Myth 5: Mesh Hernia Repair in the Peritoneal Dialysis Patient Is Associated With High Mesh Infection Rates and Requires Avoiding or Discontinuing Peritoneal Dialysis. Prevalent Peritoneal Dialysis Patients Undergoing Mesh Hernia Repair Should be Converted Temporarily or Permanently to Haemodialysis
The incidence of wound infection after inguinal and femoral mesh hernia repair in the general population is between 0.03 and 1.56%.[18–21] However, the mesh infection rate in peritoneal dialysis patients is unknown. We were unable to find any report of mesh infection with peritoneal dialysis after hernia repair. Most reports of mesh hernia repair in peritoneal dialysis patients have been small case series with variable follow-up periods (Table 1). Many did not specifically report on mesh infection.[22,23]
Different surgical approaches have been used for mesh repair: open versus laparoscopic; extra/preperitoneal retro-rectus mesh placement with minimal breach of the peritoneum versus intraperitoneal onlay mesh placement with exposure of the mesh to the peritoneal cavity; with or without simultaneous peritoneal dialysis catheter placement. Mesh infection rates are assumed to be higher with intraperitoneal compared with preperitoneal mesh placement, especially in the initial period before neoepithelialization of the mesh, which presumably forms a barrier against mesh infection, but randomized controlled trials comparing the two approaches are lacking. Similarly, mesh infection rates for ventral and umbilical hernia mesh repairs in peritoneal dialysis patients, as opposed to inguinal repairs, are unknown.
Reports suggest that the risk of mesh infection is very low with extra/preperitoneal mesh placement, even with early resumption of peritoneal dialysis after surgery. Martinez-Mier et al. reported only one wound infection amongst 58 hernia repairs but did not state if this was a mesh infection. In fact, they recommended the use of mesh because hernioplasties without mesh carried a 12% hernia recurrence. They restarted low volume peritoneal dialysis within 72 h postoperatively in 96.5% of their hernioplasties. Of 47 patients followed up for 2–45 months, none had mesh infection. Continuing low volume peritoneal dialysis perioperatively or restarting peritoneal dialysis 2–10 days postoperatively has been practiced without mesh infection over follow-up periods of up to 21, 39 and 56 months.[26–28] Shah et al. resumed intermittent peritoneal dialysis 48 h postoperatively in 20 elective mesh hernia repairs with no mesh infection over a mean follow up of 33 months.
Sodo et al. performed 26 simultaneous inguinal or umbilical mesh hernia repairs and peritoneal dialysis catheter insertions in 21 incident ESRD patients and started peritoneal dialysis 3 weeks later. There were no mesh infections over a follow-up of 342–1274 days. Reviews of mesh hernia repair did not cite peritoneal dialysis as a risk factor for mesh infection.[31,32]
Mesh infection secondary to peritonitis is a concern, especially for intraperitoneal mesh hernia repair. However, Schoenmaeckers et al. reported a remarkable case of laparoscopic ventral incisional hernia repair wherein a large 30 × 20 cm e-PTFE mesh was documented to be neoepithelialized 6 months after surgery at the laparoscopic insertion of a peritoneal dialysis catheter at a lateral site away from the mesh. The mesh remained uninfected despite a first episode of peritonitis 3 months later that required peritoneal dialysis catheter removal and reinsertion, and a second episode of peritonitis 10 months after restarting peritoneal dialysis that again required peritoneal dialysis catheter removal and reinsertion. The mesh was left in place throughout as there were no signs of mesh infection. Neoepithelialization of intraperitoneally implanted mesh is present by 2 weeks and well developed by 1 month postsurgery. In the latter report, the neoepithelium was protective against mesh infection in five nonperitoneal dialysis patients with intraperitoneal infection. Adhesions are common after intraperitoneal mesh hernia repair and the incidence of dense adhesions ranged from 6 to 39%.[33,34] During adhesiolysis, the integrity of the neoepithelium should be preserved to avoid infection of the underlying mesh.
Published reports from 1994 to 2015 (Table 1,[22–30]), document at least 130 mesh hernia repairs in peritoneal dialysis patients with no report of mesh infection despite a few episodes of peritonitis,[24,25] but cases of mesh infection with peritoneal dialysis in other centres may not have been reported. The true incidence of mesh infection in peritoneal dialysis patients remains unknown but the available data suggest that it is very low in elective repairs. Early postoperative resumption of peritoneal dialysis appears safe, especially with preperitoneal mesh repair, and conversion to haemodialysis is not routinely required even in anuric patients. For intraperitoneal mesh repair with e-PTFE mesh, the evidence favours waiting for a month to allow complete neoepithelialization before starting peritoneal dialysis.
Curr Opin Nephrol Hypertens. 2016;25(6):602-608. © 2016 Lippincott Williams & Wilkins