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Table of Contents
ORIGINAL ARTICLES
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 95-102

Management of incisional hernias in liver transplant patients: Perioperative optimization and an open preperitoneal repair using porcine-derived biologic mesh


Department of Surgery, Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC, USA

Date of Submission18-Feb-2021
Date of Decision28-Mar-2021
Date of Acceptance30-Mar-2021
Date of Web Publication30-Sep-2021

Correspondence Address:
Dr. Vedra A Augenstein
Department of Surgery, Gastrointestinal and Minimally Invasive Surgery, 1025 Morehead Medical Drive Suite 300, Charlotte, NC.
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijawhs.ijawhs_14_21

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  Abstract 

PURPOSE: The purpose of this study is to describe an optimal management strategy for incisional hernias in liver transplant patients. METHODS: Patients were identified who underwent open preperitoneal hernia repair for incisional hernia following liver transplantation. Perioperative management and surgical technique were described; wound complications and hernia recurrence were the primary outcomes assessed. RESULTS: A total of 17 patients met our criteria. All patients were on immunosuppression, and one patient (5.9%) had sirolimus stopped prior to the operation. One patient (5.9%) quit smoking, and two patients (11.8%) required optimization of their diabetes to have an A1c ≤7.2. Two patients (11.8%) received botulinum toxin A preoperatively due to significant loss of domain. The mean size of the biologic mesh was 818.8 ± 210 cm2, one patient (5.9%) received an anterior component separation and four (23.5%) received a panniculectomy. Postoperatively, three patients (17.7%) developed wound complications and one patient required reoperation for seroma. There were no 30-day readmissions and no hernia recurrences with mean follow-up time of 21.6 ± 11.6 months. CONCLUSION: The use of preperitoneal biologic mesh is an effective method for the management of incisional hernia in liver transplant patients; perioperative optimization and care are also influential in assuring positive outcomes for patients.

Keywords: Biologic mesh, hernia, liver, preperitoneal, transplant


How to cite this article:
Ayuso S, Elhage SA, George MB, Anderson M, Levi DM, Heniford B T, Augenstein VA. Management of incisional hernias in liver transplant patients: Perioperative optimization and an open preperitoneal repair using porcine-derived biologic mesh. Int J Abdom Wall Hernia Surg 2021;4:95-102

How to cite this URL:
Ayuso S, Elhage SA, George MB, Anderson M, Levi DM, Heniford B T, Augenstein VA. Management of incisional hernias in liver transplant patients: Perioperative optimization and an open preperitoneal repair using porcine-derived biologic mesh. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2021 Dec 6];4:95-102. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/3/59/327061




  Introduction Top


Over a 5-year period, there has been a 20% increase in orthotopic liver transplants in the United States.[1] Nearly 9,000 liver transplants are performed in this country each year.[2] The rate of incisional hernia following liver transplantation ranges from 4.9% to 43% in the literature.[3],[4] When compared to non-transplant patients undergoing laparotomy, who have an incisional hernia rate of 20%–25%, liver transplant patients have a higher rate of incisional hernia.[5],[6],[7] Liver transplant patients are a high-risk population given their frequently high number of comorbidities and requirement for immunosuppression.[8],[9]

The same risk factors that predispose non-transplant patients to hernia formation apply to liver transplant patients. For instance, advanced age, smoking, diabetes and obesity place patients at increased risk for hernia development.[10],[11] Several studies have also identified risk factors for hernia formation that are specific to the liver transplant population. A history of cirrhosis, acute rejection, steroid-induced diabetes, paramedian incision, and type of immunosuppression have been associated with the development of hernias.[3],[8],[12] The use of sirolimus and steroids are particularly high risk due to their detrimental effect on wound healing and decrease in overall mechanical strength of tissues.[12],[13] In addition, patients may also develop an eventration due to denervation in the right upper quadrant which may compound the appearance of the incisional hernia and impose challenges in repair.[14] Subcostal hernias are difficult to repair due to need for bony fixation and lack of adequate fascia, and they are known to have a high rate of recurrence.[15]

