PD is grossly underused in Renal Replacement Therapy though it is often the best & cheapest option in ESRF. There are many reasons for this, including issues with placement of the PD catheter. There are 4 PD catheter insertion techniques: 1. Open surgery 2. Laparoscopic surgery (the commonest) 3. “Peritoneoscopic” techniques (becoming obsolete) 4. Seldinger technique – the future. The Seldinger technique has many advantages but is not standardised & often poorly done. We describe a Modified Seldinger PD Insertion technique developed and introduced at our institution. It is very safe, can be done in the sickest patient, on the fully anticoagulated, under Local Anasthetic, thru a single 5mm incision. It allows immediate PD catheter use for full volume, Samed Day & Urgent Start PD, without peritoneal leak. The technique places the catheter in the Pouch of Douglas & keeps it there. This should become the default option for PD insertion. Technique: * Under LA, +/- sedation; * With US & fluoroscopic guidance * Pre-op mapping with US * Seldinger access 22g spinal needle & microwire * Peritoneography at multiple stages * Low peritoneal entry with gently angled track * Catheter insertion thru 16F sheath * Reverse exit tunnel Results: * To date we have performed >150 procedures, often in the sickest patients, without major complications, significant bleeding or gut injury. * Technical Success Rate 97% * Same Day full volume PD 17%; Urgent Start PD 37% * Significant leak, catheter migration both < 2% Published: Swinnen JJ, Baker L, Burgess D, et al. Changing the peritoneal dialysis access algorithm with a precise technique of percutaneous Seldinger PD catheter placement. J Vasc Access. Published online February 14, 2022. doi: 10.1177/11297298221077607