Strangulated umbilical hernia in a peritoneal dialysis patient
A 40-year-old nondiabetic man was diagnosed with CKD in March 2006. He was initiated on hemodialysis through left brachiocephalic arteriovenous fistula (AVF). He underwent surgical placement of double-cuffed, swan-neck, Tenckhoff catheter under local anesthesia in December 2008. He was initiated on regular CAPD exchanges after 2 weeks of break-in period. His peritoneal equilibration test showed high-average transporter status. His residual urine output was 250 ml per day. He was on three exchanges per day with 2.5% dextrose solution and achieved around 1500 ml ultrafiltration daily. After 2 months of initiation of CAPD, he noticed a small swelling at the umbilicus which reduced in size in lying posture and increased on standing. After 4 months, he presented with complaints of pain abdomen and vomiting of 5 days’ duration. Pain abdomen was severe in intensity, colicky in nature, periumbilical, and nonradiating. He had bilious vomiting 4–5 episodes a day. He also complained of progressive abdomen distension and constipation of 2 days’ duration. There were no complaints of fever, loose motion, or cloudy PD fluid. There were no previous episodes of peritonitis. He also denied history of abdominal surgeries or hernias prior to CAPD initiation. On physical examination, he was dehydrated and blood pressure was 100/70 mmHg. Abdominal examination showed irreducible umbilical hernia of 6 cm in size. The swelling was tense and tender. There was no expansile cough impulse. Bowel sounds were absent. Rectal examination showed empty rectum. Cardiovascular and respiratory system examination were unremarkable. Investigations revealed hemoglobin 8.6 g/dl, total leukocyte count 11,000/mm3, blood urea 70 mg/dl, serum creatinine 11.2 mg/dl, serum sodium 136 meq/l, potassium 4.2 meq/l, chlorides 94 meq/l, total proteins 7.0 g/dl, serum albumin 3.2 g/dl, serum alkaline phosphatase 196 IU/L, alanine aminotransferase 10 U/L, and aspartate aminotransferase 13 U/L; viral markers were negative; chest radiograph was normal; and abdominal radiograph showed dilated small bowel loops with multiple air fluid levels. A diagnosis of obstructed umbilical hernia was made. CAPD exchanges were continued till a day before surgery. He underwent laparotomy under general anesthesia. On opening the abdomen, hernial sac of 6 cm was found and there was 4 cm defect in the rectus. The rectus defect was enlarged on either side and the peritoneum over the umbilical hernia was opened. Ileal gangrene of 15 cm was noted, proximal small bowel loops were mildly dilated []. He underwent resection of the gangrenous ileum and end-to-end anastomosis in two layers. After reducing the peritoneum of the hernial sac, the rectus defect was closed. Tenckhoff PD catheter was not disturbed []. He was on Ryles tube aspiration for 2 days, and antibiotics for 10 days. Sutures were removed on the 10th postoperative day. He was temporarily shifted to hemodialysis through left brachiocephalic AVF on the second postoperative day and was continued on hemodialysis three times a week for 2 weeks. On the third week, he was initiated on CAPD exchanges with 1 L of 2.5% dextrose three times a day. Initially the PD fluid was slightly hemorrhagic. Gradually by the fourth week, he returned to normal CAPD exchanges with 2 L of 2.5% dextrose and around 1 L clear ultrafiltration. There was no leakage either from the incision site or the exit site.