Purpose: Peritoneal dialysis (PD) is an important form of kidney replacement therapy. The optimal technique for PD catheter insertion is unknown. This study compares the efficacy and safety of surgical versus percutaneous approaches to PD catheter insertion for patients with end-stage kidney disease. Methodology: Electronic databases (MEDLINE, Embase, CENTRAL) were searched for relevant RCTs. Patient- and catheter-related outcomes were analysed. Risk of bias was assessed using the Cochrane Risk of Bias Tool, and certainty of evidence using the GRADE approach. Results: Four studies (397 participants) were included. Regarding surgical techniques, one study included laparoscopic approaches to PD catheter insertion; all other studies reported on open techniques. Percutaneous techniques varied significantly between RCTs. No difference in patient mortality was found (RR=0.82, 95%CI=0.43-1.57, I2 = 0%). Percutaneous techniques were associated with lower rates of early peritonitis (RR=0.34, 95%CI=0.12-0.91, I2=0%) and long-term catheter failure (RR=0.69, 95%CI=0.47-1.00, I2=0%) than surgical approaches. Percutaneous catheter insertion was also associated with reduced late peri-catheter leak rates (RR=0.35, 95%CI=0.12-0.98, I2=0%) and peri-procedural complications (RR=0.25, 95%CI=0.07-0.90, I2=0%). The overall risk of bias was moderate, and certainty of evidence was low or very low. Conclusions: While percutaneous PD catheter insertion may be associated with lower early and late complication rates compared to surgical approaches, there is a lack of high-quality evidence. Further RCTs are required to compare the safety and efficacy of modern percutaneous with laparoscopic techniques to better inform future clinical practice.