There is no consensus as to how to manage incisional hernias that develop after liver transplantation. Traditionally, repair of incisional hernias in transplant patients has been achieved by means of primary fascial closure due to fear of synthetic mesh placement in an immunocompromised setting.[16] There are high rates of recurrence in this population with rates reported between 11% and 77% depending on the type of repair that is used. Given this, the use of mesh in incisional hernia repair for this patient population has been adopted.[17] While synthetic and biologic meshes have both shown decreased rates of hernia recurrence, the benefit of biologic mesh is that it incorporates into the native tissues through neovascularization and is less prone to chronic infection.[17],[18] Liver transplant patients that develop mesh infection or wound infection after hernia, an estimated one third of patients, are less likely to tolerate these complications given their immunosuppression.[12],[19] Avoiding reoperation and postoperative complications is especially important in these patients, already predisposed to poor wound healing.

In our study, we describe the use of an open pre-peritoneal repair with a porcine-derived biologic mesh for the management of incisional hernias in liver transplant patients. We also describe the preoperative optimization and perioperative management of our patients at a tertiary care hernia center. Postoperative outcomes, particularly wound complications and hernia recurrence are tracked prospectively. Our study is the first to describe the use of a preperitoneal technique using biologic mesh for liver transplant patients. We hypothesized that our method would be safe and effective with low rates of wound complications and hernia recurrence.


  Methods Top


Study design

This study was conducted at Carolinas Medical Center (CMC), an 874-bed tertiary care facility in Charlotte, North Carolina with a referral base extending throughout the United States. CMC is a tertiary hernia referral center, and the Section of Gastrointestinal and Minimally Invasive Surgery performs over 200 open abdominal wall reconstructions annually.

Following Institutional Review Board approval, we used our prospective institutional hernia specific database to query for all patients who underwent hernia repair from 2017 to 2020 and who had a prior liver transplantation; 2017 marks the year when our current method for repairing incisional hernias in liver transplant patients came into practice. Baseline demographics, such as age, body mass index (BMI), comorbidities, and hernia recurrence were obtained for all patients. Our primary outcomes were wound complications and hernia recurrence. Secondary outcomes included operative time, hospital cost, length of stay, reoperation, and 30-day readmission rate. We excluded patients that underwent laparoscopic repair, patients that had synthetic mesh placed and patients that were not able to have their fascia closed primarily at time of operation. Perioperative outcomes were tracked in the database and follow-up was achieved through a means of reviewing documentation from follow-up clinic visits, reviewing postoperative imaging, and telephone encounters with patients.

Statistical analysis

All data were analyzed using Statistical Analysis Software, version 9.4 (SAS Institute, Inc., Cary, NC). Descriptive statistics were reported as means with corresponding standard deviations for continuous variables and percentages for categorical variables.

Surgical technique and perioperative management

All patients who are found to have an incisional hernia are referred to our clinic by the transplant surgeons or hepatologists. Prior to operation, a thorough history and physical exam is performed, abdominal imaging reviewed, and a decision is made whether the patient is appropriate for operation [Figure 1]. Patients are optimized preoperatively, focusing specifically on modifiable factors that are associated with increased risk for postoperative complications.[20] Diabetic patients are counseled on glycemic control with a target A1c below 7.2. Patients who smoke are counseled and only offered repair after they quit smoking for at least 4 weeks. Weight loss prior to surgery is also encouraged with diet and exercise; we do not, however, have a cutoff BMI prior to performing surgery, and the decision is made to operate on an individualized basis. Patients who had a significant pannus are offered concurrent panniculectomy. Patients who have significant loss of domain are offered preoperative chemical denervation with botulinum toxin A (BTA) as a means of increasing chances for fascial closure during the operation.[21],[22]
Figure 1: The patient in this figure presented to clinic with a Mercedes type incision following liver transplantation. A bulge is demonstrated at the center of his previous incision

