Incisional Hernia After Corrective Omentectomy for Peritoneal Dialysis Catheter Malposition

Joon Ho Song, Kyoung Joo Lee, Seoung Woo Lee, Moon-Jae Kim
From: Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University College of Medicine, Inchon City, Korea.

Key words

Introduction

Various hernia types have been reported to develop in 9% – 24% of continuous ambulatory peritoneal dialysis (CAPD) patients (1). The incidence of incisional hernia ranges between 1.8% and 17.1% after open dissection for PD catheter implantation (2–7). Laparotomic correction is occasionally required to relieve malposition of PD catheters. Because no data are available on the incidence of incisional hernia after laparotomy to correct PD catheter malposition, we reviewed the incidence and clinical course of incisional hernia following laparotomic PD catheter correction with and without omentectomy.

Patients and Methods

We collected 4617 patient–months of data on 148 patients who started CAPD in Inha University Hospital Kidney Center from January 1996 to December 1998. Patients with hernia at the time of PD catheter implantation, those with liver cirrhosis, and those with malignancy were excluded. Straight, double-cuff Tenckhoff catheters (CPD-12042: Bard Canada Inc., Mississauga, ON, Canada) were implanted by non open-dissection technique using a trocar at the paramedian site in all patients. Deep cuffs were placed within the rectus muscle and fastened using 4 purse-string sutures. Our institute’s method of initiating CAPD has been previously described (8).
When PD catheter malposition occurred with malfunction and was not rectified after fluoroscopic correction, laparoscopic (peritoneoscopic) correction was initially recommended whenever available. When laparoscopic correction failed or was not available, laparotomic correction was used.
With the patient under general anesthesia, one senior surgeon opened the skin through a 3 – 5 cm midline incision below the umbilicus. The peritoneal cavity was opened through the linea alba. Omentectomy was performed when omentum adhered tightly or densely to the PD catheter and partial excision was inevitable for stripping, when the omentum was large enough to fill the pelvic cavity, or when migration of the PD catheter had recurred after fluoroscopic or laparoscopic correction. After catheter repositioning and omentectomy if indicated, the opening was closed with interrupted or continuous layered polyglycolide-lactide polymer sutures. Dialysis was resumed on the third or fourth day after laparotomy with an initial infusion volume of 500 mL. Dialysate volume and dwell time were gradually increased to standard protocol over one or two weeks.

Statistical analysis
Contingency tables were analyzed using the chi-square test. Continuous variables were analyzed using the Student t-test. Statistical significance was assumed at a p value of less than 0.05.

Results

Subject characteristics, and incidence and clinical course of hernias
The mean follow-up period was 40 ± 15 months. The 148 patients included 91 men (61.5%) and 57 women. Patients ranged in age from 16 years to 64 years. During the 4617 patient–months of follow-up, 36 cases of PD catheter malposition associated with malfunction occurred in 33 patients (22.3%). Blind or fluoroscopic maneuvers failed to correct the malposition in 26 patients. Nine patients initially underwent laparoscopic correction, but 3 of these had to undergo laparotomy because of recurrent malposition with malfunction. Seventeen patients initially underwent laparotomic correction because peritoneoscopy was not available. In all, 20 of 148 patients underwent laparotomic correction, with 11 patients undergoing simultaneous omentectomy for the indications described in “Patients and methods.” Laparotomic corrections were performed between 4 days and 12 days after catheter implantation (Table I).
During the follow-up period, 2 inguinal hernias and 1 umbilical hernia occurred in patients with non laparotomic correction. Hernia related to catheter implantation site occurred in none of the subjects. Incisional hernia occurred in 6 of 20 patients (30%) undergoing laparotomic correction. The incidence was significantly higher in the patients with omentectomy: 5 of 11 (45.5%) as compared with 1 of 9 without omentectomy (11.1%, p < 0.05).
All patients with incisional hernia were multiparous obese women (Table II). Laparotomy had been performed at least 6 days after catheter implantation. Of the 6 patients, 5 had undergone omentectomy. Hernia repair was performed at 7.2 ± 0.9 months after laparotomy (range: 5 – 11 months). Eventually, 3 patients gave up CAPD because of leakage (through the herniorrhaphy site in 1 patient and relapse of the incisional hernia in 2 patients). Failure of CAPD occurred most frequently in patients undergoing laparotomic correction with omentectomy (36.4%) as compared with those without laparotomic correction (7.8%, p < 0.05, Table I).

Clinical characteristics related to the development of incisional hernia
We compared clinical characteristics according to the development of incisional hernia in patients undergoing laparotomic correction (Table III). The patients with incisional hernia were all female and high-parity as compared with those without incisional hernia (p < 0.05). The presence of diabetes, obesity, and previous pericatheter leakage were not different. Laparotomy tended to be performed later in the patients showing incisional hernia. Omentectomy had been performed in 5 of 6 patients (83.3%) with incisional hernia and in 6 of 14 patients (42.9%) without incisional hernia (p < 0.05). The follow-up period was shorter in the patients showing incisional hernia because of CAPD failure.
When the same characteristics were compared among the 11 patients undergoing omentectomy, the patients with incisional hernia (n = 5) showed high parity (2.4 ± 0.2 vs 0.5 ± 0.3, p < 0.05) and tended to have had the laparotomy performed at later time (9.5 ± 1.2 days vs 6.8 ± 0.7 days).

