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Repair of a Recurrent Ventral Hernia after Kidney-Pancreas Transplant

Maki Yamamoto MD, Clarence E. Foster III MD, and David K. Imagawa MD, PhD University of California, Irvine, CA Challenge History
Recurrent ventral hernia repair in an immunosuppressed patient, diabetes, obesity The patient is an obese 39-year old male with a history of diabetes who had undergone a simultaneous cadaveric kidney-pancreas transplant (SPK) 3 years prior. The patient was admitted with poorly controlled blood sugars and was being evaluated for possible rejection of his transplant. The patient had undergone a laparoscopic ventral hernia repair with ePTFE mesh one year prior and presented with a recurrent ventral hernia. Since the hernia had been causing considerable discomfort, the patient elected for an open repair of his hernia during which time a pancreas biopsy could be obtained to rule out acute rejection as a cause of the hyperglycemia. Immunosuppressed patients present a unique clinical problem that highlights the important role of the immune system. These patients are not only susceptible to opportunistic organisms, but they are also at increased risk for infection from common pathogens. In addition, the organ failure that necessitates transplantation impairs the healing of the large surgical wounds left after the transplant. Immunosuppressive agents required for graft survival not only target cell- mediated immunity, but also inhibit fibroblasts and key cytokines of the Figure 1. The patient presented with a recurrent ventral hernia inflammatory response which play a valuable role in wound healing. Consequently, many patients develop incisional hernias which can become symptomatic and require repair. A midline incision was made over the previous scar. The scar was excised and the dissection was carried down through the subcutaneous tissue. Multiple dense adhesions were taken down. In the course of the dissection, a 3x3 cm defect in the fascia was noted to the right of the umbilicus. The previously placed ePTFE mesh from the initial repair was noted to be intact. The defect was dissected and incorporated into the midline fascial incision. A pancreas biopsy was obtained prior to repair of the hernia with AlloDerm. Using an underlay technique, a 4x12 cm piece of AlloDerm was sutured under significant tension in a running fashion with a 1-0 PDS suture.

susceptible to opportunistic also at increased risk for infection from common pathogens. organisms, but they are

patients...are not only


Surgical Intervention



Surgical Intervention (continued) Post-operative patient status

The inferior most aspect of the midline fascial defect was closed primarily without tension using interrupted polypropylene sutures. The skin was closed over the AlloDerm with a running suture. The entire wound was covered with a clean, dry dressing. The patient was placed in an abdominal binder and was ambulating without any difficulties on postoperative day 1. The results of the pancreas biopsy were negative for acute rejection. In fact, the hyperglycemia was caused by type II diabetes related to the patient's weight gain since the SPK. A serum C-peptide confirmed this diagnosis. He was started on an oral diabetes agent with good results. The wound was examined on post-operative day 3 and appeared to be healing well without any signs of dehiscence. He was discharged home on post-operative day 3. At 6 months follow-up, the patient was doing well with no recurrence of the hernia and no other complications. The diabetes is under control with an oral agent.

AlloDerm was chosen for its significant benefits...especially in this immunospressed transplant patient. Conclusion

For many individuals with an intact immune response, an incisional hernia may be repaired using one of several options available to the surgeon. However, the options are limited in immunosuppressed patients. For example, if a synthetic mesh is seeded with bacteria and becomes infected, it must be removed as the offending organisms are extremely difficult, if not impossible to clear with antibiotics. Also, the secondary interventions needed to deal with seromas common after the hernia repair increase the possibility of mesh infection and the need for re-operation. Figure 2. Using an underlay technique, one sheet Under these circumstances, a biological material such as of AlloDerm (4 x 12 cm) was placed in the midline AlloDerm may be preferred over a synthetic, since it may defect. be less vulnerable to infection and is even a viable option in clean-contaminated cases. Therefore, AlloDerm was chosen for its significant benefits, including its ability to support rapid revascularization for infection resistance, integration into native tissue, and resistance to adhesion formation, especially in this immunosuppressed transplant patient.
Many variables including patient pathology, anatomy, and surgical techniques may influence procedural outcomes. Before use, physicians should review all risk information, which can be found in the Directions for Use attached to the packaging of each AlloDerm graft. LifeCell Corporation
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