Background <p>Children with kidney failure may have congenital or acquired gastrointestinal comorbidities requiring laparotomy, which can complicate the initiation/continuation of peritoneal dialysis (PD) because of peritoneal adhesions.</p> Methods <p>This retrospective observational study included patients younger than 18&#xa0;years who initiated PD after laparotomy or underwent laparotomy after PD initiation between February 1, 2006, and July 31, 2024. The primary endpoint was post-laparotomy PD failure, and the secondary endpoint was death. The characteristics and surgical details of patients categorized based on PD success after laparotomy were compared.</p> Results <p>The study included 21 of the 22 eligible patients with kidney failure who underwent laparotomy, after the exclusion of one patient who did not resume postoperative PD. The median age at laparotomy was 1.5 (interquartile range [IQR], 0.3–15.7) months, and the median age at postoperative PD commencement was 5.3 (IQR, 1.3–13.0) months. PD failure occurred in five of the seven patients with bowel resection compared to none of the 14 patients without bowel resection (<i>P</i> = 0.001). In all cases, PD failure was associated with extensive small bowel or sigmoid colon resection. PD was successfully performed after other procedures, including colostomy alone, hepatectomy, and liver transplantation. The cause of death was septic shock in all four young patients who died, and postoperative sepsis was significantly associated with mortality.</p> Conclusions <p>In children with kidney failure, PD is generally feasible after laparotomy, except in cases involving extensive bowel resection. Effective infection control is crucial to improve survival after laparotomy, especially in younger infants.</p> Graphical abstract <p></p>