Y-TEC® Procedure Step by Step Guide
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Step 1: Catheter preparation
Soak the catheter in sterile saline or water and flush
saline/water through it to remove any residues from the
manufacturing process. Squeeze air out of the cuffs by
rotating the submerged cuffs between your fingers. This
will aid tissue in-growth into the cuff.
Step 2: Abdominal preparation
Sterilise the portion of the abdomen that will be used for
the procedure using chlorhexidine or povidone-iodine
(scrub, solution or gel). Place sterile surgical drapes
around the operation site so only the incision site is
exposed. A sterile vertical drape should be placed
between the operator’s and patient’s head.
Step 3: Calculating the local anaesthetic
requirement
Decide on the concentration of lignocaine that is required
and calculate the total volume of drug that is allowed
based on the table below. The lowest dose and volume
that results in effective anaesthesia should be used
and must be tailored to the individual patient. Usually,
the maximum dose allowed at any one time is 3 mg/kg,
or 7 mg/kg of body weight if lignocaine with adrenaline
(1:200,000) is used.1 Adrenaline is added to reduce the
speed of absorption of the anaesthetic, reducing the
maximum blood concentration of the anaesthetic by
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,
healthy, 70 kg adult)*
Lignocaine 1%
Lignocaine 1% with adrenaline 1:200,000 (5 mcg/
mL)
* Use lower doses in frail patients or in those who are extremely young or old.
Essential Precautions2
1. A
 lways secure intravenous access before injecting any
dose that may cause toxic effects.
2. Always have adequate resuscitation equipment and
drugs available before commencing injections.
3. A
 lways inject the drug slowly (slower than 10 mL/
minute) and aspirate regularly, looking for blood to
indicate an accidental intravenous injection.
4. M
 ake sure that the patient is monitored closely
by the anaesthetist or a trained nurse during the
administration of the local anaesthetic and following
the surgery.
5. N
 ote that injecting a test dose of 2 to 3 mL of a local
anaesthetic containing adrenaline may (but not always)
cause increased heart rate if accidental intravenous
injection occurs.
References: 1. Xylocaine Approved Product Information, October 2008. 2.
Bukwirwa HW et al. Toxicity from local anaesthetic drugs. Update Anaesthesia
1999; 10: 50–52.
Step 4: Anaesthetising the catheter
implantation incision site avoiding the
epigastric artery
Create a 2 to 3 cm subcutaneous bleb with local
anaesthetic at the proposed incision entrance point.
Ask the patient to lift their head to tense the abdominal
muscles and anaesthetise along the projected insertion
tract angling towards the pelvis. Avoid wasting a lot of
local anaesthetic in the subcutaneous fat. A lumbar
puncture needle is often required to anaesthetise the
abdominal muscles and peritoneum. Some operators
prefer to inject 3 to 5 mL of lignocaine intraperitoneally,
slowly withdrawing the needle while injecting it.
mL mg
20 200
50 500
Figure 13: Anaesthetising the catheter implantation incision site.
As the inferior and superior epigastric vessels lie centrally
along the rectus muscle it is wise to stay close to the
muscle’s borders when instilling anaesthetic. If preferred,
ultrasound can be used to visualise the blood vessels
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
introduction
Ask the patient to tighten their abdominal muscles and
then insert the Quill® Catheter Guide Assembly (trocar
with stylette and surrounding Quill® catheter guide) at
a 20­to 30 degree angle toward the coccyx into the
peritoneum. Control the progress of the Quill® catheter
guide by placing a finger along the guide close to the
skin, as demonstrated in Figure 15.
position
Once the Quill® Catheter Guide Assembly is in the
peritoneum, remove the trocar from the guide and
insert the Y-TEC® scope into the cannula, locking them
together. Ask the patient to take several deep breaths.
If the cannula is in position you will generally see the
omentum, a yellow glistening structure, or bowel loops
move under the scope. Remove the scope once the
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
Air insufflation creates a space through which the
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
18) and inject between 700 and 1200 cc of filtered room
air into the patient. (The amount of air required will
depend on the patient’s size).
