD or increase the risk of infection (e.g., surgi- cally irreparable hernia, omphalocele, gastroschisis, diaphragmatic hernia, and bladder exstrophy). Relative contraindications for PD include the following. (Guideline 31: NKF KDOQI). (a) Fresh intra-abdominal foreign bodies (e.g., 4-month wait after abdominal vascular prostheses, recent ventricular-peritoneal shunt). (b) Peritoneal leaks. (c) Body size limitations. (d) Intolerance to PD volumes necessary to achieve adequate PD dose. (e) Inﬂammatory or ischemic bowel disease. (f) Abdominal wall or skin infection. (g) Morbid obesity (in short individuals). (h) Severe malnutrition. (i) Frequent episodes of diverticulitis. 4. Conclusions The success of a peritoneal dialysis programme depends upon functional and durable long term access to the peritoneal cavity; this depends on placement techniques and competent surgeons. The various technical tips and manoeu- vres elaborated here should be considered options carried out to improve outcome and reduce catheter dysfunction.