Y-TEC® Procedure Step by Step Guide

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Step 1: Catheter preparation minute) and aspirate regularly, looking for blood to
indicate an accidental intravenous injection.
Soak the catheter in sterile saline or water and flush
saline/water through it to remove any residues from the 4. M
 ake sure that the patient is monitored closely
manufacturing process. Squeeze air out of the cuffs by by the anaesthetist or a trained nurse during the
rotating the submerged cuffs between your fingers. This administration of the local anaesthetic and following
will aid tissue in-growth into the cuff. the surgery.

5. N
 ote that injecting a test dose of 2 to 3 mL of a local
Step 2: Abdominal preparation anaesthetic containing adrenaline may (but not always)
Sterilise the portion of the abdomen that will be used for cause increased heart rate if accidental intravenous
the procedure using chlorhexidine or povidone-iodine injection occurs.
(scrub, solution or gel). Place sterile surgical drapes References: 1. Xylocaine Approved Product Information, October 2008. 2.
around the operation site so only the incision site is Bukwirwa HW et al. Toxicity from local anaesthetic drugs. Update Anaesthesia
1999; 10: 50–52.
exposed. A sterile vertical drape should be placed
between the operator’s and patient’s head.
Step 4: Anaesthetising the catheter
Step 3: Calculating the local anaesthetic implantation incision site avoiding the
requirement epigastric artery
Decide on the concentration of lignocaine that is required Create a 2 to 3 cm subcutaneous bleb with local
and calculate the total volume of drug that is allowed anaesthetic at the proposed incision entrance point.
based on the table below. The lowest dose and volume Ask the patient to lift their head to tense the abdominal
that results in effective anaesthesia should be used muscles and anaesthetise along the projected insertion
and must be tailored to the individual patient. Usually, tract angling towards the pelvis. Avoid wasting a lot of
the maximum dose allowed at any one time is 3 mg/kg, local anaesthetic in the subcutaneous fat. A lumbar
or 7 mg/kg of body weight if lignocaine with adrenaline puncture needle is often required to anaesthetise the
(1:200,000) is used.1 Adrenaline is added to reduce the abdominal muscles and peritoneum. Some operators
speed of absorption of the anaesthetic, reducing the prefer to inject 3 to 5 mL of lignocaine intraperitoneally,
maximum blood concentration of the anaesthetic by slowly withdrawing the needle while injecting it.
about 50%. Note that the addition of adrenaline will make
no difference to the toxicity of the local anaesthetic if it is
injected intravenously.2 Solutions containing adrenaline
should not be injected into the extremities e.g. fingers
and toes.

Recommended doses for lignocaine1

Maximum dose for infiltration (in average,

mL mg
healthy, 70 kg adult)*

Lignocaine 1% 20 200

Lignocaine 1% with adrenaline 1:200,000 (5 mcg/

50 500
mL)

* Use lower doses in frail patients or in those who are extremely young or old.

Essential Precautions2
Figure 13: Anaesthetising the catheter implantation incision site.
1. A
 lways secure intravenous access before injecting any
dose that may cause toxic effects. As the inferior and superior epigastric vessels lie centrally
2. Always have adequate resuscitation equipment and along the rectus muscle it is wise to stay close to the
drugs available before commencing injections. muscle’s borders when instilling anaesthetic. If preferred,
ultrasound can be used to visualise the blood vessels
3. A
 lways inject the drug slowly (slower than 10 mL/ before and during the procedure.
Step 5: Incision and blunt dissection onto
the rectus muscle
Make a 2 cm horizontal incision in the skin. Blunt dissect
onto the rectus muscle using the curved artery forceps.

Figure 16: Use a rotating motion to advance.

Figure 14: Blunt dissection.

Step 7: Using the scope to check cannula

Step 6: Quill® Catheter Guide Assembly position
introduction Once the Quill® Catheter Guide Assembly is in the
Ask the patient to tighten their abdominal muscles and peritoneum, remove the trocar from the guide and
then insert the Quill® Catheter Guide Assembly (trocar insert the Y-TEC® scope into the cannula, locking them
with stylette and surrounding Quill® catheter guide) at together. Ask the patient to take several deep breaths.
a 20­to 30 degree angle toward the coccyx into the If the cannula is in position you will generally see the
peritoneum. Control the progress of the Quill® catheter omentum, a yellow glistening structure, or bowel loops
guide by placing a finger along the guide close to the move under the scope. Remove the scope once the
skin, as demonstrated in Figure 15. intraperitoneal position of the cannula has been visually
confirmed.

