Retrospective studies reported a prevalence of abdominal wall hernias in polycystic kidney disease between 45% and 61% [7, 19]. The increased intra-abdominal pressure or the increased inside-out pressure on the abdominal wall due to large polycystic kidneys and/or primary collagen anomalies have been all postulated as being responsible for hernia formation [7, 19]. Interestingly, Modi et al. [19] showed a higher prevalence of inguinal hernias in patients with polycystic kidney disease treated with continuous ambulatory peritoneal dialysis (CAPD), compared with CAPD patients with other renal diseases. In contrast, Hadimeri et al. found no increased incidence of hernias among patients with polycystic kidney disease [20]. In retrospective studies, patients treated with automated peritoneal dialysis (APD) seem to have a lower prevalence of hernias compared those treated with CAPD [7, 21]. It was originally observed that patients who are at risk for hernias include those with higher body mass index, due to higher intra-abdominal pressure for a given dwell volume [22]; other studies have found the opposite result when the height and weight are adjusted for sex [8, 9]. The pathophysiological role of intra-abdominal pressure on the development of hernias has been often advocated but not been thoroughly studied in PD patients. In fact, in all the studies, the intra-abdominal pressure has been measured at rest and in a supine position and not during the patient’s daily physical activities [13, 22, 23]. Since the intra-abdominal pressure varies greatly from patient to patient according to their daily physical activities, the current methodology of intra-abdominal pressure determination might be inadequate to detect patients at risk [22]. However, until the existence of a putative relation between intra-abdominal pressure and the development of hernias in PD patients has been thoroughly studied, it is prudent to continue teaching our PD patients to refrain from physical activities, which could cause straining, such as pushing, pulling and jumping. In addition, they should avoid straining with bowel movements by eating a high fiber diet or taking stool softeners to avoid constipation, without draining the peritoneal cavity first. This is particularly important postoperatively following PD catheter insertion in order to minimize the occurrence of incisional hernias.

Incisional hernia, a known complication of previous surgery, has different definitions; the most widely accepted is any abdominal wall defect, with or without a bulge, identified on clinical examination or imaging by 1 year after the index operation [24, 25]. The incidence of this complication in the literature ranges between 0% and 44%, reflecting the heterogeneity of definitions, patients, operations and follow up [26]. The discussion on the best surgical technique, type of sutures to use for which abdominal operation in order to minimize this complication is beyond the scope of this chapter [27, 28]. Incisional hernia can develop after any type of abdominal wall incision. The incidence depends upon the location and size of the incision [29–37]. Based on a recent meta-analysis on the general surgical population, midline incisions have a significantly increased risk of incisional hernia compared to transverse (relative risk [RR] 1.77, 95% CI, 1.09–2.87) and paramedian incisions (RR 3.41, 95% CI 1.02–11.45, respectively) [36]. The highest reported incidence is with midline abdominal incisions (3–20%) [31, 32]. Muscle-splitting incisions (para-median) have a cumulative incidence of incisional hernia ranging from 1% to 6% [38, 39]. Laparoscopic port sites can also develop incisional hernia, with a reported incidence between 0% and 5% [40–42]. The highest risk being 10 mm or larger ports and below the umbilicus. These findings in the general surgical population, showing the importance of the operative technique as a determinant of incisional hernia occurrence, can be applied to the PD population. We believe that in the PD population, where, unfortunately, comparative studies are missing and the incidence of all types of hernia is very high, the laparoscopic insertion technique has to be considered the gold standard since it decreases the risk of incisional hernia. The effect of hernias and their management on PD technique survival remains poorly characterized in the literature. Furthermore, the effect of hernia occurrence and treatment on residual renal function (RRF), which is known to confer significant prognostic benefit in PD, remains unknown [43].