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 Table of Contents     
ORIGINAL ARTICLE
Year : 2016  |  Volume : 12  |  Issue : 1  |  Page : 58-62
 

The usefulness of laparoscopic hernia repair in the management of incisional hernia following liver transplantation


1 Department of Liver Transplant and Hepatobiliary Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, National Liver Institute, University of Menoufiya, Menoufiya, Egypt
2 Department of Liver Transplant and Hepatobiliary Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; Department of General Surgery, University Of Alexandria, Faculty of Medicine, Menoufiya, Egypt
3 Department of Liver Transplant and Hepatobiliary Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia

Date of Submission28-Sep-2014
Date of Acceptance23-Nov-2014
Date of Web Publication17-Dec-2015

Correspondence Address:
Mohamed Rabei Abdelfattah
Department of Liver Transplantation and Hepatobiliary Surgery, MBC 72, King Faisal Specialist Hospital and Research Center, Riyadh - 11211, P.O box 3354. Kingdom of Saudi Arabia

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9941.152102

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 ¤ Abstract 

Introduction: The reported incidence of incisional hernia following orthotopic liver transplantation (OLT) varies from 4% to 23%. Postoperative wound complications are less frequent after laparoscopic repair while maintaining low recurrence rates. We present our experience in managing this complication. Materials and Methods: Retrospectively, collected data of all patients who underwent liver transplant and developed incisional hernias were analyzed. Patients' demographic data, anthropometric data, transplantation-related data, and repair-related operative and postoperative data were collected. Risk factors for post-transplant incisional hernia were appraised in our patients. Patients were divided into two groups: Group A included patients who had their incisional hernia repaired through the laparoscopic approach, and Group B included patients who had their incisional hernia repaired through open conventional approach. Results: A total of 488 liver transplantations were performed at our institution between May 2001 and end of December 2012. Thirty-three patients developed incisional hernias after primary direct closure of the abdominal wall with an overall incidence of 6.9%. Hernia repair was done in 25 patients. Follow-up ranged from 6.4 to 106.1 months with a mean of 48.3 ± 28.3 months. All patients were living at the end of the follow up except four patients (16%). Group A included 13 patients, and Group B included 12 patients. The size of defects and operative time did not differ significantly between both the groups. On the other hand, hospital stay was significantly shorter in laparoscopic group. Complication rate following laparoscopic repair was insignificantly different for open repair. Conclusion: In experienced hands, laparoscopic incisional hernia repair in post-liver transplant setting proved to be a safe and feasible alternative to open approach and showed superior outcome expressed in shorter hospital stay, with low recurrence and complication rate.


Keywords: Incisional hernia, liver transplant, laparoscopic repair


How to cite this article:
Hegab B, Abdelfattah MR, Azzam A, Al Sebayel M. The usefulness of laparoscopic hernia repair in the management of incisional hernia following liver transplantation. J Min Access Surg 2016;12:58-62

How to cite this URL:
Hegab B, Abdelfattah MR, Azzam A, Al Sebayel M. The usefulness of laparoscopic hernia repair in the management of incisional hernia following liver transplantation. J Min Access Surg [serial online] 2016 [cited 2019 Nov 18];12:58-62. Available from: http://www.journalofmas.com/text.asp?2016/12/1/58/152102



 ¤ Introduction Top


Incisional hernia is a common and often debilitating complication after laparotomy. Despite significant advances in many areas of surgery, correction of incisional hernias continues to be problematic, with recurrence rates ranging from 5% to 63% depending on the type of repair used. [1] With the introduction of modern two-layered mesh, laparoscopic incisional hernia repair has become an accepted therapeutic option. Many authors have reported recurrence rates between 3.4% and 10% and very low serious infection rates (1%-3%) with the laparoscopic mesh repair. [2],[3],[4],[5] Open prosthetic repair displays a recurrence rate of 10%-20%, but an infection rate that ranges from 5% to 12% in many large series. [6],[7] The open mesh repair also is reported to have a longer hospital stay, longer time to resolution of ileus, and prolonged postoperative pain compared with the laparoscopic repair. [8],[9] The reported incidence of incisional hernia following orthotopic liver transplantation (OLT) varies from 4% to 23%. [10],[11],[12],[13],[14] The risk factors for incisional hernia formation after liver transplantation include advanced age, male gender, obesity, use of steroids, wound infection, incision type, and reoperation. [15],[16],[17] Mesh and tissue repair were used to treat incisional hernia following OLT. Multiple studies demonstrated that mesh repair decreases the risk of recurrence without increasing the risk of infection in this subset of patients. These studies demonstrate recurrence rates ranging from 6% to 15%. [10],[11],[12],[13],[14] Similarly, many studies reported excellent outcome of laparoscopic repair of incisional hernia. [2],[3],[15],[16],[17],[18] We report here our institutional experience for repair of post-OLT incisional hernia.

