Immediate Dialysis After Simultaneous Laparoscopic Peritoneal Dialysis Catheter Placement and Laparoscopic Inguinal Hernia Repair

Abstract

Background and Objectives:

Peritoneal dialysis (PD) is an accepted renal replacement therapy for end-stage renal disease (ESRD). Managing inguinal hernia in patients with PD is not standardized. Thus, this study reported the outcomes of simultaneous laparoscopic peritoneal dialysis catheter (PDC) placement and transabdominal preperitoneal (TAPP) repair of inguinal hernia.

Methods:

Thirteen patients with chronic renal disease and inguinal hernia attending a tertiary hospital between May 1, 2016 and June 30, 2021 were evaluated for laparoscopic PDC placement. Concurrent laparoscopic inguinal herniorrhaphy and laparoscopic PDC placement were performed. Dialysate fluid was measured intraoperatively to the level below the incised peritoneum by 1 inch. The inflow and outflow was smooth without leakage. The amount was increased gradually in the two weeks after regular PD was obtained.

Results:

Laparoscopic PDC was inserted for 13 patients. Ten patients had unilateral hernia and two had bilateral inguinal hernia. Associated paraumbilical hernia was discovered in two patients. The median follow-up was 30 months. The measured safe amount of dialysate fluid intraoperatively was 400 – 600 mL. There was no death, intraoperative complication, or dialysate leakage. Three PDCs were removed owing to noncompliance. No hernia recurrence was observed.

Conclusion:

Simultaneous laparoscopic PDC placement and laparoscopic repair of inguinal hernia with immediate dialysis is a safe and feasible surgical technique. Utilizing minimally invasive surgery affords PDC placement and inguinal hernia repair simultaneously.

INTRODUCTION

Pre-existent hernia in patients with end-stage renal disease (ESRD) may be repaired before or at the time of peritoneal dialysis catheter (PDC) placement.^1–3 The high prevalence of inguinal hernias has been reported in patients before or while undergoing PDC placement.^1,4 It is important to examine and repair a hernia before initiating peritoneal dialysis (PD). However, occult inguinal hernia is difficult to diagnose clinically or radiologically.^5,6 Furthermore, the occurrence of inguinal hernias can cause serious complications after PD initiation.^2,7–9

Regular daily PD in patients with ESRD with a weak abdominal wall increases intra-abdominal pressure, which may contribute to the formation of new hernia and may provide insight regarding occult hernia.^1,10 Indeed, the occurrence of inguinal hernia in PD may lead to complications such as hernia obstruction, strangulation, hydrocele bowel obstruction, and dialysate leakage.^1,2,11 Hence, surgeons should examine patients for hernia and repair them before initiating PD.³

The laparoscopic placement of PDC is well documented.^3,12 Laparoscopic identification of occult inguinal hernia with simultaneous open inguinal hernia repair reported promising outcome.¹⁰ Thus, we reported the first simultaneous laparoscopic placement of PDC and laparoscopic inguinal hernia repair with immediate use of PD.

MATERIALS AND METHODS

This single-center retrospective study was conducted at a university hospital. All patients with ESRD booked for laparoscopic PDC placement between May 1, 2016 to June 30, 2021 were screened. All patients were examined for abdominal wall hernia. Patients with abdominal wall hernia who underwent simultaneous laparoscopic PDC placement and laparoscopic inguinal hernia repair were included in this study. Patients with only ventral hernia were excluded. All patients were educated about peritoneal dialysis. Informed consent for laparoscopic PDC placement and laparoscopic inguinal hernia repair was obtained. A prophylactic antibiotic was administered upon induction. Moreover, the position of the PDC was confirmed postoperatively with abdominal x-ray for position documentation and following hospital policy. The study was approved by the institutional review board committee.

Operative Technique

The patient was placed in the supine position and incisions for PDC and hernia were made as shown in (Figure 1). The procedure was performed by marking the sites of entrance and exit of PDC. The inguinal hernia was repaired using transabdominal preperitoneal (TAPP) technique. The exact technique was documented by this study's first author in a previous publication.¹³ The site of entrance of the catheter was proximal to the peritoneal flaps (Figure 2). The proper positioning of the PDC was ensured before initiating intraoperative peritoneal dialysis. The technique of PDC placement was described previously.¹⁴ The inflow and outflow of the dialysate fluid were repeated, and the amount infused at levels below the peritoneal fluid by inch were measured (Figure 3). The procedure was conducted with the PD nurse who was instructed about the amount that could be reached without dialysate leakage. The intraoperative dialysate fluid measured 400 – 600 mL in our study with an average of 480 mL. Postoperatively, the amount of dialysate fluid increased gradually until the target level within 10 days. Patients were instructed to be in a supine position during the dialysis sessions for the first 10 days.

