Laparoscopic Inguinal Hernia Repair and Synchronous Peritoneal Dialysis Catheter Placement: A Single-Center Experience

Introduction

Peritoneal dialysis (PD) has the advantages of easy to use and relatively low cost compared with hemodialysis, and it is currently one of the main renal function replacement therapies for patients with end-stage renal disease (ESRD). ¹ The presence of inguinal hernia in ESRD patients before treatment is an important reason for the cessation of PD or the conversion to hemodialysis. However, periodic injection of dialysate unavoidably increases intra-abdominal pressure, which may lead to hernia formation, especially in patients with abdominal weakness or defects.^2,3 Although several previous studies have demonstrated the feasibility of synchronous tension-free hernia repair and PD catheter placement in a limited number of patients.^4,5 There is no consensus or gold standard for the treatment of patients with inguinal hernias during PD.

In the epoch of minimal invasive surgery, laparoscopic technology has been widely used in hernia repair and PD catheter placement.^6,7 Herein we present a single-center experience of laparoscopic inguinal hernia repair and synchronous PD catheter placement to evaluate the safety and effectiveness of this approach in ESRD patients.

Materials and Methods

Results

A total of 216 patients were given placement of PD catheter during the study period. Among these patients, 41 patients all had inguinal hernias, 32 of which were diagnosed preoperatively and 9 of which were found intraoperatively. All 41 patients underwent laparoscopic inguinal hernia repair and synchronous PD catheter placement, inguinal hernia was bilateral in 10 patients and unilateral in 31 patients (Fig. 1). Clinical characteristics of patients with inguinal hernia are shown in Table 1.

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FIG. 1.

Flow chart for included patients. ESRD, end-stage renal disease; PD, peritoneal dialysis.

The mean age was 46.49 years (range, 28–72 years), including 39 males and 2 females. The mean body mass index was 23.82 kg/m² (range: 19.00–28.40). The causes of renal failure were chronic glomerulonephritis (n = 15), diabetes nephropathy (n = 14), hypertensive nephropathy (n = 5), lupus nephropathy (n = 4), obstructive nephropathy (n = 2), and unknown (n = 1). In addition, 22 patients suffered from hypertension and 19 patients suffered from diabetes.

Table 2 presents perioperative data of patients with inguinal hernia. All operations were performed successfully, with a mean length of operation of 73.03 minutes for unilateral inguinal hernia and 128.7 minutes for bilateral inguinal hernia. There were no recurrent hernias and only 1 patient (2.4%) developed incisional hernia located in the umbilicus region (trocar site hernia) at 17 months after surgery, which required hernia repair and termination of PD. No postoperative complications occurred, such as bleeding, infections, and dialysate leakage. After a median follow-up of 37 months (20–58 months), there were no deaths and 97.6% (40) of the catheters were still working. PD catheter was replaced in 1 patient owing to omental wrapping on 26 months postoperatively.

Discussion

The occurrence of inguinal hernia during PD period is a primary cause of termination of PD. Weakened connective tissue and increased abdominal pressure due to the infusion of PD fluid are the main reasons for the high incidence of inguinal hernia in patients with chronic renal failure. ⁹ The prevalence of symptomatic inguinal hernia in patients undergoing PD ranges from 11% to 33%^10–12 and the incidence (14.8%) in our study is within this range. A thorough examination of groin region before PD is necessary. However, occult inguinal hernias are commonly asymptomatic before PD treatment and are difficult to detect by preoperative imaging assessment. The advantage of laparoscopic PD catheter placement is evident especially for patients with occult hernias. Because laparoscopic approach can simultaneously solve the problem of hernia repair to avoid secondary surgery, which is most important for patients with highly impaired renal function.

Kou et al. ¹³ demonstrated that synchronous hernia repair during PD catheter placement reduces the risk of symptomatic inguinal hernias development after initiation of PD therapy. No recurrent hernias were found in our study during follow-up, perhaps due to the timely intraoperative detection of occult hernias and the delicate and complete repair of the area around myopectineal orifice. However, one patient developed trocar site hernia located in the umbilicus region after 17 months postoperatively. This suggests that we should completely close the trocar incisions at a minimum of 10 mm located mostly in the umbilicus region after the laparoscopic surgery.

Compared to conventional open approach, patients can benefit from laparoscopic PD catheter placement with smaller scars and quicker recovery. ¹⁴ Also, it can ensure optimal placement of the catheter under visual guidance and reduce the postoperative complications, including catheter dysfunction and dialysate leakage. ¹⁵ No complications relating to catheter displacement occurred during the follow-up in this study, and the catheters worked for a long time; only 1 patient suffered from catheter blockage and catheter replacement at 26 months after surgery. Although techniques such as omentectomy, fixation of catheter, and omentum have been studied to reduce catheter occlusion and improve functional outcome,^16–18 these operations may cause an increased risk of infection, bleeding, intra-abdominal hernia, and difficulty in extubation. We are neutral about these surgical procedures and fixation of catheter and omentum is not our operative practice. But we may take these measures to prevent catheter blockage in the future.

Dialysate leakage is a common complication associated with PD catheter implantation which can lead to catheter replacement, peritonitis, or temporary suspension of PD. ¹⁹ To avoid the occurrence of the dialysate leakage, Dombros et al. ²⁰ recommend low volume exchange for 2 weeks after PD catheter implantation. In addition, Yang et al. ²¹ showed that there were no differences between early (<14 days) and late (>14 days) PD in term of dialysate leakage. Several studies have noted that the healing time of the peritoneum ranges from 7 to 14 days.^22,23 Therefore, the principle of starting with low volume and gradually increasing the volume was implemented in our study, which made possible obtaining of good results without postoperative complications such as dialysate leakage. Similar results are also reported by some previous research.^24,25 Another significant reason for this satisfactory result is that the subcutaneous tunnel can minimize the risk of dialysate leakage around the catheter.

To the best of our knowledge, our study is the largest investigation which included 41 ESRD patients who underwent laparoscopic hernia repair and synchronous PD catheter placement and analyzed the outcomes, postoperative complications, and catheter survival. However, this study is inevitably associated with certain shortcomings, namely, the lack of a control group and relatively limited number of patients. In addition, our study is a single-center experience with a rather short follow-up period. A prospective study with longer follow-up and larger sample size is needed in the future.

Conclusions

In the epoch of minimal invasive surgery, laparoscopic approach is feasible and safe for hernia repair and synchronous PD catheter placement in ESRD patients without hernia recurrence and postoperative complications during the follow-up time.