Can a patient with a small abdominal hernia be a candidate for peritoneal dialysis (PD)?

Small Abdominal Hernia and Peritoneal Dialysis Candidacy

A patient with a small abdominal hernia can be a candidate for peritoneal dialysis, but the hernia should ideally be repaired before initiating PD to prevent complications, technique failure, and the need for emergency surgery. 1, 2

Understanding the Contraindication Framework

The NKF-K/DOQI guidelines distinguish between absolute and relative contraindications for PD related to hernias 1, 2:

• Absolute contraindication: Only "surgically irreparable hernias" that cannot be corrected are absolute contraindications 1, 2
• Small, repairable hernias: These fall into a manageable category where surgical correction enables safe PD 1, 3

The key distinction is correctability—if the hernia can be surgically repaired, it does not permanently exclude the patient from PD 1, 2.

Why Hernias Matter in PD

The increased intra-abdominal pressure from dialysate infusion (typically 2-3 liters) exacerbates any existing structural defects 1:

• Hernias can trap dialysate in the hernia sac, preventing effective contact with the peritoneal membrane and impairing dialysis efficiency 1
• The mechanical stress increases risk of incarceration and strangulation 4, 5
• Hernias are associated with peritoneal leaks, which compromise dialysate drainage and increase infection risk 1

Optimal Management Strategy

Pre-PD Hernia Repair (Preferred Approach)

Repair all detected hernias before PD catheter insertion 3, 4, 5:

• Systematic pre-PD screening identifies hernias in approximately 10-20% of candidates 3, 4
• Elective repair before starting PD eliminates the risk of hernia-related PD failure 3, 5
• In one series, 9 patients who had hernias repaired before PD had zero recurrences during dialysis 3
• Patients can safely start PD after adequate healing (typically 4-6 weeks post-repair) 5

Simultaneous Repair and Catheter Placement

One-stage surgery (hernia repair + PD catheter insertion) is a safe alternative 6:

• A prospective study of 23 patients showed 96% catheter survival with no hernia recurrences 6
• PD flushing can begin on postoperative days 1-3 6
• This approach avoids delaying dialysis initiation in patients with urgent need 6

Surgical Technique Considerations

Use tension-free mesh repair techniques 7, 6:

• Anterior tension-free mesh or plug repair under local anesthesia is safe and effective in PD patients 7
• Synthetic mesh can be used in clean surgical fields (CDC Class I) without increased infection risk 1
• Open alloplastic procedures have low recurrence rates in this population 3

If PD Must Start Before Hernia Repair

When dialysis cannot be delayed and the hernia is small 5:

• Use low-volume exchanges initially (reduce from standard 2-3L to 1-1.5L) 5
• Plan elective hernia repair as soon as medically feasible 4, 5
• Monitor closely for signs of incarceration (pain, inability to reduce, bowel obstruction symptoms) 4
• Consider temporary hemodialysis postoperatively to allow optimal wound healing 5

Critical Pitfalls to Avoid

Do not ignore pre-existing hernias 4, 5:

• Attempting PD with an unrepaired hernia leads to 17% hernia complication rate in CAPD patients 5
• Incarceration occurs in approximately one-third of untreated hernias during PD 4

Do not attempt primary tissue repair in PD patients 3, 7:

• Two of four patients who had simple herniorrhaphy without mesh had recurrences 5
• The metabolic derangements of uremia impair wound healing and tensile strength 5

Do not delay repair of hernias that develop during PD 4:

• Median time to hernia development during PD is 12.5 months 3
• Elective repair prevents emergency surgery for incarceration 4

Risk Factors for Hernia Development During PD

Monitor patients with these characteristics more closely 3, 5:

• History of previous abdominal surgery or pre-dialysis hernias 5
• Higher BMI (median 27 in patients who developed hernias) 3
• Female sex (2:1 female-to-male ratio) 3
• Larger dialysate volumes 8
• History of peritoneal leaks or peritonitis 5

Bottom Line for Clinical Decision-Making

For a patient with a small abdominal hernia being considered for PD: Proceed with PD candidacy, but schedule elective hernia repair before catheter insertion whenever possible 3, 4. If dialysis is urgently needed, simultaneous repair and catheter placement is safe 6. The hernia itself does not disqualify the patient—only irreparable hernias are absolute contraindications 1, 2.