Inguinal Herniorrhaphy in the Continuous Ambulatory Peritoneal Dialysis Patient David G. Pauls, MD, Bradley B. Basinger, MD, and Charles F. Shield III, MD • Inguinal hernia repair In the patient on continuous ambulatory peritoneal dialysis (CAPO) is complicated in theory by an increased potential for recurrence. In addition to the constant increased intraabdominal pressure, chronic renal failure has been shown to impair tissue healing. Controversy exists regarding the waiting period before resuming CAPO postoperatively. A retrospective review of all CAPO patients undergoing inguinal herniorrhaphy was performed. The patient's age, type ofrepair, duration of renal failure preoperatively, length of time on CAPO postoperatively, and date of resumption of CAPO were recorded. An inpatient and outpatient chart review was performed on all patients. Telephone follow-up was performed on surviving patients. From April 1981 to June 1989, 30 patients underwent 36 inguinal herniorrhaphies while on CAPO. One immediate postoperative death occurred due to underlying cardiac disease. The mean follow-up for surviving patients was 34 months (range, 16 to 91) and for those deceased was 25 months (range, 1 to 60). No recurrent hernias were identified either by extensive inpatient and outpatient chart review, or by direct patient telephone contact in all surviving patients. We conclude that inguinal herniorrhaphy can be safely performed in CAPO patients. Peritoneal dialysis can be initiated immediately after repair in this high-risk group of patients. There is a low risk of recurrence; however, long-term patient survival is not expected due to concurrent underlying medical problems. © 1992 by the National Kidney Foundation, Inc. INDEX WOROS: Inguinal hernia; herniorrhaphy; peritoneal dialysis.
A
LTHOUGH PERITONITIS is the most common and the most serious problem in the patient on continuous ambulatory peritoneal dialysis (CAPD), the development of an inguinal hernia has been recognized as a complication, with a reported incidence ranging from 1.5% to 13% in adults l -4 and 11.8% to 36.8% in children. 5-? In a review of five dialysis units with 337 patients, Engeset and Youngson found that inguinal hernias were the most common type, followed closely by incisional hernias. 1 Other reports from Digenis et aV O'Connor et aV and Stone et al 6 show a higher incidence of ventral hernias. Normally, complications from inguinal hernias are rare, but these hernias are progressive in size and can become quite large if left alone. These patients also have the problem of scrotal and lower abdominal tissue fluid accumulation, which can become massive without surgical intervention. CAPO has . several theoretical considerations that can complicate the management of an inguinal hernia. Chronically increased intraabdominal pressure places physical stress on the abdominal wall, which contributes to the high incidence of hernias in general. Chronic renal failure has been shown to impair wound healing through several mechanisms, including a reduction in cellular proliferation at the wound edges and a decrease in the growth offibroblasts. 8 These implications for repair of the hernia are obvious. Controversy regarding the type of hernia repair and the time of resumption of CAPO postoper-
atively continues. We have been unable to discover a series of inguinal hernia repairs in the CAPO patient population; therefore, we present a retrospective review of all inguinal herniorrhaphies performed on patients on CAPO at our dialysis units.
METHODS A retrospective review was performed of all CAPO patients at our dialysis centers undergoing inguinal herniorrhaphy from April 198 I to June 1989. The patient's age, type of repair, duration of renal failure preoperatively, length of time on CAPO postoperatively, and date of resumption of CAPO were recorded. Areview of inpatient and outpatient dialysis charts was performed on all patients. Telephone follow-up was performed on surviving patients. A Kaplan-Meier life-table was generated to evaluate the mortality of this patient population.