Objectives

  • To report our institutional experience for development of post-transplant incisional hernia and to detect risk factors for such complication.
  • To report our institutional experience for laparoscopic repair of incisional hernias following liver transplantation.
  • To compare outcome of both laparoscopic and conventional open approach in the management of incisional hernias following liver transplantation.



 ¤ Materials and Methods Top


Retrospectively collected data of all patients who underwent liver transplant and developed incisional hernias were analyzed.

Liver transplant is done at our institution through bilateral subcostal incision with upward vertical extension. Our post-transplant immunosuppression protocol entails the use of triple therapy, including calcineurin inhibitor (CNI), mycophenolate mofetil (MMF), and corticosteroids. Steroids are usually stopped within 3 months post-transplant unless the patient had autoimmune hepatitis as indication for liver transplant. MMF is usually stopped within 2 years following liver transplant. CNI is usually continued for life. The patient is shifted to sirolimus if he develops major complication on either CNI drugs. Sirolimus is to be stopped for at least 6 weeks before attempted repair of incisional hernia and is not started before 6 weeks at least after repair. Decision was taken to proceed to laparoscopic or open repair based on the anesthetic clearance of patient to undergo laparoscopic procedures.

Our technique for laparoscopic repair entails creation of pneumoperitoneum using Veress needle passed into the abdominal cavity through a skin puncture mostly in the left upper quadrant. Carbon dioxide insufflation is used to obtain a pressure of 15 mmHg. Following this and with the help of a 5-mm, 30° viewing scope, three trocars are positioned as follows: 10 mm trocar in the left side of the abdomen midway between costal margin and iliac crest along the midaxillary line, 5 mm trocar located next to the left costal margin along the anterior axillary line, and the last 5 mm trocar is inserted next to the left iliac crest along the anterior axillary line also.

After application of the needed dissection using vascular sealing device, the edges of the hernia defect are clearly identified. A suitable size polyester mesh PARIETEX Composite mesh (Covidien, Mansfield, MA, USA) is fashioned and passed to the abdomen and spread to cover the edges of the defect 5 cm radially. The mesh was then fixed to the abdominal wall by multiple stay sutures of number 0 GORE-TEX ® Suture (W. L. Gore disposable W. L. Gore and Assoc., Flagstaff, AZ, USA) fixed in place using fascial closure device. This was then reinforced by multiple applications of 5-mm metal 5-mm spiral tacking device PRO-TACK (AutoSuture Pro Tack A .174006, US Surgical, Fort Worth, TX, USA). Trocars are then removed and abdomen is deflated. A 10 mm trocar site is closed using 2/0 polyglycolic acid suture. Then skin is closed using metal clips followed by pressure dressing.

On the other hand, our technique for the open hernia repair entails dissection and excision of hernia sac. Closure of the defect is then done using interrupted number 1 prolene suture. This is to be followed by onlay mesh repair using synthetic prolene mesh to cover the repaired defect and to extend beyond its edges by 5 cm all around. Closed suction drainage of 12 F size is used for big-sized hernias with extensive dissection. Closure of skin is done using metal clips.

Patients' demographic data, anthropometric data, and transplantation-related data

Risk factors for post-transplant incisional hernia were appraised in our patients. Age > 60 years, body mass index (BMI) > 28 kg/m 2 , and presence of ascites > 4 L at the time of liver transplant were considered as our institutional risk cutoff level for age, obesity, and ascites, respectively. Repair-related operative and postoperative data were collected including operative time, number of defects, defect size, mesh size, postoperative complications, hospital stay, and hernia recurrence. All patients undergo clinical screening for development of incisional hernias for the first 2 years. Size of the hernia defect was measured using clinical estimation of width and length of the defect. The width was measured as the widest horizontal distance between the lateral margins of the hernia defect on both sides. Similarly, the length was measured as the widest vertical distance between the most upper and the lower margin of the defect.

In case of multiple hernia defects that will be reconstructed using a single sheet of mesh, it was measured using the following method: The width was considered as the widest measurement between the most laterally located margins of the most lateral defects. Likewise, the length is the widest measurement between the upper margin of the most cranial defect and the lower margin of the most caudal defect. In case of multiple defects, which are lying far from each other and that will reconstructed multiple sheets of mesh, it was measured by applying the same roles used for single defect measurement to each of these defects. Radiological estimation of hernia defect per se was not part of our preoperative evaluation of incisional hernia patients.

For the sake of analysis, the patients who had incisional hernia repair were divided into two groups:

Group A: Laparoscopic incisional hernia repair
Group B: Open incisional hernia repair.

