Abstract
Editor
We describe the case of a 60-year-old man with established renal failure secondary to IgA nephropathy. After a brief period on peritoneal dialysis, the patient received a cadaveric renal transplant at age 47. Thirteen years later, declining allograft function led to the requirement for alternative renal replacement therapy and Tenckhoff catheter insertion was arranged. The catheter was inserted via a 5-cm right lower paramedian incision. This technique does not permit direct visualization of the pelvis, but allows the operator to confirm that the catheter has passed inferiorly. Omental adhesions were palpated during insertion. Automated peritoneal dialysis was commenced but, after instilling 150 mL of dialysate, it became impossible to inject fluid through the Tenckhoff catheter. A plain abdominal radiograph was requested to check the position of the Tenckhoff catheter (Figure 1). The catheter was seen to pass vertically down after entering the abdomen, passing a point midway between the right anterior superior iliac spine and the right pubic tubercle. The tip was in an abnormal position, overlying the right inferior pubic ramus, and appeared to be in an extraperitoneal location. Clinical assessment of the patient revealed a new swelling in the right inguinal region. On examination, the swelling was tender, had a fluctuant consistency, and was irreducible. The swelling increased in size on standing and was expansile on coughing. The patient confirmed that he had become aware of swelling in the groin after Tenckhoff insertion. No hernias had been found at preoperative assessment. The following day, he was taken back to theater and a moderate indirect sliding inguinal hernia was excised. The Tenckhoff catheter was located within the hernial sac and was repositioned to the retrovesical pouch. The hernia was repaired using a polypropylene mesh.
Plain abdominal radiograph.
Failure of peritoneal dialysate drainage is commonly due to Tenckhoff catheter migration so that the tip no longer lies in the pelvis, and occasionally as a result of fibrin deposition on the catheter tip. We could find no previous reports of peritoneal dialysis catheter insertion into an inguinal hernia. The patient we describe had a small asymptomatic inguinal hernia into which the tip of the Tenckhoff catheter was inadvertently placed. Intra-abdominal adhesions noted during insertion may have increased the risk of the catheter taking an abnormal route. Abdominal hernias are a common complication of peritoneal dialysis, resulting from increased intra-abdominal pressure during dialysate dwells and occurring in up to 25% of patients within 2 years of starting peritoneal dialysis (1–3). This case emphasizes that patients undergoing Tenckhoff catheter insertion require careful preoperative evaluation for inguinal hernias.