RESULTS From April 1981 to June 1989, 30 patients (29 men, one woman) underwent 36 inguinal herniorrhaphies while on CAPO. The average age was 63 years (range, 29 to 83). The etiology of renal failure was diabetic nephropathy in eight patients, nephrosclerosis in eight patients, glomerulonephritis in five patients, and interstitial From the Department ofSurgery, the University of Kansas School of Medicine- Wichita, Wichita, KS. Received February 7, 1992; accepted in revised form July 9, 1992. Address reprint requests to David G. Pauls, MD, Department of Surgery Education, 929 NSf Francis, Wichita, KS 6 72 ]4, © 1992 by the National Kidney Foundation, Inc, 0272-6386/92/2005-0009$3.00/0
American Journal of Kidney Diseases, Vol XX, No 5 (November), 1992: pp 497-499
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nephritis, renal artery occlusion, amyloidosis, systemic lupus erythematosus, and hypertension in one patient each. Three patients had an unknown etiology for their renal failure. There were 19 indirect hernias, 13 direct hernias, and four with both direct and indirect components. Two hernias, one direct and one indirect, were recurrent from repairs done before initiation of CAPO. Patients had been on dialysis an average of 5 months prior to herniorrhaphy (range, 0 to 31). One half of the patients (15) had a herniorrhaphy performed either at the time of catheter placement or within 2 weeks of catheter placement. One immediate postoperative death occurred secondary to underlying cardiac disease. The actuarial patient survival at 1, 2, 3, and 4 years postrepair was 80%,69%,47%, and 26%, respectively, with 13 patients still alive at the time of the study completion. The mean follow-up for surviving patients was 34 months (range, 16 to 91) and for those deceased was 25 months (range, 1 to 60). The mean age of those patients still alive was 58 years versus 67 years for those patients deceased. Mean catheter survival postoperatively was 16 months (range, 1 to 60). Thirteen of the patients were on CAPO less than 1 year following herniorrhaphy. Reasons for discontinuing CAPO during the first year were conversion to hemodialysis (5), transplantation (4), death (3), and infection (1). Those patients converted to hemodialysis were changed over at 9, 8, 7, 3, and 2 months after herniorrhaphy. No hernia recurrences were identified either by extensive inpatient and outpatient chart review, or by patient telephone contact in all surviving patients. Patients resumed CAPO by postoperative day 1, 7, 14, and 21 in 51 %, 77%, 94%, and 100% ofrepairs. Patients repaired by the Shouldice, McVay, and Bassini methods were immediately restarted on CAPO in 65%, 40%, and 38% of the cases, respectively. DISCUSSION
Inguinal hernia as a complication of peritoneal dialysis was first reported by Edwards et al 9 in 1972. They presented a case report of a 46-yearold man who suffered multisystems trauma and postoperative acute tubular necrosis. The patient had a known inguinal hernia, which swelled to the size of a soccer ball after 24 hours of acute peritoneal dialysis. At the time of surgery, he was found to have a rupture of the hernia sac, which
was repaired with high ligation of the sac and reconstruction of the posterior wall of the inguinal canal. Acute peritoneal dialysis was resumed 12 hours later for a period of 10 days, with subsequent complete recovery. The patient on CAPO presents an environment that is adverse to healing following inguinal herniorrhaphy. The presence of 2 or more L of dialysate has been shown to increase the intraabdominal pressure by 2.0,2.7, and 2.8 cm of water per liter of intraperitoneal volume in the supine, upright, and sitting positions, respectively. In the vertical position, pressure at the level of the inguinal canal would be 30 cm of water higher than at the xiphoid. IO,11 This increase in pressure should transpose into an increase in tension on a hernia repair. A second factor to consider is the effect of uremia on wound healing. In the rat model, Colin et al 8 showed there was a decrease in the bursting strength of midline abdominal wounds and intestinal anastomoses. A depression on cellular proliferation was demonstrated using radiolabeled fibroblasts, endothelial cells, and mononuclear cells. The combination of these two factors has generated concern as to the time of resumption of CAPO after inguinal herniorrhaphy. There are several limitations of our study. Follow-up is limited by the increased mortality of these patients due to their underlying chronic medical problems. The actuarial survival of our patient population was 80%, 69%, 47%, and 26% at 1, 2, 3, and 4 years, respectively, with an average age of 63 years. This is comparable with the report of the National Institutes of Health CAPO Registry, 12, 13 which reported 1- and 2-year survival rates of 85% and 74% overall, with survival rates of 78% and 63% at 1 and 2 years for those patients over the age of 60. These rates are similar to those found by Nissenson et aI, 14 who reported a 1- and 2-year survival rates of 76% and 60% in those patients over the age of 60. The primary cause of death in these patients is related to coexisting cardiovascular disease, which is present in many of these patients. The other major limitation of the study is that physical examination was not performed on these patients by the investigators. These patients are followed-up in their outlying communities, which creates logistical difficulties. However, in defense of this, the patient who has the subclinical defect
