Patients with end stage renal failure (ESRF) treated with continuous peritoneal dialysis (PD) may have been complicated with several types of abdomina
Abdominal hernias in continuous peritoneal dialysis
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Patients with end stage renal failure (ESRF)
treated with continuous peritoneal dialysis (PD) may have been complicated with
several types of abdominal hernias.
INCIDENCE
Incidence of abdominal hernias has been
reported to be about 10-15 % per year (reported in 1980). As compared to the continuous
ambulatory PD, intermittent PD may show lower incidence that is approaching an
annual rate of < 5%. However, the paramedian approach for PD catheter
placement may be associated with a lowered incidence of exit site and
incisional hernias. Recent reports observe that hernia rates may approach 0.06-0.08 per patient
per y.
RISK FACTORS FOR HERNIA FORMATION
Several risk factors for hernia
development have been recognized, they include:
1) Female
sex,
2) Multiparous
women,
3) Increased
age,
4) Prolonged
time on PD,
5) Small
body size,
6) CAPD
(vs cycler only),
7) Multiple
times of laparotomies, and
8) APKD
(Autosomal dominant polycystic kidney disease).
These risk factors may reflect anatomical,
hydrostatic, or metabolic risks that may impact the rate of hernia development.
CLINICAL MANIFESTATIONS
Abdominal hernias can be presented by painless
swelling at different sites, discomfort or disfiguring, and symptoms related to
hernia complications e.g. strangulation and sepsis (peritonitis). Peritoneal
fluid may escape to the surrounding structures that may result in edema formation
in the lower abdominal wall or onto the genitalia either male or female.
Moreover, dialysate fluid may traverse the peritoneal membrane into the
anterior wall of the abdomen that results in an abdominal wall edema. The
latter complication can be diagnosed through two signs, first, increased
abdominal girth, second, diminished volume of the drained peritoneal
fluid.
However, dangerous complications, such as small intestinal
obstruction or and strangulated hernia, are rarely
observed. Whilst umbilical hernia can be incarcerated, the inguinal may be
developed as an incisional hernia around the area of the inserted PD catheter.
Both incarcerated and strangulated hernias are more likely if the hernia is
small in size, impeding the free movement of the bowel in and out through the
hernia sac. Clinical presentation is variable, it ranged from tender site of
the hernia sac to a perforated or obstructed bowel.
PREVENTION
Several precautions should be performed either
preoperatively or after the operation to limit the risk of hernia development
and fluid leaks. They include:
1)
Early detection and correction of the already developed hernias.
2)
Intraoperative inspection and correction of the processus vaginalis
by the operating surgeon during the insertion of PD catheter.
3)
Preference of the paramedian rather than the midline location
during catheter placement.
4)
Locating the deep cuff of the PD catheter into the subaponeurotic
area (instead of the rectus muscle).
5)
Preventive measures of constipation and coughing particularly in
the early period.
6)
Utilization of the laparoscopic technique for placing rectal sheath
tunneling.
7)
The catheter break-in period is considered for 2 weeks at least. If
DX is required, it can be provided as either low volume (1.0 -1.5 L), supine,
rapid cycling (6 exchanges per d.) PD plan or commencing HDX. The latter module
is better provided if there’s possibility of inadequate DX with administration
of a lowered volume PD.
TREATMENT
Hernias can be surgically repaired. Cases developing
hernia after commencing PD should be electively repaired. The introduction of
polypropylene mesh to limit the risk of hernia development post-operatively may
allow resumption of PD several days after hernia repair. Resumption of PD can
be performed several days after herniotomy, with lowered volume, supine, rapid
cycling PD and the previous PD protocol can be gradually reinstituted within
2-4 weeks. In some centers, intermittent PD can be resumed 48 hours post-operative
and PD can be slowly reintroduced.
Treatment of dialysate leaks with or without hernia
Uncomplicated PD leaks (i.e., with no hernia)
can be primarily treated with either lowered volume, supine posture with a dry
day or HDX.
Abdominal wall or genital edema
In uncomplicated abdominal wall/genital edema
(with no hernia), conservative therapy is suggested with bed rest and transient
HDX. Resting for 3-7 d. may be enough period for tissue defect to repair and permit
the resumption of PD. If recurred, abdominal wall edema can be managed via a
more prolonged course of HDX (4-6 weeks) or surgically repaired. The latter may
be difficult to perform in absence of an obvious hernia, as the location of
leak cannot be easily determined.
Imaging techniques, may help recognition of the
defect. In contrary, management of recurred genital edema depends upon its
etiology:
v With patent processus vaginalis surgical
repair is suggested. The anatomic location of the defect can be recognized via
technetium scan, CT with contrast, MRI with no gadolinium or by explorating
laparotomy.
v Fluid migration through the anterior abdominal
treated as before.
N.B. This Blogger is created to declare the risk factors and management of abdominal hernias in a PD patient.
References
6)
Tast C, Kuhlmann U, Stölzing
H, et al. Continuing CAPD after herniotomy. EDTNA ERCA J 2002; 28:173.
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