Despite the increasing need for elective abdominal surgery for patients with end-stage renal disease (ESRD), there are still limited data on the indications and surgical technique in this fragile population. The most frequent abdominal surgeries performed in ESRD are cholecystectomy, appendectomy and surgical anal disease. Indications for such surgeries need to be carefully evaluated considering the benefits and risks of each procedure. In fact, ESRD is an independent risk factor for postoperative morbidity due to underlying disease and severe comorbidities. Common surgical complications such as infections, vascular access related-issues and bleeding are due to uremia-related alterations in immune response and platelet function and consequently the optimal perioperative management still remains challenging. Different strategies should be considered for ESRD patients undergoing abdominal surgery, including prophylactic antibiotics, optimal timing of dialysis before and after surgery, moderate fluid administration as well as management of bleeding risk related to chronic antiplatelet or anticoagulant therapy. A minimally invasive approach should always be adopted to reduce postoperative complications, and therefore cholecystectomy and appendectomy are usually performed by a laparoscopic technique. In the perioperative period, ESRD patients should be managed within a multidisciplinary team consisting of nephrologists, surgeons and anesthesiologists.