Feasibility and Effectiveness of Laparoscopic Incisional Hernia Repair

After Liver Transplantation

R. Gianchandani, E. Moneva, P. Marrero, M. Alonso, M.J. Palacios, J.M. Del Pino, V. Concepción,
M. Barrera, and A. Soriano

ABSTRACT
Background. Incisional hernia is a frequent problem after liver transplantation. It is
related to immunosuppression, use of steroids, obesity, as well as the type of incision.
Laparoscopic repair shows a lower rate of complications in terms of infection and
recurrence, as well as reduced postoperative pain and faster recovery.
Methods. We reviewed our experience with laparoscopic incisional hernia repair
(LIHR) in patients after liver transplantation, using the BARD Composix mesh which is
composed of two layers of polypropylene and polytetrafluoroethylene (PTFE) and fixed
with metal ProTack.
Results. Between March 2002 and April 2010, we performed 20 LIHR in 17 male and
three female subjects of overall mean age of 58.3 years, and body mass Index of 31.05
kg/m2. The mean size of the defects was 215.25 cm2. All patients had undergone bilateral
subcostal incisions with a midline extension, and seven had additional operations after the
transplantation for various reasons. There were no differences in immunosuppression.
Three patients had needed steroid boluses for acute graft rejection episodes. There was no
conversion of therapy. The size of mesh was 18 ⫻ 23 cm in seven cases and 20 ⫻ 25 in 12
cases. The mean postoperative hospital stay was 2.1 days. Oral feeding was initiated a few
hours after surgery, and routine immunosuppression was not discontinued. There were no
major early complications. During follow-up, we identified one patient with a mesh
infection (5%) and one with a recurrence (5%).
Conclusion: LIHR is safe and feasible even for major hernias after liver transplantation
with few complications.

HE REPORTED INCIDENCE of incisional hernia
T following orthotopic liver transplantation (OLT) var-
ies from 4% to 23%.1–3 Identified risk factors include male
gender, advanced age, body mass index (BMI) ⬎ 25, type of
prior incision, multiple operations, bolus of steroids, immu-
nosuppression (tacrolimus or sirolimus), stage of cirrhosis,
ascites, complications, and reoperations after OLT.4,5
Laparoscopic incisional hernia repair (LIHR) has been
shown to result in less pain, reduced postoperative ileus,
shorter length of hospital stay, earlier recovery, and re-
duced overall costs compared with traditional open repairs.
It is also associated with a decreased risk of recurrence and
infection.6,7 However despite all of the evidence, there has
been reluctance in the use of LIHR following OLT. This is
attributed mainly to the possibility of immunosuppression-
related morbidity and the extent of previous surgery. There-
fore, we undertook the following study to assess the feasi-
bility and effectiveness of LIHR post-OLT as well as its
safety profile.
MATERIALS AND METHODS
Using a comprehensive database, we undertook a retrospective
review of all OLT patients in our unit from January 1996 to April
2010. All patients were reviewed at the surgical clinic at 1, 3, 6, 12
months following OLT and then annually. Patients with large,
From the Department of General Surgery, Hospital Universi-
tario Nuestra Señora de Candelaria, Santa Cruz de Tenerife,
Spain.
Address reprint requests to Rajesh Haresh Gianchandani
Moorjani, Calle Bethencourt Alfonso n°10 38002 Santa Cruz de
Tenerife, España. E-mail: rjgianchandani@hotmail.com

0041-1345/11/$–see front matter © 2011 by Elsevier Inc. All rights reserved.

doi:10.1016/j.transproceed.2011.01.092 360 Park Avenue South, New York, NY 10010-1710