The insufflation process should not cause pain. If it does,
it is likely that the peritoneum has not been penetrated
and air is being forced into the rectus sheath or muscle.
Once sufficient air has been injected into the patient’s
peritoneum, detach the air insufflation kit from the
cannula, placing a thumb or finger on the cannula to
retain the air within the cannula as you do so.
NB: An alternative approach to achieving Steps 6 to
8 is to first insert air into the peritoneum (creating a
‘pneumoperitoneum’) using a VERESS needle before
proceeding with Step 6.
Step 9: Positioning the Quill® Guide
Assembly with the scope ready for catheter
insertion
The next step is to re-insert the scope and establish
the best location for the catheter within the peritoneum.
Advance the scope and Quill® Guide Assembly fully into
the peritoneum so that the distal end of the cannula is
pointed to the desired location (see Figure 19).
Figure 19: Re-insert the scope and establish the best location for the catheter.
As the image below demonstrates, this often requires the
scope and operator to be more horizontal to the patient
than vertical.
Figure 20: The scope and operator has to be more horizontal to the patient.
Once you are satisfied that the cannula is well placed,
remove the scope from the Quill® guide and return the
patient to the normal supine position.
Use a haemostat to clip the end of the quill guide so that
it cannot be lost intraperitoneally. Remove the tape from
the Quill® Guide and cannula using a straight haemostat
and twisting it in a clockwise rotation.
The best site for the catheter is the longest and
most clear space between the visceral and parietal
peritoneum until the hub of the cannula reaches skin
level or the top reaches the tissues at the end of the air
space.1
References: 1. Ash SR et al. Clinical dialysis, 4th edition. Editors: Nissenson AR
and Fine RN. McGraw-Hill Professional, 2005, p326.
Step 10: Removing the cannula from the
Quill® guide
As the Quill guide is now in the desired location (see
Figure 21), the cannula can be removed. Retract the
cannula from the Quill® Guide using a slight twisting
motion. Exert downward pressure on the Quill® guide so
that it is not removed accidently. Be patient – the cannula
can be difficult to withdraw on occasions.

Figure 21: Removing the cannula.
Step 11: Radial dilatation of the Quill® guide
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 22: Radial dilatation.
Step 12: Catheter insertion
Lubricate the catheter stylette and prepared catheter
with sterile gel or saline and insert the stylette into the
catheter. Leave 1 to 2 cm of catheter extending beyond
the stylette as the stylette can advance in the catheter
during insertion. Now insert this catheter setup into the
Quill® guide (see Figure 23).
Figure 23: Catheter insertion.
To prevent the stylette from advancing in the catheter,
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
side and down on the right side).
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
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
to withdraw and re-insert the stylette and so some
operators choose not to check the catheter at this point.
If you choose to check that the catheter is working at
this point withdraw the stylette and instil 50 to 100 mL of
normal saline into the catheter using the air insufflation
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
Implantor ® will stop automatically once the cuff is in the
correct location. Visually or digitally confirm that the
catheter cuffs have been positioned correctly.
Step 15: Retracting the Quill® guide, cuff
implantor and catheter stylette
As the catheter is now held in place by the cuffs, it is
possible to remove the Cuff Implantor ® and then retract
the Quill® guide by exerting downward pressure on the
catheter. Finally, retract the catheter stylette, allowing any
remaining air to exit the patient’s body.
Step 16: Testing the catheter and removing
air
Catheters that are doubled on themselves rarely function.
Kinked catheters inhibit fluid flow and twisted catheters
migrate within 48 hours.
Step 17: Blunt dissection to create pouch for
catheter
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 18: Tunnelling and testing the catheter
Anaesthetise the chosen exit area, which should be 3 to
4 cm from the distal cuff. Using the number 11 scalpel
blade, make a stab incision to the full width of the blade.
The Tunnelor® tool can now be inserted into the exit site
and advanced through the subcutaneous tissue and the
implantation incision site until it reaches the end of the
catheter. Slide approximately 3 to 4 cm of the implanted
catheter end over the tip of Tunnelor® tool and then
retract the Tunnelor® tool. This pulls the catheter into the
tunnel and out of the exit site (see Figure 27).

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.