Figure 1.

Illustration of laparoscopic ports placement sites and dialysis catheter inlet in simultaneous laparoscopic peritoneal dialysis catheter placement and transabdominal preperitoneal repair of inguinal hernia in patients with (A) Right inguinal hernia, (B) Left inguinal hernia, and (C) Bilateral inguinal hernia. C, Camera port; W1, working port 1; W2, working Port 2; W3, working port 3; U, umbilicus, A; entry site of peritoneal dialysis catheter; B, exit site of peritoneal dialysis catheter.

Figure 2.

Intra-abdominal illustration of dialysis catheter inlet, peritoneal flap incision and dialysate fluid level.

Figure 3.

Laparoscopic view of dialysis catheter inlet, peritoneal flap, and dialysate fluid level.

RESULTS

Between May 1, 2016 and June 30 2021, 91 patients underwent laparoscopic PDC placement, and among them 13 patients (14.3%) were discovered to have inguinal hernia. All the patients underwent simultaneous laparoscopic PDC placement and laparoscopic inguinal hernia repair. Baseline patient demographics are shown in Table 1. The mean age of the patients was 55 (± 9.79) years, and only one patient was female. Twelve patients were diagnosed as having inguinal hernia pre-operatively. One patient was discovered with inguinal hernia intraoperatively. Ten patients had unilateral hernia and two patients had bilateral inguinal hernia. Associated paraumbilical hernia was discovered in two patients. The median follow-up time was 29.5 months (interquartile range [IQR] 22.1 – 42.3).

Table 1.

Baseline Demographics

	Number (n = 13)	Percentage
Age* (years)	55	± 9.79
Medical comorbidities
Diabetes mellitus	5	38.5%
Hypertension	10	77%
Respiratory diseases	5	38.5%
IHD/heart failure	5	38.5%
Hypothyroidism	2	15.4%
Others	6	46.2%
ASA score
II	1	7.7%
III	11	84.6%
IV	1	7.7%
Hernia type
Unilateral inguinal	10	77%
Bilateral inguinal	2	15.4%
Associated PUH	2	15.4%
Removal of PDC	3	23.1%
Follow-up** (in months)	29.5	(22.1 – 42.3)

Abbreviations: IHD, Ischemic heart disease; ASA, American Society of Anesthesiology; PUH, paraumbilical hernia; PDC, Peritoneal dialysis catheter.

^*Data are presented as mean (SD, standard deviation).

^**Data are presented as median (interquartile range [IQR]).

No complications were observed 90 days postoperatively. Three patients were not compliant with peritoneal dialysis, and thus, the PDC was removed. There was no hernia recurrence during follow-up.

DISCUSSION

PD is a strategy for renal replacement in patients with ESRD. It achieves a survival rate comparable to hemodialysis while preserving residual renal function. Home and overnight PD are cost-effective choices for renal dialysis.¹⁵ PD is advantageous for working people, older patients, and individuals who are handicapped because of decreased hospital visits.¹⁶ Furthermore, the recent COVID-19 outbreak, which caused the shutdown of transport and increased the demands on hospital services, highlighted the need for home dialysis, and PD was the most suitable for home dialysis.^16,17

The occurrence of inguinal hernia during PD may lead to a temporary shift to hemodialysis. Furthermore, the development of serious complications can occur after initiating PD, such as intestinal obstruction or strangulation.^7,8,15 Encouraging hernia orifice examination and treatment is essential before PDC placement. In this study, all patients with ESRD who were scheduled for PDC placement were examined for hernia by the primary surgeon. PDC was inserted laparoscopically, and inguinal hernia was repaired laparoscopically at the same operation. This could lead to avoiding expensive investigations, complications, and additional operation. Moreover, initiating PD immediately after placement with measuring the appropriate and safe amount of dialysate fluid avoids dialysate leakage and the need for bridging hemodialysis.