INGUINAL HERNIORRHAPHY IN THE CAPO PATIENT
499
will have rapidly enlarging hernia and not be able to have adequate exchange with peritoneal dialysis. In our study, we have found no recurrences after inguinal hernia repair, including those patients who had resumption of dialysis 24 hours after repair. This is felt to represent no recurrences, since hernias in this patient population rapidly enlarge and become symptomatic. This is in contrast to the report from Wetherington et allO summarizing the experience at the University of Indiana from 1979 through 1983. They reported five inguinal herniorrhaphies in three patients with one recurrence at 10 months after resumption of CAPD. The initial repair had been done 8 weeks before starting peritoneal dialysis. Catheter survival does not seem to be adversely affected by inguinal herniorrhaphy. Only one catheter was removed for peritonitis during the first postoperative year, which is certainly within the overall rate for peritonitis in the general CAPD population of approximately one per 10 patient-months. IS This is logical when one considers the repair of an inguinal hernia is primarily performed in an extraperitoneal fashion. The only time that the sac should be entered is after
the base has been ligated. Five patients were converted to hemodialysis because of inadequate exchange on peritoneal dialysis. The overall rate of conversion to hemodialysis in the general population is 19%16 during the firSt year, which correlates with our experience in this group. We believe peritoneal dialysis can be resumed in the early postoperative period without immediate adverse effects on the inguinal herniorrhaphy. This should favorably affect the postoperative recovery period by negating the need for hemodialysis and possible need for placement of an access device. This is particularly important in our patient population, since many of them live in outlying rural areas across the state without access to a nearby hemodialysis unit. In conclusion, patients on continuous ambulatory peritoneal dialysis are theoretically at high risk for recurrence after inguinal herniorrhaphy. We reviewed all patients on CAPD who underwent inguinal hernia repair at our institution for recurrence. However, since the quality of life is important and is often the underlying reason for selection of CAPD, the data suggest that CAPD can be safely restarted immediately after inguinal herniorrhaphy.
REFERENCES I. Engeset J, Youngson 00: Ambulatory peritoneal dialysis and hernial complications. Surg Clin North Am 64:385-392, 1984 2. O'Connor JP, Rigby RJ, Hardie IR, et al: Abdominal hernias complicating continuous ambulatory peritoneal dialysis. Am J NephroI6:271-274, 1986 3. Nelson H, Lindner M, Schuman ES, et al: Abdominal wall hernias as a complication of peritoneal dialysis. Surg GynecolObstet 157:541-544, 1983 4. Digenis GE, Khanna R, Mathews R, et al: Abdominal hernias in patients undergoing continuous ambulatory peritoneal dialysis. Perit Dial Bull 2:115-117, 1982 5. Tank ES, Hatch DA: Hernias complicating chronic ambulatory peritoneal dialysis in children. J Pediatr Surg 21 :4142, 1986 6. Stone MM, Fonkalsrud EW, Salusky IB, et al: Surgical management of peritoneal dialysis catheters in children: Fiveyear experience with 1,800 patient-month follow-up. J Pediatr Surg 21:1177-1181, 1986 7. von Lilien T, Salusky IB, Yap HK, et al: Hernias: A frequent complication in children treated with continuous peritoneal dialysis. Am J Kidney Dis 10:356-360, 1987 8. Colin JF, Elliot P, Ellis H: The effect of uraemia upon wound healing: An experimental study. Br J Surg 66:793-797, 1979
9. Edwards DH, Gardner RD, Williams DG: Rupture of a hernia sac: A complication of peritoneal dialysis. J Urol 108:255-256, 1972 10. Wetherington GM, Leapman SB, Robison RJ, et al: Abdominal wall and inguinal hernias in continuous ambulatory peritoneal dialysis patients. Am J Surg 150:357-360, 1985 11. Twardowski ZJ, Prowant BJ, Nolph KD, et al: High volume, low frequency continuous ambulatory peritoneal dialysis. Kidney Int 23:64-70, 1983 12. Nolph KD, Cutler SJ, Steinberg SM, et al: Findings from the NIH National CAPD Registry January 1985. Trans Am Soc ArtifIntern Organs 31:333-337, 1985 13. Nolph KD, Cutler SJ, Steinberg SM, et al: Continuous ambulatory peritoneal dialysis in the United States: A threeyear study. Kidney Int 28: 198-205, 1985 14. Nissenson AR, Gentile DE, Soderblom RE, et al: Morbidity and mortality of continuous ambulatory peritoneal dialysis: Regional experience and long-term prospects. Am J Kidney Dis 7:229-234, 1986 15. Sanderson MC, Swartzendruber DJ, Fenoglio ME, et al: Surgical complications of continuous ambulatory peritoneal dialysis. Am J Surg 160:561-566, 1990 16. Diaz-Buxo, JA: Clinical use of peritoneal dialysis, in Nissenson AR, Fine RN, Gentile DE, (eds): Clinical Dialysis. Norwalk, CT, Appleton & Lange, 1990, pp 256-300