742 Transplantation Proceedings, 43, 742–744 (2011)

LAPAROSCOPIC INCISIONAL HERNIA REPAIR
symptomatic incisional hernias were offered repair; those with
small, asymptomatic hernias were treated expectantly.
The first two incisional hernia repairs in our unit were performed
using the sublay mesh open technique. However, following our
development of laparoscopic expertise, we converted to a laparo-
scopic approach early in our experience.
Briefly, patients were admitted the evening before surgery and
given their oral immunosuppressive medications in the morning
before surgery; they were continued on schedule in the evening. All
procedures were performed under general anesthesia, with stan-
dard prophylactic antibiotic cover. After induction, we inserted a
nasogastric tube and a urinary catheter.
We used three trocars (one 12 mm and two 5 mm) with a
30-degree 10-mm laparoscope. Pneumoperitoneum was estab-
lished using a Veress needle in left upper quadrant. Trocars were
placed in the left side of the abdominal wall. We dissected the
adhesions using diathermy shears and, in selected cases, a har-
monic (Ethicon) scapel. Once the defect was dissected free of
adhesions, we used a Bard Composix mesh, which has two layers,
one of polypropylene and another of polytetrafluoroethylene
(PTFE), that can be placed in direct contact with the intestine
overlapping by 5 cm in all directions. We fixed the mesh using
metal ProTack 5 mm (Covidien) with a double crown technique.
No drains were placed.
Patients were allowed oral fluids on the evening of surgery and
discharged when comfortable. Follow-up was performed at 1 week
as well as 1, 6, and 12 months postsurgery.
RESULTS
We identified 22/362 (6%) consecutive OLT patients who
required an incisional hernia repair following OLT. In
addition, we operated on one patient who developed an
incisional hernia following an OLT in another unit.
The first two cases, before 2002, were performed using an
open sublay mesh technique. Since March 2002, all cases
were attempted laparoscopically except one, which was a
complex large hernia with loss of domain. During this
period, we operated on 20 patients with LIHR, 17 males
and three females, with an overall mean age of 58.3 years
(range 43– 69; Table 1). The BMI was 31.05 kg/m2 (range
Table 1. Main Outcomes
Gender
Male 17 (85%)
Female 3 (15%)
Age (y) 58.35 (43–69)
BMI (kg/m2) 31.05 (24–44)
Time between the OLT and LIHR (mo) 41.33 (9–156)
Size defect (cm2) 215.25 (9–413)
Mesh size (cm)
8 ⫻ 10 1 renal failure. The mean length of the postoperative stay was
10 ⫻ 15 2 2.1 days (range 1–11).
18 ⫻ 23 7 During follow-up, one patient displayed a seroma, which
20 ⫻ 25 12
Operation time (min) 74.5 (25–180)
Length of stay (d) 2.1 (1–11)
Follow-up (mo) 54 (1–98)
BMI, body mass index; OLT, orthotopic liver transplantation; LIHR, laparo-
scopic incisional hernia repair.
Data expressed in means and ranges.
743
Table 2. Indications for Liver Transplantation
n
Alcoholic cirrhosis 11
Hepatocarcinoma ⫹ alcohol 1
Hepatitis C virus 2
Hepatitis C virus ⫹ alcohol 2
Hepatitis C virus ⫹ hepatocarcinoma 3
Autoimmune cirrhosis 1
24 – 44). The indications for the OLT are shown in Table 2.
The majority of patients were cirrhotic secondary to alco-
holic liver disease or hepatitis C. After the OLT, the
immunosuppression included tacrolimus (n ⫽ 7), tacroli-
mus plus mycophenolate mofetil (n ⫽ 3), cyclosporine (n ⫽
7), or cyclosporine plus mycophenolate mofetil (n ⫽ 3).
Acute rejection episodes observed in three patients were
treated with steroid boluses. The main medical complica-
tions after OLT among this group had been acute rejection
(n ⫽ 3), hydropic decompensation (n ⫽ 4), diabetes melli-
tus (n ⫽ 8), acute renal failure (n ⫽ 5), arterial hyperten-
sion (n ⫽ 4), and thrombocytopenia (n ⫽ 1).
Seven patients had needed a reoperation after OLT due
to bleeding (n ⫽ 2), one of whom required a splenectomy),
retransplant (n ⫽ 1), hepaticojejunostomy (n ⫽ 1), right
hemicolectomy (n ⫽ 1), oophorectomy (n ⫽ 1), or umbilical
hernia repair (n ⫽ 1).
The median time between the OLT and the LIHR was 27
months (range ⫽ 9 –156 m). The single patient who under-
went LIHR after 156 months undergone had the OLT in
another institution in 1991.
All patients initially had bilateral subcostal incisions with
a midline extension. The majority of hernias were located at
the trifurcation. The defects showed a mean size of 215.25
cm2 (range ⫽ 9 – 413 cm2) and were repaired with Bard
Composix mesh. The required mesh sizes were 20 ⫻ 25 cm
(n ⫽ 12), 18 ⫻ 23 cm (n ⫽ 7), 10 ⫻ 15 cm (n ⫽ 2), and 8 ⫻
10 cm (n ⫽ 1). One patient needed three overlapping
meshes due to the large defect.
The mean operative time was 74.5 minutes (range 35–
120). Postoperative pain was controlled with oral analgesia.
All patients restarted oral feeding and scheduled immuno-
suppression a few hours after surgery.
There were no major immediate complications. One
patient developed port site bleeding and another ascites,
which needed medical treatment. A third patient experi-