The poor tissue condition of patients with chronic renal failure may explain the high incidence of inguinal hernia. Old age, high body mass index, and history of abdominal operations are risk factors for hernia development.^18,19 Moreover, the incidence of inguinal hernia is 4% – 14% in patients with PD, while the incidence in the general population is 1.5%.^18–20 In the absence of a consensus regarding the management of inguinal hernia in patients with a plan of PDC placement and our unit experience in laparoscopic TAPP inguinal hernia repair and laparoscopic PDC placement, encourages us for a simultaneous procedure while measuring the initial amount of dialysate fluid to avoid leakage and safe commencement of PD immediately.

A study on managing open inguinal repair and PDC placement has been conducted.^10,21 Kou et al. reported diagnosis of inguinal hernia using laparoscopic approach with open inguinal hernia repair.¹⁰ However, in our study, laparoscopic PDC placement and laparoscopic inguinal hernia repair was performed utilizing a 1-cm incision and three incisions of 5-mm size. This eliminates two admissions and operations and reduces cost and risk of anesthesia. Moreover, the technique was performed laparoscopically with immediate dialysis, ensuring the merits of the minimal invasive technique.

Hernia recurrence in simultaneous repair with PDC placement was 11% reported by Nicholson et.al.21 There was no hernia recurrence reported in open approach of PDC placement and modified Lichtenstein repair of inguinal hernia.²² In our study, laparoscopic approach was used in both PDC placement and inguinal hernia repair with no hernia recurrence. The rate of new-onset hernia was 36% in the Gracia Urena series and 22% in the study by Horvart et al.^23,24 No new-onset hernia was observed during the follow up of the present study. This could be related to proper exploration and laparoscopic diagnosis of inguinal hernia and repairing of occult hernia.

Occult hernia is asymptomatic hernia not detected on physical examination.²⁵ Vanden Heasy et al. noted that a ≤ 2-cm sac will not allow herniation in the general population. Furthermore, the size of a hernia defect is important in symptomatic inguinal hernia.²⁶ We had one case of occult hernia and 7.1% cases were observed by Kou et al. in another study.¹⁰ Furthermore, radiological diagnostic methods such as ultrasound and computed tomography are expensive procedures with a high false-negative ratio.^5,6 Additional investigation will be waived by laparoscopy.¹⁰ In the described technique, two 5-mm incisions were made for unilateral inguinal hernias and three 5-mm incisions for bilateral inguinal hernias.

In the reported technique, no dialysis leakage was encountered. However, three patients had dialysate leak in a study reported by Nicholson,²¹ and four weeks' interruption of PD after placement was reported in the study by Gracia Urena et al.²³ There is a recommendation for avoiding dialysate leakage.^27,28 Low-volume exchanges for two weeks was recommended by the European best practice guidelines.²⁷ Furthermore, Yang et al. found no difference in dialysate leakage between early and late dialysis.²⁸ In the study, the amount of dialysate fluid was measured when fluid reached the distal level to the inlet of the PDC and by 1 inch to cut peritoneal surface. The amount of dialysate fluid measured to be around 400 – 600 mL in our study with an average of 480 mL. This technique was conducted with the PD nurse who continued this plan until regular peritoneal dialysis was attained. This amount of dialysate fluid was highlighted by Kou et al. as the safe amount that will not cause dialysate leakage.¹⁰ The successful continuation of PD with the absence of complications and hernia recurrence encouraged us to adopt this technique.

Radiological confirmation of PDC was performed for all our patients. This practice is for baseline catheter position and following our hospital policy. However, none of our patients required reintervention after imaging. Post operative surgical PDC placement confirmation has limited clinical significance and no clinical guideline recommend routine imaging.^29,30 However, imaging guidance and catheter position confirmation recommended following percutaneous catheter placement techniques.⁷

The limitations of the current study included its retrospective nature, limited number of patients, and absence of a control group. A prospective study with longer follow-up and a larger sample size is required.

CONCLUSION

PD was safely used immediately after simultaneous laparoscopic PDC placement and laparoscopic inguinal hernia repair. Using this technique resulted in avoidance of PD interruption and need for temporary HD. There was no hernia recurrence during the follow-up time.