Figure 17: Using the scope to check cannula position.

Figure 15: Control the progress of the Quill catheter guide.

This will prevent any sudden forward motion of the

catheter occurring as it enters the peritoneum and avoid
puncturing the major vascular structures underneath,
which include the aorta. You will usually feel two ‘pops’
during this part of the procedure – one as the needle
passes through the muscle and one as it passes into the
peritoneum.

Once the Quill® catheter guide reaches the abdominal

muscle, use a rotating motion to advance it through the
muscle and into the peritoneum (see Figure 16).
Step 8: Sterile air insufflation As the image below demonstrates, this often requires the
scope and operator to be more horizontal to the patient
Air insufflation creates a space through which the
than vertical.
cannula and Quill guide can be advanced to the
parietal peritoneum for catheter placement. To perform
this procedure, the patient should be placed in the
Trendelenberg position at an angle of 10 to 15 degrees to
allow air to fill the pelvis.

Figure 18: Attach the air insufflation kit to the cannula.

Attach the air insufflation kit to the cannula (see Figure Figure 20: The scope and operator has to be more horizontal to the patient.
18) and inject between 700 and 1200 cc of filtered room
air into the patient. (The amount of air required will Once you are satisfied that the cannula is well placed,
depend on the patient’s size). remove the scope from the Quill® guide and return the
patient to the normal supine position.
The insufflation process should not cause pain. If it does,
it is likely that the peritoneum has not been penetrated Use a haemostat to clip the end of the quill guide so that
and air is being forced into the rectus sheath or muscle. it cannot be lost intraperitoneally. Remove the tape from
the Quill® Guide and cannula using a straight haemostat
Once sufficient air has been injected into the patient’s and twisting it in a clockwise rotation.
peritoneum, detach the air insufflation kit from the
cannula, placing a thumb or finger on the cannula to The best site for the catheter is the longest and
retain the air within the cannula as you do so. most clear space between the visceral and parietal
NB: An alternative approach to achieving Steps 6 to peritoneum until the hub of the cannula reaches skin
8 is to first insert air into the peritoneum (creating a level or the top reaches the tissues at the end of the air
‘pneumoperitoneum’) using a VERESS needle before space.1
proceeding with Step 6. References: 1. Ash SR et al. Clinical dialysis, 4th edition. Editors: Nissenson AR
and Fine RN. McGraw-Hill Professional, 2005, p326.

Step 9: Positioning the Quill® Guide

Assembly with the scope ready for catheter Step 10: Removing the cannula from the
insertion Quill® guide
As the Quill guide is now in the desired location (see
The next step is to re-insert the scope and establish
Figure 21), the cannula can be removed. Retract the
the best location for the catheter within the peritoneum.
cannula from the Quill® Guide using a slight twisting
Advance the scope and Quill® Guide Assembly fully into
motion. Exert downward pressure on the Quill® guide so
the peritoneum so that the distal end of the cannula is
that it is not removed accidently. Be patient – the cannula
pointed to the desired location (see Figure 19).
can be difficult to withdraw on occasions.

Figure 19: Re-insert the scope and establish the best location for the catheter.
 Figure 23: Catheter insertion.

To prevent the stylette from advancing in the catheter,

Figure 21: Removing the cannula. hold the catheter and stylette at the end of the catheter
as illustrated in the image below. Position the radio-
opaque line appropriately for a swan neck (up on the left
Step 11: Radial dilatation of the Quill® guide side and down on the right side).
This step dilates the coiled Quill® guide and the rectus
abdominis muscle to a diameter of 6 mm.

Clamp tab with the Quill® perpendicular to the axis of

the Quill®, near the shoulder of the tab as shown in the
diagram below. Wet the dilators with saline or sterile
gel and insert the smaller dilator into the Quill® catheter
guide and advance the dilator using a twisting motion.
Withdraw it intermittently as you go to avoid the dilator
becoming stuck on the Quill®. Advance the tip to just
beyond the Quill®’s length. Repeat this process with the
larger dilator.

Figure 24: Holding catheter and stylette.

Carefully advance the catheter plus stylette through

the Quill® guide until the deep (distal) cuff reaches the
rectus sheath, taking care to keep the tip of the stylette
within the abdomen to help guide the catheter through
the rectus. An increase in resistance indicates when the
distal cuff has reached the rectus sheath.