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Prior to the start of the case, patients receive preoperative antibiotics, chemoprophylaxis, and have a Foley catheter inserted. Patients are positioned supine on the operating table with both arms out. If panniculectomy is performed, then it is done prior to repair of the hernia. The hernia portion of the operation begins with excision of the transverse scar from the transplant operation [Figure 2]. Subcutaneous flaps are elevated as needed to aid in eventual closure, and the subcutaneous tissue and skin are carefully taken off the hernia sac. We then make entry into the abdomen and any incarcerated hernia contents are reduced back into the abdomen. Patients who reported obstructive symptoms prior to the operation have an appropriate enterolysis performed. Otherwise, lysis of adhesions is performed to the degree it took to reduce the incarcerated hernia and proceed with definitive repair. Any attenuated tissue or fascia is excised to get to healthy layers of muscle. While inside the peritoneal cavity, a liver biopsy is often performed using a Tru-Cut® needle to assess liver morphology post-transplant and per request by the transplant team.
Figure 2: Excision of the hernia scar is the first step in the operation. The excision of the scar is performed prior to the development of subcutaneous flaps and entry into the abdomen

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The next step of the operation is to develop of a pre-peritoneal plane. This plane is created by dissecting into the Space of Retzius inferiorly and then carrying this plane superiorly all the way up to the diaphragm as well as extending out laterally in both directions. The peritoneum is completely reapproximated using a 2-0 absorbable, braided suture in running fashion [Figure 3]. For patients who cannot easily have their fascia approximated, a component separation is performed at this time by releasing the external oblique or transversus abdominis muscles. A porcine-derived biologic mesh, Strattice™, is placed in the preperitoneal space. The mesh is appropriately sized to get a generous overlap, often >10 cm, and it is oriented diagonally to ensure maximum coverage. Once the mesh is fixed taut [Figure 4], it is anchored with transfascial absorbable sutures. The tension on the mesh is relieved when the fascia is closed. It is important to have the mesh as flat as possible against the abdominal wall. At this time, a transverse abdominis myofascial block is performed with lysosomal bupivacaine, Exparel®.
Figure 3: Once the hernia is reduced and the pre-peritoneal dissection is complete, the peritoneum is closed with absorbable suture

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Figure 4: Mesh was placed in the pre-peritoneal space, as shown. The placement of mesh in the pre-peritoneal space is a proven technique and allows for large overlap of the mesh

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Before closing the fascia, we use bacitracin irrigation and a place a subfascial drain. The fascia is closed in running fashion with 1-0 absorbable, monofilament suture [Figure 5]. Hemostasis is ensured, an additional subcutaneous drain is placed, and then the skin is closed either with staples or running 4-0 absorbable, monofilament suture. An incisional wound vacuum-assisted closure (VAC) device is placed at the end of the operation. Patients are admitted to the hospital after the operation for monitoring, pain control, and to await return of bowel function and are followed by the Transplant Hepatology team while in the hospital. Patients are enrolled in in an Enhanced Recovery after Surgery (ERAS®) program, in which early ambulation is required, pain is controlled with a multimodal regimen, and diet is advanced with resumption of bowel function. The incisional VAC placed is removed after 7 days, and patients typically have clinic follow-up 2 weeks after the operation [Figure 6].
Figure 5: In this patient, the fascia was closed transversely over the mesh once it is fixed taut

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Figure 6: An incisional vacuum-assisted closure is placed at the end of the case and is not taken off until 7 days after the operation

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  Results Top


A total of 17 patients with incisional hernias following liver transplant were included in this study. The etiology of liver failure in all these patients was cirrhosis, and there were no patients who underwent liver transplant for fulminant hepatic failure. Patient characteristics [Table 1] included mean age 58.1 ± 12.3 years, 88.2% male, and mean BMI of 30.0 ± 6.7 kg/m2. One (5.9%) patient had a prior kidney transplant, and four (23.5%) patients had two liver transplants prior to repair of their hernia. Two (11.8%) of the liver transplants were performed at outside hospitals, and all patients had a Makuuchi, Chevron or Mercedes type incision [Figure 1]. Incisional hernias developed soon after transplant with 15 (88.2%) of the patients having their hernia repaired within 2 years of transplant. Of the five (29.5%) hernias that were recurrent, three (17.7%) had mesh placed previously. There were no patients who had a mesh infection or fistula at time of operation. The most common immunosuppression regimen used was tacrolimus alone (47.0%). Only one (5.9%) of the patients undergoing repair was on prednisone, and one patient had sirolimus held prior to their operation. Prior to operation, two patients (11.9%) required targeted glycemic control to get their A1c below 7.2 and one patient (5.9%) had to stop smoking 4 weeks preoperatively.
Table 1: Patient characteristics

