The first peritoneal accesses were devices that had been used in other fields (general surgery, urology, or gynecology):
trocars, rubber
catheters, and sump drains. In the period after World War II, numerous papers were published with various modifications of
peritoneal dialysis. The majority of cases were treated with the continuous flow technique; rubber
catheters for inflow and sump drains for outflow were commonly used. At the end of the 1940s, intermittent
peritoneal dialysis started to be more frequently used. Severe complications of peritoneal accesses created incentive to design accesses specifically for
peritoneal dialysis. The initial three, in the late 1940s, were modified sump drains; however, Ferris and Odel for the first time designed a soft,
polyvinyl intraperitoneal tube with
metal weights to keep the
catheter tip in the pelvic gutter where the conditions for drain are the best. In the 1950s, intermittent
peritoneal dialysis was established as the preferred technique;
polyethylene and
nylon catheters became commercially available and
peritoneal dialysis was established as a valuable method for treatment of
acute renal failure. The major breakthrough came in the 1960s. First of all, it was discovered that the
silicone rubber was less irritating to the peritoneal membrane than other plastics. Then, it was found that
polyester velour allowed an excellent tissue ingrowth creating a firm bond with the tissue. When a
polyester cuff was glued to the
catheter, it restricted
catheter movement and created a closed tunnel between the integument and the peritoneal cavity. In 1968, Tenckhoff and Schechter combined these two features and designed a
silicone rubber catheter with a
polyester cuff for treatment of
acute renal failure and two cuffs for treatment of
chronic renal failure. This was the most important development in peritoneal access. Technological evolution never ends. Multiple attempts have been made to eliminate remaining complications of the Tenckhoff
catheter such as exit/tunnel
infection, external cuff extrusion, migration leading to obstruction,
dialysate leaks, recurrent
peritonitis, and infusion or pressure
pain. New designs combined the best features of the previous ones or incorporated new elements. Not all attempts have been successful, but many have. To prevent
catheter migration, Di Paolo and his colleagues applied the old idea of providing weights at the
catheter tips to Tenckhoff
catheters. In another modification, Twardowski and his collaborators created a permanent bend to the intra-tunnel portion of the
silicone catheter to eliminate cuff extrusions. The Tenckhoff
catheter continues to be widely used for chronic
peritoneal dialysis, although its use is decreasing in favor of swan-neck
catheters. Soft,
silicone rubber instead of rigid tubing virtually eliminated such early complications as bowel perforation or massive
bleeding. Other complications, such as obstruction, pericatheter leaks, and superficial cuff extrusions have been markedly reduced in recent years, particularly with the use of swan-neck
catheters and insertion through the rectus muscle instead of the midline. However, these complications still occur, so new designs are being tried.