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Despite the wide popularity of laparoscopic incisional hernia repair (LIHR) in the nontransplant population, there are very few reports of LIHR available in abdominal organ transplant patients and none exclusively on kidney and/or pancreas (KP) transplant patients. We retrospectively reviewed a consecutive series of LIHR in KP transplant recipients performed over a period of 4 years and compared the results with LIHR in non-transplant patients during the same period. A total of 36 transplant patients were compared with 62 nontransplant patients. There were five patients converted to the open procedure in the transplant and four in nontransplant patients (p-NS). There were three seromas and one patient had a bowel perforation in the transplant group versus eight seromas, one bowel perforation and one small bowel obstruction noted in the nontransplant group. One patient in each group had a mesh infection requiring explant. Patients were followed up for a mean period of 2.2 years in the transplant group and 3 years in the nontransplant group. Overall there were five recurrences in the transplant group and four in the nontransplant group (p = NS). These results suggest that that LIHR is a safe and effective alternative to open repair.
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The incidence of incisional hernia after laparotomy varies between 10% and 50% (1). Incisional hernias occur in an estimated 17% of patients after liver transplantation and 4% after kidney transplantation (2,3). Of the various methods of repair, laparoscopic incisional hernia repair (LIHR) has become popular because of the documented decrease in hospital stay, complication and recurrence rates (4–6). Traditionally, incisional hernias in organ transplant patients were repaired by open primary closure alone. Surgeons were reluctant to use prosthetic mesh in immunosuppressed patients for the fear of wound-related complications (2,7–9). Recently, use of mesh for incisional hernia repair was found to be safe in solid organ transplant patients (2,7,10). The success of LIHR in nontransplant patients has warranted this approach in the surgical management of incisional hernia in transplant patients. Despite this, there are only a few published reports of LIHR in organ transplant patients, and none exclusively on kidney and/or pancreas (KP) transplant patients.
Several factors determine the safety and effectiveness of LIHR in KP transplant recipients:
First, of the various immunosuppressive medications; mTOR inhibitors, mycophenolate mofetil (MMF) and steroids are used more frequently in KP recipients than other solid organ recipients. mTOR inhibitors and steroids are known to affect wound healing. Rapamycin, in particular, is reported to have a higher rate of wound-related complications due to its inhibitory effect on several factors critical to wound healing (11,12) and problems in mesh incorporation after prosthetic mesh repair (13). It is recommended that immunosuppressed patients should not be treated with rapamycin after incisional hernia repair to allow adequate mesh incorporation (13).
Second, the incidence of peritoneal adhesions after abdominal surgery has been reported to be as high as 93% and up to 70% of small bowel obstructions are due to peritoneal adhesions (14,15). Bowel obstruction secondary to peritoneal adhesions after organ transplantation has been very low. This could possibly be due to immunosuppressant medication (16). This is of great relevance during LIHR because adhesiolysis is one of the critical steps that determine the ability to successfully complete the laparoscopic repair and determines the risk of bowel injury. Based on this evidence it may be technically easier to do LIHR in transplant patients than in nontransplant patients.
Third, some KP transplant patients require both midline and lower abdominal hockey stick incisions and this puts at the patient higher risk for incisional hernias. In addition, incisional hernias closer to bony prominences such as lower abdominal hockey stick incisions are notoriously difficult to repair. Recent advances in laparoscopic repair of incisional hernias closer to bony prominences encourages LIHR role in such cases (17,18).
Fourth, certain diseases, leading to KP transplantation such as autosomal dominant polycystic kidney disease (ADPKD) have a higher than average risk for occurrence of incisional hernias (19). There are no reports of LIHR in this group of patients.
Finally, obesity is prevalent among KP transplant recipients and predicts an increased risk of morbidity and mortality (20). Though earlier studies reported higher recurrences (21–24), several recent studies show that LIHR is safe and effective with no significant difference in perioperative complications or recurrence rates between obese and nonobese patients. Some studies reported that the recurrence rates were correlated with the size of the fascial defect, but not on degree of obesity (25).
We have been utilizing LIHR for a selected group of KP patients. Given the concerns noted above, the aim of the present study is to compare the outcome of LIHR in the transplant and the nontransplant patients.
