Long term outcomes of abdominal wall reconstruction using open component separation and biologic mesh in the liver, kidney, and small bowel transplant population

Contemporary Abdominal Wall Reconstruction: Emerging Techniques and Trends

Abdominal wall reconstruction is a common and necessary surgery, two factors that drive innovation. This review article examines recent developments in ventral hernia repair including primary fascial closure, mesh selection between biologic, permanent synthetic, and biosynthetic meshes, component separation, and functional abdominal wall reconstruction from a plastic surgery perspective, exploring the full range of hernia repair's own reconstructive ladder. New materials and techniques are examined to explore the ever-increasing options available to surgeons who work within the sphere of ventral hernia repair and provide updates for evolving trends in the field.

Incisional hernias post renal transplant: a systematic review and meta-analysis

PURPOSE

Incisional hernia (IH) post renal transplant (RT) is relatively uncommon and can be challenging to manage clinically due to the presence of the kidney graft and patient immunosuppression. This systematic review and meta-analysis synthesises the current literature in relation to IH rates, risk factors and outcomes post RT.

METHODS

PubMed, EMBASE, and Cochrane Central Registry of Controlled Trials (CENTRAL) were searched up to July 2023. The most up to date Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines were followed. Pertinent clinical information was synthesised. A meta-analysis of the pooled proportions of IH rates, the rates of patients requiring surgical repair and the rates of recurrence post RT are reported.

RESULTS

Twenty studies comprising 16,018 patients were included in this analysis. The pooled rate of IH occurrence post RT was 4% (CI 3-5%). The pooled rate of IH repair post RT was 61% (CI 14-100%). The pooled rate of IH recurrence after repair was 16% (CI 9-23%). Risk factors identified for IH development post RT are BMI, immunosuppression, age, smoking, incision type, reoperation, concurrent abdominal wall hernia, lymphocele formation and pulmonary disease.

CONCLUSIONS

IH post RT is uncommon and the majority of IH post RT are repaired surgically on an elective basis.

Outcomes of Ventral Hernia Repair After Orthotopic Liver Transplant Using Component Separation and Onlay Biologic Mesh

INTRODUCTION

The management of ventral hernias (VHs) after orthotopic liver transplant (OLT) can be uniquely challenging because of immunosuppression coupled with large laparotomy size that can compromise the quality of the abdominal wall. The component separation with multipoint suture onlay acellular dermis fixation technique has proven to be effective in high-risk abdominal wall reconstructions. The goal of this study was to elucidate the factors that affect safety and efficacy of VH repair in post-OLT patients.

METHODS

A retrospective review of 345 patients who underwent repair of VH with compartment separation and onlay acellular dermal matrix reinforcement from a single surgeon from 2012 to 2020 was conducted. Of these, 27 patients were identified with a history of OLT and were stratified based on whether the defect was a initial or recurrent hernia repair. The majority of patients had a standard chevron incision (70%). Data abstraction was performed for preoperative risk factors, hernia characteristics, surgical site complications, and postoperative course including hernia recurrence.

RESULTS

A majority of cases in the study period were initial hernia repairs (59%) with no significant differences in the patient demographics and size of VH defects (190 ± 112.69 cm 2 ). Comorbidities were similar between the groups with the exception of a significantly higher baseline creatinine levels and higher history of smoking in the recurrent hernia repair group ( P < 0.05). Of the 27 cases, there were no demonstrable hernia recurrences noted and an overall 11% complication rate. Univariate analysis noted a statistically significant difference in surgical site complication rate ( P = 0.017), with the initial hernia repair group having the lowest rate of surgical site complications.

CONCLUSIONS

In complex post-OLT patients with large VH, modified component separation with onlay acellular mesh was shown to have acceptable medium-term results. Further studies investigating the factors leading to postoperative complications are necessary to reduce recurrence in this evolving patient population.