A
LTHOUGH PERITONITIS is the most common and the most serious problem in the patient on continuous ambulatory peritoneal dialysis (CAPD), the development of an inguinal hernia has been recognized as a complication, with a reported incidence ranging from 1.5% to 13% in adults l -4 and 11.8% to 36.8% in children. 5-? In a review of five dialysis units with 337 patients, Engeset and Youngson found that inguinal hernias were the most common type, followed closely by incisional hernias. 1 Other reports from Digenis et aV O'Connor et aV and Stone et al 6 show a higher incidence of ventral hernias. Normally, complications from inguinal hernias are rare, but these hernias are progressive in size and can become quite large if left alone. These patients also have the problem of scrotal and lower abdominal tissue fluid accumulation, which can become massive without surgical intervention. CAPO has . several theoretical considerations that can complicate the management of an inguinal hernia. Chronically increased intraabdominal pressure places physical stress on the abdominal wall, which contributes to the high incidence of hernias in general. Chronic renal failure has been shown to impair wound healing through several mechanisms, including a reduction in cellular proliferation at the wound edges and a decrease in the growth offibroblasts. 8 These implications for repair of the hernia are obvious. Controversy regarding the type of hernia repair and the time of resumption of CAPO postoper-
atively continues. We have been unable to discover a series of inguinal hernia repairs in the CAPO patient population; therefore, we present a retrospective review of all inguinal herniorrhaphies performed on patients on CAPO at our dialysis units.
METHODS A retrospective review was performed of all CAPO patients at our dialysis centers undergoing inguinal herniorrhaphy from April 198 I to June 1989. The patient's age, type of repair, duration of renal failure preoperatively, length of time on CAPO postoperatively, and date of resumption of CAPO were recorded. Areview of inpatient and outpatient dialysis charts was performed on all patients. Telephone follow-up was performed on surviving patients. A Kaplan-Meier life-table was generated to evaluate the mortality of this patient population.
RESULTS From April 1981 to June 1989, 30 patients (29 men, one woman) underwent 36 inguinal herniorrhaphies while on CAPO. The average age was 63 years (range, 29 to 83). The etiology of renal failure was diabetic nephropathy in eight patients, nephrosclerosis in eight patients, glomerulonephritis in five patients, and interstitial From the Department ofSurgery, the University of Kansas School of Medicine- Wichita, Wichita, KS. Received February 7, 1992; accepted in revised form July 9, 1992. Address reprint requests to David G. Pauls, MD, Department of Surgery Education, 929 NSf Francis, Wichita, KS 6 72 ]4, © 1992 by the National Kidney Foundation, Inc, 0272-6386/92/2005-0009$3.00/0
American Journal of Kidney Diseases, Vol XX, No 5 (November), 1992: pp 497-499
497
498
PAULS, BASINGER, AND SHIELD
nephritis, renal artery occlusion, amyloidosis, systemic lupus erythematosus, and hypertension in one patient each. Three patients had an unknown etiology for their renal failure. There were 19 indirect hernias, 13 direct hernias, and four with both direct and indirect components. Two hernias, one direct and one indirect, were recurrent from repairs done before initiation of CAPO. Patients had been on dialysis an average of 5 months prior to herniorrhaphy (range, 0 to 31). One half of the patients (15) had a herniorrhaphy performed either at the time of catheter placement or within 2 weeks of catheter placement. One immediate postoperative death occurred secondary to underlying cardiac disease. The actuarial patient survival at 1, 2, 3, and 4 years postrepair was 80%,69%,47%, and 26%, respectively, with 13 patients still alive at the time of the study completion. The mean follow-up for surviving patients was 34 months (range, 16 to 91) and for those deceased was 25 months (range, 1 to 60). The mean age of those patients still alive was 58 years versus 67 years for those patients deceased. Mean catheter survival postoperatively was 16 months (range, 1 to 60). Thirteen of the patients were on CAPO less than 1 year following herniorrhaphy. Reasons for discontinuing CAPO during the first year were conversion to hemodialysis (5), transplantation (4), death (3), and infection (1). Those patients converted to hemodialysis were changed over at 9, 8, 7, 3, and 2 months after herniorrhaphy. No hernia recurrences were identified either by extensive inpatient and outpatient chart review, or by patient telephone contact in all surviving patients. Patients resumed CAPO by postoperative day 1, 7, 14, and 21 in 51 %, 77%, 94%, and 100% ofrepairs. Patients repaired by the Shouldice, McVay, and Bassini methods were immediately restarted on CAPO in 65%, 40%, and 38% of the cases, respectively. DISCUSSION