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Two (11.8%) patients with large defects and loss of domain had BTA injected into the bilateral obliques preoperatively to help with fascial closure.[23] All but one (5.9%) patient had a CDC class 1 wound.[24] The mean size of the hernia defect was 311.7 ± 97.4 cm2 and the mean size of mesh was 818.8 ± 210.5 cm2. Complete operative details are recorded in [Table 2]. Each of the patients that had mesh-based ventral hernia repairs (VHRs) had the mesh placed had it excised at the time of operation. There were no enterotomies, nor other intra-operative complications. Strattice™ mesh was appropriately sized and placed in the preperitoneal space. One (5.9%) patient had an anterior component separation performed; this patient also received BTA preoperatively due to significant loss of domain after undergoing previous liver and kidney transplants. Long-term absorbable fixation sutures were deployed as needed to stretch the mesh against the posterior fascia. Every patient had their fascia closed and had placement of an incisional skin VAC.
Table 2: Operative details

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Postoperatively [Table 3], patients were sent to the general surgical floor for their care. An aspiration event occurred postoperatively in one patient who required transfer to the intensive care unit. This patient ended up being in the hospital for 13 days, however, the mean length of stay was 6.7 ± 2.8 days. Three (17.7%) patients developed wound complications after their surgery. A single return to the operating room was required for a patient who developed a large seroma. There was no 30-day mortality and no recurrences with a mean follow-up time of 21.6 ± 11.6 months.
Table 3: Postoperative outcomes and complication

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  Discussion Top


Patients undergoing liver transplant frequently develop an incisional hernia after their operation.[8],[10] They are a high-risk patient population given their high number of comorbidities and need for immunosuppression. In our study, we used an open preperitoneal approach, which has been well described as safe and very effective in both simple VHRs and complex abdominal wall reconstructions. In the current study of this technique following liver transplant, the operation resulted in few overall complications, no readmissions to the hospital, and no hernia recurrences with a mean follow-up time of 21.6 months.

As problematic as hernia-related complications can be, such as incarceration or strangulation, for nontransplant patients, they carry much greater concern for transplant patients. Postoperative complications, such as mesh infection, seroma formation, and wound dehiscence can also carry a greater degree of risk in this immunosuppressed patient population. Our intended approach for these patients is have the hernia repaired with few complications, reinterventions, and failure of the repair as possible. While this is the charge for all patients, it is especially important for transplant recipients due to their need for immunosuppression and the potential to put their graft at risk.

From previous studies, we know that factors that are specific to the transplant population predispose them to having complications.[25] Steroid use and immunosuppression put patients at up to 4 times the risk of developing a wound complication.[13],[26] In follow to that, patients who develop a wound complication may have a recurrence rate that is up to 5 times higher than those who do not have wound complications.[27] The difficult nature of managing subcostal incisions further contributes to a high risk of recurrence for liver transplant patients.[25] The patients in the current study, asides from being immunosuppressed, had an average of seven comorbidities. Both the wound complication rate (17.7%) and hernia recurrence rate (0%) in our study are favorable to what has been published in the literature for liver transplant patients and for the general population.[17],[28],[29]

Due to the likelihood for complications and the gravity such complications may carry, we elected to use a biologic mesh, Strattice™, for repair. Biologic mesh is used primarily to minimize risk of mesh infection.[30] Based on our experience, the durability of biologic mesh is equivalent to that of synthetic mesh. A recent propensity-matched analysis from our institution showed that there was no difference in recurrence rate (mean follow-up, 15 months) between biologic and synthetic mesh in CDC Class 1 and 2 patients undergoing abdominal wall reconstruction.[31] Previous data from our institution favors the use of Strattice™ over other biologic meshes, such as Xenmatrix™ or Alloderm®, because it associated with the lowest rates of hernia recurrence.[32] Considering the high-risk patient population and previously demonstrated low ventral hernia recurrence rates in patients using Strattice™, we used it in this group.

