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The cumulative incidence of herniae among CAPD patients is 10-15% with inguinal (23%), exit site (19%) and umbilical (19%) predominating. The mean time for development is one year with an annual increased risk of 20% for each year on PD. The paramedian approach to catheter placement has reduced the incidence of exit site and incisional herniae.
Risk factors:
- Older patients
- Time on PD
- Previous hernia repair
- Previous laparotomies
- Polycystic kidneys
- Intra-abdominal masses
- Collagen diseases
- Obesity
- Small body size
- Malnutrition
Diagnosis. The clinical manifestations are painless swelling at the site of herniation. The presence of tenderness, Gram negative peritonitis, bowel obstruction or perforation suggest incarceration and/or bowel strangulation.
Prevention and Treatment. To reduce the risk of herniae, it is best to avoid catheter placement over the linea alba and instead use a paramedian approach with insertion through the rectus muscle. Infusion of high volumes of dialysate should be delayed until the catheter has completely healed. If PD start is mandatory, the use of reduced volumes in the supine position are recommended.
Large ventral herniae offer little risk of bowel incarceration but are prone to enlarge. Small herniae offer higher risk of bowel strangulation and should be promptly repaired. Traditional surgical techniques are used to repair the hernia, including reinforcement of the abdominal wall with polypropylene mesh whenever necessary.
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