Laparoscopic Incisional Hernia Repair After Liver Transplantation: Long-Term Series and Literature Review

Minimally Invasive Surgery in Liver Transplantation: From Living Liver Donation to Graft Implantation

Since the end of the 20th century and the establishment of minimally invasive techniques, they have become the preferred operative method by many surgeons. These techniques were applied to liver surgery for the first time in 1991, while as far as transplantation is concerned their application was limited to the living donor procedure. We performed a review of the literature by searching in Pubmed and Scopus using the following keywords: Liver transplantation, Minimally invasive surgery(MIS) living liver donor surgery. Applications of MIS are recorded in surgeries involving the donor and the recipient. Regarding the recipient surgeries, the reports are limited to 25 patients, including combinations of laparoscopic, robotic and open techniques, while in the living donor surgery, the reports are much more numerous and with larger series of patients. Shorter hospitalization times and less blood loss are recorded, especially in centers with experience in a large number of cases. Regarding the living donor surgery, MIS follows the same principles as a conventional hepatectomy and is already the method of choice in many specialized centers. Regarding the recipient surgery, significant questions arise mainly concerning the safe handling of the liver graft.

Outcomes of a Large Series of Laparoscopic Ventral Hernia Repairs after Liver Transplantation

BACKGROUND

The hernia defects that develop in liver transplant recipients tend to be complex. Unfortunately, there is a paucity of data to guide post-transplant hernia management. Our goal was to evaluate the outcomes following laparoscopic ventral hernia repair (LVHR) in liver transplant recipients.

METHODS

A retrospective review of a prospectively kept database of liver transplant patients at a single tertiary healthcare facility was completed. All patients between 2007 and 2020 who underwent LVHR for a hernia at their transplant incision site were included. The primary outcome studied was hernia recurrence. Secondary outcomes included time-to-hernia repair, complications, and length of stay (LOS).

RESULTS

There were 89 patients who met inclusion criteria. 82% were male, mean age was 60 years, and mean body mass index was 30.2 kg/m2. 94.4% were on tacrolimus and 36% on mycophenolate mofetil. Median time-to-hernia repair was 16 months with a mean mesh size of 743 cm2 and length of stay of 3.7 days. None required conversion to an open operation. Postoperative complications included ileus (20.2%), acute kidney injury (11.2%), pneumonia (6.7%), and bleeding requiring re-operation (1.1%). Hernia-related complications included chronic suture site pain (1.1%), seroma requiring intervention (3.3%), surgical site infection (3.3%), nonoperative mesh infection (1.1%), and mesh infection requiring explantation (1.1%). Median follow-up was 23 months. Hernia recurrence occurred in 4.5% and no predictive variables for recurrence were identified.

CONCLUSIONS

Although the hernia defects that develop in liver transplant recipients are complex and their comorbidities significant, LVHR can safely and effectively repair these defects with low rates of recurrence and complications.

Minimally invasive surgery and liver transplantation: is it a safe, feasible, and effective approach?

The minimally invasive approach (MIS) is undoubtedly one of the most important breakthroughs in surgery in recent decades. Consequently, MIS has been increasingly in the field of liver transplantation (LT). The objective of the present review was to determine the current status of MIS with respect to liver transplantation (LT) and what would be the indications for an MIS in this context today. The literature was searched for publications reporting the MIS in LT. Only those articles that described the results according to whether the MIS had been performed to treat transplant complications (urgent or late), another pathology not related to the LT, or to perform the liver explantation and graft implantation were included. From 2000 to 2022, 33 studies and 261 patients were included. Most frequent indications were incisional hernias secondary to LT followed by the treatment of other pathologies not related with the LT and treatment of LT complications. Only a 12% were urgent interventions. Few studies describe conversions with an average rate of 2.5%. Morbidity do not differ significantly from open surgery. No case of mortality or graft loss was described. Purely laparoscopic liver explants in 9 patients with 2 conversions and 3 cases of graft implantation with a higher warm ischemia in the MIS implants grafts were described. The limitations of MIS in LT are relative and probably depend more on training, experience, and skills of the surgeons. This approach could be safety and feasibility to solved complications or in other individualized indications in LT patients. The initial experiences in liver explant and graft implantation need further investigations.

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.