Closing the abdomen: update on the current surgical toolkit

PURPOSE OF REVIEW

Achieving abdominal wall closure after intestinal transplantation (ITx) is one of the crucial surgical challenges. This problem is present in 25-50% of all transplants due to reduction in abdominal domain, fistulae and extensive adhesions due to previous surgeries. Failure to achieve closure is an independent risk factor for mortality and graft loss. The aim of this paper is to summarize the current options to achieve this.

RECENT FINDINGS

Successful closure of the abdomen requires a tension-free repair. Primary closure of the fascia can be reinforced with synthetic or biological mesh. For more complex fascial defects bridging mesh, nonvascularised or vascularised rectus fascia can be utilised. If all components of the abdominal wall are affected, then a full-thickness abdominal wall transplantation may be necessary.

SUMMARY

A variety of successful techniques have been described by different groups to enable abdominal wall closure after ITx. Emerging developments in preoperative imaging, reconstructive surgery and immunology have expanded the surgical toolkit available. Crucial is a tailor-made approach whereby patients with expected closure issues are identified prior to surgery and the simplest technique is chosen.

Abdominal wall complications after kidney transplantation: A clinical review

Introduction

Abdominal wall complications are common after kidney transplantation, and although they have a minor impact on patient and graft survival, they increase the patient's morbidity and may have an impact on quality of life. Abdominal wall complications have an overall incidence of 7.7–21%.

Methods

This review will explore the natural history of abdominal wall complications in the kidney transplant setting, with a special focus on wound dehiscence and incisional herni, with a particular emphasis on risk factors, clinical characteristics, and treatment.

Results

Many patient‐related risk factors have been suggested, including older age, obesity, and smoking, but kidney transplant recipients have an additional risk related to the use of immunosuppression. Wound dehiscence usually does not require surgical intervention. However, for deep dehiscence involving the fascial layer with concomitant infection, surgical treatment and/or negative pressure wound therapy may be required.

Conclusions

Incisional hernia (IH) may affect 1.1–18% of kidney transplant recipients. Most patients require surgical treatment, either open or laparoscopic. Mesh repair is considered the gold standard for the treatment of IH, since it is associated with a low rate of postoperative complications and an acceptable rate of recurrence. Biologic mesh could be an attractive alternative in patients with graft exposition or infection.

Reconstrucción de la pared abdominal en pacientes con inmunosupresión: experiencia en una institución de alta complejidad

Introducción. Los pacientes con inmunosupresión llevados a cirugía abdominal convencional tienen un mayor riesgo de desarrollar hernias incisionales en el posoperatorio, y cuando ellas ocurren, es necesario individualizar el procedimiento quirúrgico de elección, según las características anatómicas, fisiológicas y clínicas de cada paciente. Este estudio describe las características demográficas y clínicas de los pacientes con inmunosupresión, llevados a reconstrucción de la pared abdominal, y sus desenlaces después de 30 días del procedimiento quirúrgico. Métodos. Serie de casos de pacientes con inmunosupresión llevados a reconstrucción de la pared abdominal, en un centro especializado de cuarto nivel de complejidad. Se incluyeron pacientes mayores de 18 años, operados en el período de enero de 2016 a diciembre de 2019. Resultados. Se presenta una serie de 18 pacientes, cinco (27,7 %) con algún tipo de inmunosupresión primaria y 13 (72,2 %) con algún tipo de inmunosupresión secundaria. La edad promedio fue de 56 años, 11 (61 %) fueron mujeres, el peso promedio de los participantes fue de 73,3 kg. Se encontraron complicaciones en ocho pacientes (44,4 %). Dos pacientes requirieron manejo en la Unidad de Cuidados Intensivos, por un máximo de tres días. Ninguno de los pacientes presentó recidiva de la hernia ni mortalidad. Discusión. La reconstrucción de la pared abdominal en pacientes inmunosuprimidos representa un reto para cualquier equipo quirúrgico debido a las condiciones especiales de los pacientes y a las variables asociadas al procedimiento. Las tasas de recidiva y de complicaciones de este estudio, se asemejan a las descritas en la literatura.