Inguinal hernia as a complication of peritoneal dialysis was first reported by Edwards et al 9 in 1972. They presented a case report of a 46-yearold man who suffered multisystems trauma and postoperative acute tubular necrosis. The patient had a known inguinal hernia, which swelled to the size of a soccer ball after 24 hours of acute peritoneal dialysis. At the time of surgery, he was found to have a rupture of the hernia sac, which
was repaired with high ligation of the sac and reconstruction of the posterior wall of the inguinal canal. Acute peritoneal dialysis was resumed 12 hours later for a period of 10 days, with subsequent complete recovery. The patient on CAPO presents an environment that is adverse to healing following inguinal herniorrhaphy. The presence of 2 or more L of dialysate has been shown to increase the intraabdominal pressure by 2.0,2.7, and 2.8 cm of water per liter of intraperitoneal volume in the supine, upright, and sitting positions, respectively. In the vertical position, pressure at the level of the inguinal canal would be 30 cm of water higher than at the xiphoid. IO,11 This increase in pressure should transpose into an increase in tension on a hernia repair. A second factor to consider is the effect of uremia on wound healing. In the rat model, Colin et al 8 showed there was a decrease in the bursting strength of midline abdominal wounds and intestinal anastomoses. A depression on cellular proliferation was demonstrated using radiolabeled fibroblasts, endothelial cells, and mononuclear cells. The combination of these two factors has generated concern as to the time of resumption of CAPO after inguinal herniorrhaphy. There are several limitations of our study. Follow-up is limited by the increased mortality of these patients due to their underlying chronic medical problems. The actuarial survival of our patient population was 80%, 69%, 47%, and 26% at 1, 2, 3, and 4 years, respectively, with an average age of 63 years. This is comparable with the report of the National Institutes of Health CAPO Registry, 12, 13 which reported 1- and 2-year survival rates of 85% and 74% overall, with survival rates of 78% and 63% at 1 and 2 years for those patients over the age of 60. These rates are similar to those found by Nissenson et aI, 14 who reported a 1- and 2-year survival rates of 76% and 60% in those patients over the age of 60. The primary cause of death in these patients is related to coexisting cardiovascular disease, which is present in many of these patients. The other major limitation of the study is that physical examination was not performed on these patients by the investigators. These patients are followed-up in their outlying communities, which creates logistical difficulties. However, in defense of this, the patient who has the subclinical defect
INGUINAL HERNIORRHAPHY IN THE CAPO PATIENT
499
will have rapidly enlarging hernia and not be able to have adequate exchange with peritoneal dialysis. In our study, we have found no recurrences after inguinal hernia repair, including those patients who had resumption of dialysis 24 hours after repair. This is felt to represent no recurrences, since hernias in this patient population rapidly enlarge and become symptomatic. This is in contrast to the report from Wetherington et allO summarizing the experience at the University of Indiana from 1979 through 1983. They reported five inguinal herniorrhaphies in three patients with one recurrence at 10 months after resumption of CAPD. The initial repair had been done 8 weeks before starting peritoneal dialysis. Catheter survival does not seem to be adversely affected by inguinal herniorrhaphy. Only one catheter was removed for peritonitis during the first postoperative year, which is certainly within the overall rate for peritonitis in the general CAPD population of approximately one per 10 patient-months. IS This is logical when one considers the repair of an inguinal hernia is primarily performed in an extraperitoneal fashion. The only time that the sac should be entered is after
the base has been ligated. Five patients were converted to hemodialysis because of inadequate exchange on peritoneal dialysis. The overall rate of conversion to hemodialysis in the general population is 19%16 during the firSt year, which correlates with our experience in this group. We believe peritoneal dialysis can be resumed in the early postoperative period without immediate adverse effects on the inguinal herniorrhaphy. This should favorably affect the postoperative recovery period by negating the need for hemodialysis and possible need for placement of an access device. This is particularly important in our patient population, since many of them live in outlying rural areas across the state without access to a nearby hemodialysis unit. In conclusion, patients on continuous ambulatory peritoneal dialysis are theoretically at high risk for recurrence after inguinal herniorrhaphy. We reviewed all patients on CAPD who underwent inguinal hernia repair at our institution for recurrence. However, since the quality of life is important and is often the underlying reason for selection of CAPD, the data suggest that CAPD can be safely restarted immediately after inguinal herniorrhaphy.