The successful outcomes that we report in this study are a product of multiple factors in addition to mesh choice. Preoperative optimization of patients through smoking cessation, control of diabetes, weight loss, and possibly using chemical denervation with BTA in the largest hernias are integral parts of our preoperative management and are known to decrease wound complications, rate of hernia recurrence, and overall costs.[20] Each of the patients who we operated on were counseled on these factors as part of the hernia prehabilitation process. Patients who were not medically or physically optimized were seen in clinic again prior to the scheduling of surgery. The patients also underwent pre-operative evaluation by the Transplant Hepatology team for fitness for surgery and to plan their perioperative immunosuppressive regimen. Considering a change from a medication such as sirolimus may decrease the risk of postoperative wound breakdown.[13] Close communication between the surgeon and the hepatologist aids in assuring that the patient’s immunosuppressive regimen is both beneficial for the patient’s graft while attempting to minimize surgical risk.

Intraoperatively, our technique includes excision of the patient’s prior surgical scar and the development of subcutaneous flaps. We do this to respect the blood supply from the crossing transplant incision, which helps to prevent future muscular atrophy and wound breakdown.[33] We also look for and save the deep epigastric perforators that supply much of the abdominal wall skin and subcutaneous tissues. Closing the fascia at time of operation is markedly important. It allows for the avoidance of bridging mesh, which decreases long-term recurrence rates by >5 times.[34] The use of BTA provided a means for fascial closure in patients that had significant loss of domain.[22],[23] BTA also helps to reduce need for component separation, which increases the chance of wound complications by >40% in all patients and, as mentioned previously, can increase the hernia failure rate by 5-fold.[27],[35] Only one patient in our study required component separation. This patient had a prior liver and kidney transplants and without the use of component separation, this patient’s fascia would’ve likely not been closed.

An incisional VAC is placed at the end of the operation. Incisional VACs have independently demonstrated a reduction in surgical site occurrences of up to 40% in abdominal wall reconstruction.[36] After the operation, patients resume normal function and are out of bed the day of surgery with our ERAS® program. In abdominal wall reconstruction ERAS® improves clinical outcomes and recovery of functional status, although this is controversial.[37],[38] At each step in management, before, during, and after the operation, there are factors that focus on optimizing patient outcomes.

There are limitations to this study that must be acknowledged. The preperitoneal approach to repair of incisional hernias is the common approach used in our group, but it is not often used by surgeons at other institutions. We also did not include the use of minimally invasive surgery in repair of incisional hernias in this study, but this approach did not appear to be feasible for this group due to the average size being over 300 cm2. However, we do recognize laparoscopic and robotic methods of repair have been reported with low rates of morbidity and recurrence in other studies.[39],[40] The use of prophylactic mesh placement at time of transplant is another area of study that is currently being investigated.[41]


  Conclusion Top


An open preperitoneal repair with biologic mesh, utilizing careful construction of subcutaneous flaps and incisional vac dressing is an effective method for the management of incisional hernia in liver transplant patients. Patients displayed low rates of wound complication, recurrence, and overall morbidity. The preoperative, intraoperative, and postoperative care and decision making are all important in ensuring good outcomes and preventing the need for reintervention in this patient population.

Financial support and sponsorship

Nil.

Conflicts of interest

Dr. Vedra A. Augenstein is an Editorial Board member of International Journal of Abdominal Wall and Hernia Surgery. The article was subject to the journal’s standard procedures, with peer review handled independently of this Editorial Board member and their research groups.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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