Peritoneal flap hernioplasty for repair of incisional hernias after orthotopic liver transplantation

Background

Repair of incisional hernias following orthotopic liver transplantation (OLT) is a surgical challenge due to concurrent midline and transverse abdominal wall defects in the context of lifelong immunosuppression. The peritoneal flap hernioplasty addresses this problem by using flaps of the hernial sac to bridge the fascial gap and isolate the mesh from both the intraperitoneal contents and the subcutaneous space, exploiting the retro-rectus space medially and the avascular plane between the internal and external oblique muscles laterally. We report our short and long-term results of 26 consecutive liver transplant cases with incisional hernias undergoing repair with the peritoneal flap technique.

Methods

Post-OLT patients undergoing elective peritoneal flap hernioplasty for incisional hernias from Jan 1, 2010–Nov 1, 2017 were identified from the Lothian Surgical Audit system (LSA), a prospectively-maintained computer database of all surgical procedures in the Edinburgh region of south-east Scotland. Patient demographics and clinical data were obtained from the hospital case-notes. Follow-up data were obtained in Feb 2020.

Results

A total of 517 liver transplantations were performed during the inclusion period. Twenty-six of these (18 males, 69%) developed an incisional hernia and underwent a peritoneal flap repair. Median mesh size (Optilene Elastic, 48 g/m², BBraun) was 900 cm² (range 225–1500 cm²). The median time to repair following OLT was 33 months (range 12–70 months). Median follow-up was 54 months (range 24–115 months) and median postoperative stay was 5 days (range 3–11 days). Altogether, three patients (12%) presented with postoperative complications: 1 with hematoma (4%) and two with chronic pain (8%). No episodes of infection or symptomatic seroma were recorded. No recurrence was recorded within the follow-up period.

Conclusion

Repair of incisional hernias in patients following liver transplantation with the Peritoneal Flap Hernioplasty is a safe procedure associated with few complications and a very low recurrence rate. We propose this technique for the reconstruction of incisional hernias following liver transplantation.

Risk Factors for Surgical Site Occurrence or Infection and Recurrence After Incisional Hernia Repair in Abdominal Transplant Population

PURPOSE

To investigate risk factors for hernia recurrence, surgical site occurrence/infection (SSO/I) and those requiring procedural intervention (SSOPI) after incisional hernia repair (IHR) following abdominal transplantation.

METHODS

Patients undergoing IHR following abdominal transplant were retrospectively identified in the Americas Hernia Society Quality Collaborative database. Primary outcome measures were SSO/I, SSOPI and hernia recurrence.

RESULTS

There was a total of 166 patients. Seventeen patients (10%) had an SSO/I at 30 days. Overall complication rate was 26%, and there was 1 mortality (1%). Composite recurrence rate was 28% (21/75) over 2 years. In univariate analysis, history of diabetes (DM), body mass index (BMI) >35 kg/m², and history of open abdomen were associated with SSO/I (P < .05). Immunosuppression had a negative correlation with SSO/Is and SSOPIs. BMI >35 kg/m² was associated with 180-day recurrence, whereas history of hypertension remained significant for recurrence at 2 years (P < .05).

CONCLUSION

History of an open abdomen, DM, and obesity are risk factors for SSO/I, and obesity and hypertension are associated with short-term and long-term recurrence after IHR following abdominal organ transplantation. Immunosuppression had negative correlation with SSO/I. However, long-term outcomes and those related to immunosuppression should be interpreted cautiously in view of the small sample size and low follow-up rates. Baseline comorbidities seem to be the main drive for hernia outcomes for transplant population, similar to the general population. Larger cohorts and longer follow-up are necessary to delineate preventable risk factors for SSO/Is and hernia recurrences after organ transplantation.