Incisional hernia repair in patients of CAPD: Optimizing outcomes based on the new SAGES guidelines

Brian P Rose, MS, MPH, F A Morfesis, MD. Owen Drive Surgical Clinic of Fayetteville, PLLC

Introduction: The use of a mesh material for the repair of incisional hernias in high-risk patients is often debated. To date, numerous products and techniques exists for the repair of such abdominal wall hernias. Patients on continuous ambulatory peritoneal dialysis (CAPD) represent a unique sub-group of these high-risk patients in which definitive treatment of their hernia is implicit to maintaing outpatient CAPD therapy. In this case series, we describe our institutions experience with hernia repair in CAPD patients based upon the recent SAGES guidelines for Peritoneal Dialysis Access Surgery.

Methods: PD patients who presented with a primary or incisional (trocar site) defect were offered elective open repair using a biologic graft of surgeon choice. The biologic grafts utilized include Strattice (acellular porcine dermis), Permacol (cross-linked porcine dermis), and XenMatrix (cross-linked porcine dermis). Upon repair of the abdominal wall defect, patients were placed on hemodialysis for variable periods. Retrospective chart review was then conducted.

Results: N=2 patients underwent repair with acellular porcine dermis, both of which returning to peritoneal dialysis post-repair (mean 9.2 weeks). N=1 patients underwent repair using a heavily cross-linked porcine dermis without complication and also was able to resume peritoneal dialysis readily (7 weeks). This patient has since had n=2 recurrences requiring further surgery using a non-cross linked acellular dermal product (post renal transplantation). Lastly, n=1 patient underwent repair utilizing a moderately cross-linked porcine dermis and developed an enterocutaneous fistula (EC), however this only required bowel rest, not explantation of the allograft. This patient was continued on hemodialysis only.

Conclusions: This small, long-term case series is consistent with the recommendations put forth by SAGES suggesting that concomitant hernias should be fixed timely in CAPD patients in order for those patients to minimize risks of dialysate leak, thus no longer making them acceptable candidates for therapy.

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