Discussion

Hernia is an important hindrance to CAPD. It has been reported to develop in 9% – 24% of patients, in a variety of locations [umbilical, inguinal, ventral, PD catheter insertion site, or incisional hernia (1)]. The most common is incisional hernia is through the PD catheter implantation site (6,9). The literature contains several reports describing incidences of incisional hernia ranging between 1.8% and 17.1% after open dissection for PD catheter implantation (2–7).
Although some authors recommend routine partial omentectomy at the time of catheter implantation as a means of improving long-term catheter survival (10,11), others perform omentectomy during laparotomic PD catheter correction only when necessary. No data are currently available on the incidence of incisional hernia following laparotomic PD catheter correction with and without omentectomy. In our study, the incidence of incisional hernia was 11.1% after laparotomy for PD catheter malposition without omentectomy. This result is average when compared with the incidence after open dissection for PD catheter implantation (Table IV). The incidence increased to 30% when patients undergoing omentectomy were included. Furthermore, incisional hernia developed in nearly half of patients undergoing laparotomy with omentectomy, suggesting that omentectomy may predispose to incisional hernia during laparotomy for PD catheter correction.
The development of incisional hernia appears to be due to several factors, including previously weakened incision tissue, poor healing, and increased intra-abdominal pressure. Midline incision during PD catheter implantation establishes a predilection for incisional hernia: it is well known that the change from midline to paramedian incision resulted in a significant reduction in the incidence of incisional hernia (5,7). The problem is that a midline incision is usually inevitable during laparotomy for PD catheter correction, because the paramedian site has already been used for PD catheter implantation in most cases.
Initiation of CAPD with increasing dialysate volume may cause concealed dialysate leakage and weakening of the tissue of the abdominal wall, including the aponeurosis and fiber of the linea alba. An incision during at this time provides a poor condition for healing and a risk for incisional hernia (6). A larger incision for omentectomy and subsequent injury to the preperitoneal lining may also additively increase the risk of incisional hernia. The overall situation inevitably encountered during laparotomic PD catheter correction with omentectomy seems to increase the risk of incisional hernia.
Predisposing factors of the development of hernia are older age, female sex, multiparity, obesity, previous hernia repair, and early pericatheter dialysate leakage (7). In our institute, where PD catheters are implanted by non dissection technique using a trocar at the paramedian site, a new laparotomy site for PD catheter correction provides a locus for incisional hernia. After laparotomic correction, female sex, parity, and omentectomy predisposed to the development of incisional hernia. A later time of laparotomy also seems to be related to incisional hernia.
Although the present study is insufficiently powered to confirm the results, the incidence of incisional hernia is unquestionably high after laparotomic omentectomy for PD catheter correction. A prospective study with a large number of subjects is required to confirm whether omentectomy is actually an independent risk factor for incisional hernia. Further evaluation is also required concerning whether incisional hernia occurs more frequently when omentectomy performed after a period on CAPD as compared with when it is performed preventively at the time of PD catheter implantation.

Conclusion

Our experience suggests that incisional hernia is prevalent following laparotomic PD catheter correction, especially when omentectomy is simultaneously performed. Therefore, laparotomic omentectomy should be performed as a last resort for correction of PD catheter malposition.

References

1. Bargman JM. Noninfectious complications of peritoneal dialysis. In: Gokal R, Nolph KD, eds. The Textbook of Peritoneal Dialysis. 1st edition. Boston: Kluwer Academic Publishers; 1994: 555–90.
2. Rubin J, Raju S, Teal N, Hellems E, Bower JD. Abdominal hernia in patients undergoing continuous ambulatory peritoneal dialysis. Arch Intern Med 1982; 142:1453–5.
3. Olcott C, Feldman CA, Coplon NS, Oppenheimer ML, Mehigan JT. Continuous ambulatory peritoneal dialysis: technique of catheter insertion and management of associated surgical complications. Am J Surg 1983; 146:98–102.
4. Engeset J, Youngson GG. Ambulatory peritoneal dialysis and hernial complications. Surg Clin North Am 1984; 64:385–92.
5. Spence PA, Mathews RE, Khanna R, Oreopoulos DG. Improved results with a paramedian technique for the insertion of peritoneal dialysis catheters. Surg Gynecol Obstet 1985; 161:585–7.
6. O’Connor JP, Rigby RJ, Hardie IR, et al. Abdominal hernias complicating continuous ambulatory peritoneal dialysis. Am J Nephrol 1986; 6:271–4.
7. Apostolidis NS, Tzardis PJ, Manouras AJ, Kostenidou MD, Katirtzoglou AN. The incidence of postoperative hernia as related to the site of insertion of permanent peritoneal catheter. Am J Surg 1988; 54:318–9.
8. Song JH, Kim GA, Lee SW, Kim MJ. Clinical outcomes of immediate full-volume exchange one year after peritoneal catheter implantation for CAPD. Perit Dial Int 2000; 20:194–9.
9. Griffin PJA, Coles GA. Strangulated hernias through Tenckhoff cannula sites. Br Med J (Clin Res Ed) 1982; 284:1837.
10. Nicholson ML, Burton PR, Donnelly PK, Veitch PS, Walls J. The role of omentectomy in continuous ambulatory peritoneal dialysis. Perit Dial Int 1991; 11:330–2.
11. Reissman P, Lyass S, Shiloni E, Rivikind A, Berlatzky Y. Placement of a peritoneal dialysis catheter with routine omentectomy: does it prevent obstruction of the catheter? Eur J Surg 1998; 164:703–7.

Corresponding author:

Moon-Jae Kim, md phd, Director, Kidney Center, Inha University Hospital, 7–206 3rd Street, Sinhung-Dong, Jung-Gu, Inchon City 400-103 Korea.