Step 13: Testing the catheter (optional)

It is advisable, but not essential, to check the catheter
Figure 22: Radial dilatation. at this point. If there is a problem with the catheter it
can be re-positioned before progressing further with
the procedure. However, this step necessitates having
Step 12: Catheter insertion to withdraw and re-insert the stylette and so some
Lubricate the catheter stylette and prepared catheter operators choose not to check the catheter at this point.
with sterile gel or saline and insert the stylette into the
catheter. Leave 1 to 2 cm of catheter extending beyond If you choose to check that the catheter is working at
the stylette as the stylette can advance in the catheter this point withdraw the stylette and instil 50 to 100 mL of
during insertion. Now insert this catheter setup into the normal saline into the catheter using the air insufflation
Quill® guide (see Figure 23). syringe and observe the air/fluid level fluctuations with
respiration (see Step 16 for more details on this).
Step 14: Correct cuff placement and dilation
to 6 mm
Re-insert the stylette (if the catheter was tested at Step
13) and position the Y-TEC® Cuff Implantor ® parallel with
and over the catheter, between the two cuffs (see Figure
25).

Figure 26 A: If the catheter is functioning well, fluid will flow out.

Figure 25: Correct cuff placement.

Simultaneously advance the catheter and Cuff Implantor ®

1 cm to both dilate the Quill® guide (and rectus) and Figure 26 B: Fluid will rise and fall within the tube.

advance the cuff into the rectus muscle (this is imperative

for providing a good seal at the deep cuff). The Cuff Step 17: Blunt dissection to create pouch for
Implantor ® will stop automatically once the cuff is in the
correct location. Visually or digitally confirm that the catheter
catheter cuffs have been positioned correctly. Create a small pouch at the insertion site for the swan
neck curve to sit in by performing a blunt dissection into
the subcutaneous fat.
Step 15: Retracting the Quill® guide, cuff
implantor and catheter stylette
Step 18: Tunnelling and testing the catheter
As the catheter is now held in place by the cuffs, it is
possible to remove the Cuff Implantor ® and then retract Anaesthetise the chosen exit area, which should be 3 to
the Quill® guide by exerting downward pressure on the 4 cm from the distal cuff. Using the number 11 scalpel
catheter. Finally, retract the catheter stylette, allowing any blade, make a stab incision to the full width of the blade.
remaining air to exit the patient’s body.
The Tunnelor® tool can now be inserted into the exit site
and advanced through the subcutaneous tissue and the
Step 16: Testing the catheter and removing implantation incision site until it reaches the end of the
air catheter. Slide approximately 3 to 4 cm of the implanted
catheter end over the tip of Tunnelor® tool and then
Catheters that are doubled on themselves rarely function. retract the Tunnelor® tool. This pulls the catheter into the
Kinked catheters inhibit fluid flow and twisted catheters tunnel and out of the exit site (see Figure 27).
migrate within 48 hours.

Check that the catheter is not doubled on itself, kinked,

or twisted by infusing 100 to 500 mL of sterile saline or
dialysate into the catheter. If the catheter is functioning
well, fluid will flow out in a steady drip when the catheter
tip is lowered below the primary site (see Figure 26
A); or fluid will rise and fall within the catheter tube in
conjunction with respiration when the catheter tip is
raised approximately 12 to 15 cm above the patient’s
abdomen (see Figure 26 B).
 Step 19: Suturing and dressing the catheter
to immobilise it
Suture closed the implantation and scope incision sites
(but not the exit site) using nylon or other skin sutures. If
the catheter is for early use, attach a line connector to the
titanium connector.

Figure 27: Tip of Tunnelor® tool latches onto the end of implanted catheter at the
implantation incision site and the catheter is pulled through the subcutaneous
tissue ‘tunnel’ and out of the exit site

Figure 29: Suturing and dressing the catheter to immobilise it.

Apply appropriate dressings to the catheter implantation

and exit sites, and to the catheter itself. The dressings
must be fixed in place so the catheter is immobile.

Figure 28 a: The Tunnelor® is inserted subcutaneously from the exit to the

insertion site to allow the catheter to be pulled back through the tunnel.

Figure 28 b: The catheter has been pulled through the tunnel. The radio opaque
strip faces up, which is the correct orientation for a swan neck catheter inserted
on the left side.

Once it has been confirmed that the catheter is not

twisted or kinked at either the implantation or exit site
ends, push the catheter off the Tunnelor® tool and attach
the catheter connector and cap to the end of the catheter.
Test the catheter as described in Step 16.