Both the groups were compared with regard to operative and postoperative variables. For surviving patients, follow up was estimated till the end of August 2014, whereas date of death was considered as the end of the follow up for dead patients. Follow up was done on dedicated clinical visits to assess healing and to exclude recurrence. The patient is seen in the outpatient clinic on weekly basis for the first month after discharge from the hospital. Then patient will be seen monthly for the first 6 months and then at least every 3 months for the first 2 years after repair. Hernia recurrence was detected using clinical examination. Ultrasound or computed tomography scan was used to role out clinically uncertain cases. Graft function follow up was usually conducted by separate dedicated team in the same clinical visit.


 ¤ Results Top


A total of 488 liver transplantations were performed at our institution between May 2001 and end of December 2012. Thirty-three patients developed incisional hernias after primary direct closure of the abdominal wall with an overall incidence of 6.9%. Hernia repair was done in 25 patients. They were 6 females and 19 males (24% and 76%, respectively). Liver transplant was done from deceased donor in 18 patients (72%) and from living donor in 7 patients (28%). The follow-up ranged from 6.4 to 60.1 months with a mean of 48.3 ± 28.3 months. All patients were living at the end of the follow up except four patients (16%). [Table 1] shows the relative incidence and significance of various risk factors among patients who had and who had no post-liver transplant incisional hernia.
Table 1: Incidence of different risk factors among incisional hernia and nonhernia patients with their statistical significance

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Group A included 13 patients (52%) who had their incisional hernia repaired through the laparoscopic approach. None of the laparoscopic repairs were converted in our study. On the other hand, Group B included 12 patients (48%) who had their incisional hernia repaired through open conventional approach. None were on sirolimus in Group A compared with two patients in the open group who were on sirolimus 6 weeks before the repair and they were not shifted back to sirolimus except after another 6 weeks. Three of our patients were on low-dose steroids at the time of open repair and another three were on low-dose steroid at the time of laparoscopic repair. Three patients had needed steroid boluses for biopsy-proven acute graft rejection episodes all of them were in Group A. [Table 2] compares different variables in both the groups.
Table 2: Comparison of different variables in both the groups

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In Group A, the interval between transplant and repair of incisional hernia ranged from 331 to 840 days with a mean of 613.4 ± 167 days. In Group B, it ranged from 297 to 904 days with a mean of 598.3 ± 197.2 days, P = 0.97. In Group A, the interval between transplant and hernia detection ranged from 127 to 648 days with a mean of 393.8 ± 160.4 days. And it ranged from 92 to 705 days in Group B with a mean of 389 ± 190 days, P = 0.89.

Size of defects did not differ significantly between both the groups, P value of 0.61. Median mesh size of laparoscopic group was 294 ± 182 cm 2 compared with 346.3 ± 281.4 cm 2 in Group B; P value 0.7. Operative time was insignificantly longer in the laparoscopic group with P value of 0.21. Laparoscopic group had a shorter mean postoperative stay compared with open group, 1.25±0.45 versus 2.6±0.5 days, respectively. Despite this small difference in postoperative hospital stay-1 day shorter in laparoscopic group - this was found to be statistically significant, P = 0.0001.

None of the patients in Group B were complicated following repair. On the other hand, only one patient was complicated by intraabdominal hematoma between the mesh and the omentum, which was managed by laparoscopic re-exploration. Regardless of this complication, complication rate following laparoscopic repair was insignificantly different for open repair, P = 1.0. None of the patients in either groups developed wound infection. At the end of the follow up, none of the patients developed recurrence of incisional hernia in Group B. On the other hand, only one patient developed recurrent incisional hernia 22 months following laparoscopic repair. The recurrent hernia was repaired after 11 months by open approach. Operative findings reported recurrence at the edge of the laparoscopically inserted mesh. Despite this, recurrence rate following laparoscopic repair was insignificantly different for open repair, P = 1.0. Unfortunately, data on the cost of incisional hernia repair at our institution was not detailed enough to be compared in each group.


 ¤ Discussion Top


The reported incidence of incisional hernia following OLT varies from 4% to 23%. Post-liver transplant incisional hernia occurred in 6.9% of our liver transplant patients, which falls within the reported range of this complication; fortunately toward its lower limit. This also can be attributed to detection of hernia using clinical examination only.

The risk factors associated with the development of post-liver transplant incisional hernia at our center included large volume of ascites at time of surgery; male gender, and BMI > 28 kg/m 2 and to a lesser extent with age > 60 years, and reoperation. Similarly, Kurmann et al. concluded that significant risk factors for development of incisional hernia were male gender and BMI greater than 25 kg/m 2 .