REFERENCES I. Engeset J, Youngson 00: Ambulatory peritoneal dialysis and hernial complications. Surg Clin North Am 64:385-392, 1984 2. O'Connor JP, Rigby RJ, Hardie IR, et al: Abdominal hernias complicating continuous ambulatory peritoneal dialysis. Am J NephroI6:271-274, 1986 3. Nelson H, Lindner M, Schuman ES, et al: Abdominal wall hernias as a complication of peritoneal dialysis. Surg GynecolObstet 157:541-544, 1983 4. Digenis GE, Khanna R, Mathews R, et al: Abdominal hernias in patients undergoing continuous ambulatory peritoneal dialysis. Perit Dial Bull 2:115-117, 1982 5. Tank ES, Hatch DA: Hernias complicating chronic ambulatory peritoneal dialysis in children. J Pediatr Surg 21 :4142, 1986 6. Stone MM, Fonkalsrud EW, Salusky IB, et al: Surgical management of peritoneal dialysis catheters in children: Fiveyear experience with 1,800 patient-month follow-up. J Pediatr Surg 21:1177-1181, 1986 7. von Lilien T, Salusky IB, Yap HK, et al: Hernias: A frequent complication in children treated with continuous peritoneal dialysis. Am J Kidney Dis 10:356-360, 1987 8. Colin JF, Elliot P, Ellis H: The effect of uraemia upon wound healing: An experimental study. Br J Surg 66:793-797, 1979
9. Edwards DH, Gardner RD, Williams DG: Rupture of a hernia sac: A complication of peritoneal dialysis. J Urol 108:255-256, 1972 10. Wetherington GM, Leapman SB, Robison RJ, et al: Abdominal wall and inguinal hernias in continuous ambulatory peritoneal dialysis patients. Am J Surg 150:357-360, 1985 11. Twardowski ZJ, Prowant BJ, Nolph KD, et al: High volume, low frequency continuous ambulatory peritoneal dialysis. Kidney Int 23:64-70, 1983 12. Nolph KD, Cutler SJ, Steinberg SM, et al: Findings from the NIH National CAPD Registry January 1985. Trans Am Soc ArtifIntern Organs 31:333-337, 1985 13. Nolph KD, Cutler SJ, Steinberg SM, et al: Continuous ambulatory peritoneal dialysis in the United States: A threeyear study. Kidney Int 28: 198-205, 1985 14. Nissenson AR, Gentile DE, Soderblom RE, et al: Morbidity and mortality of continuous ambulatory peritoneal dialysis: Regional experience and long-term prospects. Am J Kidney Dis 7:229-234, 1986 15. Sanderson MC, Swartzendruber DJ, Fenoglio ME, et al: Surgical complications of continuous ambulatory peritoneal dialysis. Am J Surg 160:561-566, 1990 16. Diaz-Buxo, JA: Clinical use of peritoneal dialysis, in Nissenson AR, Fine RN, Gentile DE, (eds): Clinical Dialysis. Norwalk, CT, Appleton & Lange, 1990, pp 256-300