enced a prolonged 6-days hospital stay awaiting a transjugu-
lar biopsy. We observed no cases of graft failure or acute
resolved without intervention, and another, a mesh infec-
tion requiring removal 2 years later. We had one recur-
rence, the patient with a BMI of 37 had undergone a
reoperation for hepaticojejunostomy. He developed a re-
currence at 4 years after the LIHR and underwent another
LIHR with mesh. Unfortunately, 2 years later, the inci-
744
sional hernia recurred and was treated again with LIHR. At
present, at 2 years after the last operation, he remains well
without any sign of recurrence.
DISCUSSION
Our observed 6% incidence of symptomatic incisional
hernia is consistent with 4% to 23% noted in recently
published studies. Many risk factors predispose to the
development of incisional hernia following OLT, such as
male gender, high BMI, immunosuppression, steroids, and
type of incision. In our patient cohort, all of the affected
individuals had at least one of these risk factors. All patients
had a bilateral subcostal incision with a midline extension,
which has been reported to confer a high risk to develop an
incisional hernia.1,2,4,5 Because of this relatively high inci-
dence, we started using a “J” incision in selected cases,
namely a right subcostal with a midline extension after
2007. This choice was based on liver size, previous surgery,
and surgeon’s preference. Among this group of 61 patients,
we have not yet observed any incisional hernias during a
follow-up of more than 3 years (unpublished data).
In many studies LIHR has proven to be a safe, effective
technique in nontransplant patients.6,7 The low rate of
complications include infection (1%–3%) and recurrence
(3%–10%). In addition there is prompt recovery. Despite
these observations, there have been few studies evaluating
the effectiveness of LIHR after OLT. Indeed, our series of
20 consecutive patients is the second largest presented to
date. The longest published series included 21 patients,8
and other reports have included between 9 and 17 pa-
tients.9 –11
After the development of laparoscopic surgery in our
hospital in 2000, we have attempted more complex surgery
with this approach. Since 2002, we have operated all
incisional hernias after OLT using laparoscopy. Only one
case used an open sublay technique in March 2010, due to
a large hernia with loss of domain. We had no conversions
despite operating on patients with large hernias. Our data
showed minimal complications and short postoperative
hospital stays despite being a complex group of patients.
Discontinuation of immunosuppression even for short pe-
riods carries a risk of graft rejection. In our series, oral
GIANCHANDANI, MONEVA, MARRERO ET AL
tolerance of fluids and medications including immunosup-
pessants was possible in all patients in the immediate
postoperative period. During the mean follow-up of 54
months, only one patient experienced a mesh infection
(5%) and another, a recurrence (5%), which was also able
to be approached laparoscopically. These data are compa-
rable to recent studies of this topic.8 –11
In conclusion, our data supported LIHR following
OLT as safe and feasible with a low rate of complications
or recurrence. Therefore, we recommend LIHR as the
standard approach for symptomatic incisional hernias
following OLT.
REFERENCES
1. Gómez R, Hidalgo M, Marques E, et al: Incidence and
predisposing factors for incisional hernia in patients with liver
transplantation. Hernia 5:172, 2001
2. Piazzese E, Montalti R, Beltempo P, et al: Incidence, predis-
posing factors, and results of surgical treatment of incisional hernia
after orthotopic liver transplantation. Transplant Proc 36:3097,
2004
3. Vardanian AJ, Farmer DG, Ghobrial RM, et al: Incisional
hernia after liver transplantation. J Am Coll Surg 203:421, 2006;
Epub 2006 Aug 17
4. Janssen H, Lange R, Erhard J, et al: Causative factors,
surgical treatment and outcome of incisional hernia after liver
transplantation. Br J Surg 89:1049, 2002
5. Kahn J, Müller H, Iberer F, et al: Incisional hernia following
liver transplantation: incidence and predisposing factors. Clin
Transplant 21:423, 2007
6. Heniford BT, Park A, Ramshaw BJ, et al: Laparoscopic
ventral and incisional hernia repair in 407 patients. J Am Coll Surg
190:645, 2000
7. LeBlanc KA, Booth WV, Whitaker JM, et al: Laparoscopic
incisional and ventral herniorrhaphy in 100 patients. Am J Surg
180:193, 2000
8. Harold K, Mekeel K, Spitler J, et al: Outcomes analysis of
laparoscopic ventral hernia repair in transplant patients. Surg
Endosc 23:1835, 2009
9. Andreoni K, Lightfoot H, Gerber D, et al: Laparoscopic
incisional hernia repair in liver transplant and other immunosu-
prresed patients. Am J Transplant 2:349, 2002
10. Mekeel K, Mulligan D, Reddy KS, et al: Laparoscopic
incisional hernia repair after liver transplantation. Liver Transpl
13:1576, 2007
11. Kurmann A, Beldi G, Vorburger S, et al: Laparoscopic
incisional hernia repair is feasible and safe after liver transplanta-
tion. Surg Endosc 24:1451, 2010