Intraperitoneal (i.p.) bleeding causes intense inflammatory reactions and extensive adhesions. The relationship between i.p. bleeding and adhesions is well documented in both animal and human studies. Over an 8-year period, we performed 362 permanent peritoneal dialysis (PD) catheter placements in 317 patients, using the laparoscopic technique. In the first 203 procedures (group I), we observed intra-operative bleeding in 12 patients (intra-operative i.p. bleeding seen laparoscopically, and significant blood-tinged dialysate irrigation). Patients were left dry for 3-5 days before dialysate instillation during the break-in period. During the break-in period, 7 of the 12 patients (58%) developed primary catheter failure requiring catheter removal (p = 0.03). All 7 patients underwent repeat laparoscopy for placement of a new catheter. In all 7 patients, laparoscopy showed significant adhesions. In the subsequent 159 procedures (group II), we observed intra-operative bleeding in 10 patients. We irrigated the peritoneal cavity repeatedly, until clear dialysate was obtained, then instilled 500-1000 mL 1.5% Dianeal solution (Baxter Healthcare Corporation, Deerfield, IL, U.S.A.) and capped the catheter. These patients were then placed on low-volume continuous cycling peritoneal dialysis [(CCPD) 700-1200 mL, based on the patient's size, every 2 hours, until the effluent became clear]. Following this, patients underwent daily irrigation and PD fluid cell count, and were left with 700-1200 mL dialysate to dwell. The process was continued until PD fluid drainage showed no red blood cells or until the patient was started on routine peritoneal dialysis. None of these patients were drained dry. Compared with group I, no patient among the 10 in group II developed catheter failure (p = 0.001), and mean catheter survival was 31 +/- 7 months. Of the 10 patients, 2 developed exist-site leaks, both after clearance of red blood cells from the drained dialysate. None developed peritonitis. We conclude that intra-operative i.p. bleeding associated with significant blood-tinged dialysate irrigation may lead to local adhesions if the peritoneum is drained dry. The result may be loss of the PD catheter in about 60% of cases. Continuous irrigation, combined with a moderate amount of Dianeal solution left to dwell, or early initiation of low-volume PD, or both, prevents this complication.