Incisional Hernias Post Liver Transplantation: Current Evidence of Epidemiology, Risk Factors and Laparoscopic Versus Open Repair. A Review of the Literature

Abstract

Background/Aim: The occurrence of an incisional hernia after liver transplantation consists of a potential complication that may seriously affect the postoperative course and the quality of patient's life in general. The purpose of this study was to report the current epidemiological data, analyze the risk factors, evaluate the role of laparoscopic repair in this condition, and present the technical difficulties in the management of this special patient group. Materials and Methods: A literature search was performed through PubMed. Our criteria included all studies published from March 1982 to February 2019 in English, regarding incisional posttransplant hernias and open or laparoscopic repair. Finally, we collected 19 relevant studies. Results: Incisional hernia may occur independently of the type of abdominal incision. Risk factors are both patient-and technique-related. Conclusion: Well-organized randomized controlled studies are needed, in order to estimate the best treatment strategy for these patients. An incisional hernia may complicate any abdominal incision, regardless of the type of incision (Figure 1A and B). However, median abdominal incisions have been documented to be more prone to incisional hernia formation, compared with other abdominal incisions (1, 2). According to a systematic review, median incisions carry a significantly higher risk of herniation compared to transversal [relative risk (RR) 1.77, 95%CI=1.09-2.87], and paramedian incisions (RR=3.41, 95%CI=1.02-11.45), respectively (3). Risk factors predisposing to incisional hernia are both patient-and technique-related. Patient-related factors that increase such a risk include obesity, smoking, malnutrition, connective tissue disorders, preoperative chemo-radiation and immunosuppressive therapy (4, 5). As for techniquerelated factors, excess wound tension, suturing material failure, poor surgical technique, as well as the need for emergency surgery, are amongst the most important factors predisposing to the development of incisional hernia. The development of an incisional hernia following liver transplantation (LT) comprises a potential complication that may seriously affect the postoperative course and the quality of patient's life. The purpose of the present study was to investigate the current epidemiological data, analyse the risk 1059 This article is freely accessible online.

Strategies for operative management of abdominal wall hernia after solid organ transplant

“…Preoperative patient factors that predispose to incisional hernia in transplant patients include male gender, advanced age (studies cite ages greater than 45-60 as risk factors), elevated BMI (BMI > 25), smoking, malnutrition (serum albumin levels less than 3.5 g/L), connective tissue disorders (e.g., osteogenesis imperfecta, certain subtypes of Ehlers-Danlos syndrome, and Marfan syndrome), immediately preoperative chemotherapy and/or radiation to the operative site or region, presence of large volume ascites, COPD, previous surgery in the operative area, anemia, steroid use, diabetes mellitus, and immunosuppression [2][3][4][5][6] . Furthermore, patients with end-stage renal or liver disease live in catabolic states in which muscle atrophies and the abdominal wall weakens.…”

“…Postoperative factors associated with incisional hernia include wound infection, pulmonary complications, prolonged ICU stay, severe ascites, anemia, thrombocytopenia, acute rejection with steroid treatment, and same-site repeat surgery with fascial reopening and reclosure [2][3][4][5][6] .…”

“…Common to these risk factors -obesity, ascites, and COPD -is increased intra-abdominal pressure, which puts mechanical stress on the fascial closure and weakens the abdominal wall, making patients more prone to wound necrosis, breakdown, and hernia [2,4] . Furthermore, medical issues such as benign prostatic hypertrophy chronic constipation, and chronic cough can also significantly increase intra-abdominal pressure and thus jeopardize the integrity of hernia repairs.…”

“…Technique-related factors that increase risk for an incisional hernia after transplant include excess tension upon fascial closure, emergency surgery, and type of incision [2][3][4][5][6] . A surgeon's choice of incision for solid organ transplant surgery depends on the type of organ transplanted, surgeon preference, and patientspecific factors such as previous surgeries and organ size.…”

“…The transplant population is uniquely susceptible to wound healing complications, such as wound infection and incisional hernia for multiple reasons. Lifetime incidence of incisional hernia following liver transplant has been reported to be as high as 43% in recent studies [2][3][4] . Wound complications can plague the postoperative patient experience as they cause discomfort, repeat hospitalizations, increased health care costs, and diminished quality of life.…”