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The patient characteristics are shown in Table 2. There are no age and gender differences between the groups. It is not unexpected that in the transplant group all the patients are on some form of immunosuppression whereas in the nontransplant group only four patients (with Crohn's disease) are on immunosuppressive agents (azathioprine in two patients and prednisolone in two patients). In addition, significantly higher number of transplant patients are on steroids. Immunosuppression regimes in the transplant group include a combination of tacrolimus and MMF in 26 patients; tacrolimus, MMF and prednisone in five patients; cyclosporine, MMF and prednisone in three patients; cyclosporine, azathioprine and prednisone in one patient and one patient is on rapamycin monotherapy. As shown in Table 2, patients in the transplant group had incisional hernias at multiple sites adding to the complexity of management.
Table 2. Patient characteristics
|Parameter||Transplant patients (n = 36)||Nontransplant patients (n = 62)||p Value|
|Age (mean age in years)||55.1||56.4||NS|
|BMI (mean)1||29 ± 5||35||<0.001|
| Less than 30||20||14|| |
| 30–40||13||30|| |
| over 40||2||14|| |
|No. of prior surgeries at the incision site||2.3(1–6)||2.2 (1–6)||NS|
|Previous hernia repair||12||25||NS|
| Lateral/transverse||13||2|| |
| Midline and lateral||3||0|| |
|Converted to open procedure||5||4||NS|
Mean BMI was 29.5 and 35 in the transplant and the nontransplant group, respectively, and the nontransplant group tends to have significantly higher percentage of obese patients than the transplant group. There were 15 obese patients in the transplant and 44 obese patients in the nontransplant group. Midline incisions were the dominant type in both groups and in the transplant group a significantly higher number of patients had a combination of midline and lower abdominal transverse incisions. Conversion to open surgery was necessary in 5 (15%) of the 36 transplant patients and 4 (6%) of 62 in nontransplant group. In the transplant, group, conversion was required due to: difficulty in controlling omental-bleeding (3 patients) severity of adhesions (1 patient), difficulty in identifying the lateral extent of the defect (1). In the nontransplant group, conversion was due to dense adhesions in three and inability to create a pneumoperitoneum safely in one. Of note, four out of five conversions in the transplant group occurred in the first year after institution of LIHR. Patients converted to an open operation were included in the analysis of perioperative results and complications as intent to treat but were excluded from the long-term follow-up analysis.
Hernia characteristics are shown in Table 3. There is no significant difference in the size of the hernia, number of prior repairs and duration of hospital stay between the groups. In the transplant group, Parietex mesh was used more frequently and DualMesh was preferred in the nontransplant group. This is purely surgeon's preference. The type of mesh used was significantly different in both groups. The diseases and procedures leading to incisional hernias are listed in Table 4.
Table 3. Hernia characteristics of patients in successful LIHR patients
| ||Transplant patients (n = 31)||Nontransplant patients (n = 58)||p-Value|
|Primary repair|| 22|| 33|| |
|First recurrence|| 6|| 20||NS|
|>1 prior repairs|| 3|| 5|| |
| Parietex|| 23|| 2||<0.001|
| DualMesh|| 7|| 54|| |
| Bard Composix|| 1|| 2|| |
|Prosthesis size (mean in cm2)||405||423||NS|
|Postoperative hospital stay (mean in days)|| 3|| 3.3||NS|
|Follow-up (mean in years)|| 2.3|| 3.1||0.004|
Table 4. The diseases and procedures leading to incisional hernia
|Type of surgery||Disease||N = 36||Type of surgery||Disease||N = 62|
|Kidney and pancreas transplantation (n = 10)|| ||12||Gastric bypass||Morbid obesity||16|
|Pancreas transplant alone (n = 2)||Type 1 diabetes mellitus (DM)|| ||Prior Colectomy||Colorectal cancer|| 8|
| || || ||Crohn's disease|| 5|
| || || ||Ulcerative colitis|| 4|
| || || ||Diverticular disease|| 3|
| || || ||Carcinoid|| 2|
| || || ||Rectal prolapse|| 1|
|Kidney transplant alone (n = 24)||Type 2 DM|| 7||Prior urologic surgery||Renal cell cancer|| 2|
| || || ||Prostate cancer|| 1|
|ADPKD|| 7||Prior gynecologic surgery||Gynecological cancer|| 4|
| || || ||C section|| 1|
|Glomerulonephritis|| 6||Miscellaneous|| ||15|
|Miscellaneous|| 4|| || || |
Overall, one patient in each group died during follow-up due to unrelated causes at 3.5 and 1.5 years respectively, after hernia repair. The complications are listed as per revised Clavien Grading and shown in Table 5. Two patients had features of an acute abdomen postoperatively in the transplant group; one patient underwent laparoscopy on POD 2 and no pathologic etiology was identified. Another had laparotomy on POD 2 and a perforation in the small bowel was noted. The perforation repaired and the mesh explanted for fear of infection. One other patient in the transplant group required mesh explant for the infected mesh. This resulted from IR guided seroma drainage. In the nontransplant group, one patient presented with an acute abdomen on POD 7 and was found to have a bowel perforation on laparotomy. The bowel perforation was repaired and the mesh explanted for fear of infection. Another patient had mesh explanted for infected mesh from an uncontrolled wound infection.
