2 of patients. A multidisciplinary team involving PD nurses, nephrologist, and surgeons will increase the psychosocial support to such a cohort of patients and add to the success of a PD programme. 2. Objective This paper is a brief document elaborating a recap of published literature, looking at various surgical tips and manoeuvres to enhance optimal outcome of peritoneal dialysis catheter placement. 3. Search Strategy Databases: Medline (Pubmed-1966–2011), Cochrane Cen- tral Register of Controlled Trials, EMBASE (1974–2011) the Data base of Abstracts of Reviews of Eﬀects (DARE), and Health technology assessment database (HTA). The search strategy was based on the following: (i) peritoneal dialysis catheters inserts, (ii) peritoneal dialysis catheter dysfunction, (iii) surgical manoeuvres for peritoneal dialysis, (iv) laparoscopic peritoneal dialysis catheter insertion, (v) open PDC insertions, (vi) Tenckhoﬀ PDC catheters, (vii) peritoneoscopic PDC insertions, (viii) antibiotic prophylaxis for PDC insertion, (ix) controversy of PDC, (x) role of surgeon in PDC placement. The various tips and surgical manoeuvres to enhance optimal outcome of peritoneal dialysis catheters are discussed as follows. 3.1. Peritoneal Access (PD Access): The Access Team. The Renal Association UK: Peritoneal Access Guidelines: guide- line peritoneal dialysis (RA/PAG:PD) [12] and International Society for Peritoneal Dialysis (ISPD) guidelines recommend that each centre should have a dedicated team involved in the implantation and care of peritoneal catheters. (RA/PAG: PD1.1) [13] (ISPD: 1.1) [14]. 3.2. Preoperative Antibiotic Prophylaxis. A single dose of preoperative antibiotics is recommended (based on unit microbiology policy)( RA/PAG: PD3.1) [12] (ISPD:3.1) [14] and this reduces the rate of exit-site infection and peritonitis [9, 15–20]. 3.3. Type of Catheter. RA/PAG: PD5.2 [12] and ISPD: 5.2 suggest that no particular catheter type is proven to be better than another [21]. Though, a curled tip catheter should be used and is more likely to retain position within the pelvis and oﬀers a better drainage compared to a straight tip catheter [22, 23]. Nielsen et al., published a small RCT which International Journal of Nephrology demonstrates superiority of the curled Tenckhoﬀ peritoneal dialysis catheter survival as compared to the straight catheter which was due to the higher displacement rate [24]. In addition, straight tip catheters are associated with dialysate inﬂow discomfort or the “poking pain” which is not reported with curled catheters [22]. An extended catheter system or two-piece extended catheter system can be used to provide remote exit-site locations to the upper abdomen or chest as an indication for obesity, ﬂoppy abdominal skin folds, presence of stomas, incontinence, and yeast intertrigo [25– 28]. Self locating catheters have been described, which show a lower rate of displacements [29–32]. 3.4. Catheter Exit-Site. The exit-site should be well planned, ideally on the opposite side of the dominant hand and should not be placed in skin crease, belt line and should be located dependently to the site of cuﬀ placement. (RA/PAG) Many authors have described optimum exit-sites in literature, yet, the ideal situation is that the patient should be marked in a preoperative setting. If this has not been done, then the 3-step algorithm method could be used to determine exit- site at the time of the operation [10]. It is to design a laterally directed exit-site that places the superﬁcial cuﬀ 4 cm from the exit wound and also eliminates concerns for cuﬀ extrusion from tubing resiliency forces. In brief, the three steps include the following Step 1: scribe arc from vertical to lateral plane using catheter as compass from point 2 cm 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 4 cm external of superﬁcial cuﬀ to exit-site. 3.5. Intraoperative Catheter Trial. Various volumes have been used but we prefer to use half a bag of PD ﬂuid to check for instillation and drainage. This is a very important and crucial step as this manoeuvre does predict successful function (inﬂow and outﬂow) of the PDC postoperatively. In addition, further small volume exchanges can be carried out in patients who have undergone extensive adhesiolysis until draining dialysate is no longer blood stained [9]. In addition, it should also be used to test the tightness of catheter at the peritoneum, thus excluding a possible dialysate leak. 3.6. Optimal Time to Commence PD. An approximate 2-week delay (RA/PAG: PD2.1) [12] (ISPD: 2.1) [14] results in the less likelihood of exit-site infection and dialysate leak [9, 33], though this is based on evidence from mostly retrospective studies. Reported leak rates are signiﬁcantly lower for all documented laparoscopic series, even when catheters are used straight away [1, 34–38]. Purse string sutures at the cuﬀ to anchor have been described during open surgery and do reduce the risk of early leaks [39, 40]. Yang et al., did not show higher risk of catheter-related problems in PD patients starting dialysis less than 2 weeks (earlier group (2.0 ± 2.7 days) versus late group (40.6 ± 42.8 days): 14.6% and 13.1%, resp. developed catheter-related complications within 6 months) [41]. Currently, a randomised control