In this study, we compared 13 completed laparoscopic incisional hernia repairs to 12 open conventional incisional hernia repairs. Our cohort is comparable to reports which included comparison of laparoscopic to open repair for incisional hernia following liver transplant. Andreoni et al.[3] compared 9 completed laparoscopic repairs to 12 open repairs following liver transplant, Mekeel et al.[2] compared 13 laparoscopic repairs to 14 open repairs, Kurmann et al.[17] compared 31 patients who underwent open repair, and 13 who underwent laparoscopic repair for incisional hernia following liver transplant, and Scheuerlein et al.[18] compared 15 laparoscopic repairs versus 14 conventional open hernia repair.

Theoretically, incisional hernia in post-liver transplant patients carries some special problems. These might include technical difficulties due to the extent of surgery, which entails occasionally a repair midline hernia nearby the xiphoid process. Additionally, some technical difficulties can be encountered due to the presence of dense adhesions. Other problems are related to expecting prolonged or weaker healing. This can be usually attributed to the prolonged use of immunosuppressive medications, including steroids and the otherwise sick patients because of ESLD. Moreover, complexity of liver transplant patients might extend the length of stay after surgery due to problems unrelated to the actual hernia operation. These other issues include transplant graft dysfunction, adjustment of immunosuppressive medications, or treatment of an abnormality discovered from intraoperative biopsy of the transplant organ.

In this regard, our series showed that post-liver transplant setting displayed comparable degree of difficulties as with any other setting. This was demonstrated by comparable operative time, hospital stay, conversion, and complication rates. In their meta-analysis, Bedi et al.[5] reported a mean operative time of 96.5 min and a mean hospital stay of 54.9 h for a mean defect size of 108. 74 cm 2 and a mean mesh size of 268.61 cm 2 . In our series, we report a mean operative time of 97.5 min and a mean hospital stay of 30 h for a mean defect size of 132.7 cm 2 and a mean mesh size of 293.8 cm 2 . Our postoperative hospital stay was noticeably shorter than what was reported in this meta-analysis. This is explained by our protocol to discharge the post-liver transplant recipient, who is otherwise normal, as soon as possible to minimize the chance of getting nosocomial infections. We usually discharge our post-liver transplant recipients to a nearby hospital housing.

Bedi et al. reported 2.26% mean conversion rate, 1.2% hematoma formation, and 3.7% recurrence rate. This is compared with 7.7% hematoma and recurrence rate and zero percent conversion rates in our series. These small differences in complication and conversion rates are attributed to the small series size in our study.

We reported insignificantly shorter operative time in the laparoscopic repair compared with the open repair. This can be attributed to the relatively larger hernias in open repair group. Shorter hospital stay in laparoscopic group was noted compared with open group. Similar results were reported by Scheuerlein et al., which corresponds to the general findings that hospital stay is shorter in laparoscopic hernia repair. On the contrary, Mekeel et al. reported the length of stay to be significantly longer in the laparoscopic group compared with open group. The author explained this odd finding by occurrence of prolonged admissions for two patients in the laparoscopic group who had postoperative fevers without documented infection, confusion, and elevated liver function tests. Additionally, laparoscopic group also had significantly larger hernias when compared with the open group, which might have contributed to increased pain and a longer postoperative recovery.

We had only one case of recurrent hernia following laparoscopic repair (7.7%) compared with none in the open group. Comparatively; recurrence rate following laparoscopic incisional hernia repair in the setting of liver transplant varied between 5% and 15% in various reports. These findings matched well with our results. On the other hand, recurrence rate following open incisional hernia repair in the setting of liver transplant varied between 29% and 50% in the literature. Conversely, in our study we failed to show such high recurrence rate in the open group, which may be attributed to larger proportion of patients on Sirolimus in these reports. Scheuerlein et al. reported that 10 patients were on sirolimus before hernia repair mainly in the open group.

In our report, none of the cases in the open group was complicated compared with only one complication that required reoperation to control bleeding in the laparoscopic group (7.7%). In a similar trend, Scheuerlein et al. reported a higher complication rate in laparoscopic group compared with the open group (33% vs 21%, respectively). On the contrary, Mekeel et al. and Kurmann et al. reported a higher complication rate in the open group compared with laparoscopic group. This contradiction can be explained by small series number and the inconsistency of reporting of what should be considered as complications, especially when most of these reports including ours were based on retrospective data collection.


 ¤ Conclusion Top


In experienced hands, laparoscopic incisional hernia repair in post-liver transplant setting proved to be a safe and feasible alternative to open approach and showed superior outcome expressed in shorter hospital stay, low recurrence, and complication rate. The need for larger, prospectively designed controlled trials is clearly recognized. It should use unified complication reporting system and takes in consideration confounding factors such as immunosuppressive medications.

 
 ¤ References Top

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