Table 5. Complications and management of LIHR in the transplant and the nontransplant groups
|Clavien grading and type of complication1||Transplant patients (N = 31)2||Nontransplant patients (N = 57)2|
| Paralytic ileus||3|| 5|
| SBO managed conservatively||0|| 1|
| Seroma-resolved conservatively||1|| 4|
|Grade II||4|| 5|
| Wound infection||0|| 1|
| UTI||2|| 2|
| Acute DVT||0|| 1|
| Atrial fibrillation||2|| 1|
|Grade IIIa||2|| 4|
| Seroma-required IR drainage|| 23|| 44|
|Grade IIIb||4|| 4|
| Acute abdomen||2|| 1|
| SBO||0|| 1|
| Mesh explant||2|| 2|
|Grade IV||0|| 0|
|Grade V||0|| 0|
|Recurrence||5 (16%)||4 (7%)|
To determine the influence of patient and hernia characteristics (listed in Tables 2 and 3) on occurrence of complications, a multivariate analysis was performed. None of factors influenced the occurrence of complications except BMI and mesh size, which directly correlated with seroma development.
Five of 31 patients (16%) in the transplant group and 4 of 57 (7%) in nontransplant group had a recurrence of the hernia at a median follow-up of 2.2 and 3 years, respectively. The details of recurrent hernia are listed in Table 6. Of note, three of the five recurrences in the transplant group (three recurrences in a total of seven patients with ADPKD) occurred in patients with ADPKD. Two of these patients had multiple recurrences at different points along the incision. Another factor contributing to the high recurrence rates (two out of four in the nontransplant group and one out of five in the transplant group) is mesh infection, leading to mesh explant with subsequent recurrence.
Table 6. Recurrences
|Serial no.||Primary disease and type of surgery||Type of incision||BMI||No. of prior surgeries||Comments|
|The transplant group|
|1||ADPKD-KTx|| M & L||29||2||Repaired ×5, recurrence at multiple locations of both incisions|
|2||DM – SKP|| M||27||1||Not repaired|
|3||ADPKD-KTx|| M & L||26||2||Mesh explant due to infection—not repaired|
|4||ADPKD-KTx|| M & L||26||4||Recurrence multiple times|
|The nontransplant group|
|1||Morbid obesity-gastric bypass|| M||31||4||–|
|2||Colorectal cancer-colectomy|| M||27||1||Trocar site hernia|
|3||Colorectal cancer-colectomy|| M||39||3||Mesh explant due to infection—not repaired|
|4||Gynecological-hysterectomy|| M||42||2||Mesh explant due to infection—not repaired|
Although there is an apparent trend of higher recurrence rate in transplant patients compared to nontransplant patients, the difference did not reach statistical significance. Multivariate analysis also do not show any patient and hernia-related factors correlated with occurrence of recurrence. Similarly, there is no difference in recurrence rates between obese and nonobese patients in the transplant and nontransplant group (intragroup analysis).
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LIHR has gained popularity in this decade and several studies reported overall improvement in hospital stay, complications and patient outcomes (1,4–6,30). Several advantages of LIHR over conventional surgery are reported: LIHR provides wide mesh overlap in an underlay position similar to the open retro-rectus repair without any tissue dissection (31). Component separation techniques for hernia repair have become increasingly popular and permit primary closure of the fascia with mesh reinforcement, often with biologic materials. This may maintain the integrity of abdominal wall mechanics. We have started employing this technique selectively and do not have sufficient experience to determine how this will influence the utilization of the laparoscopic underlay technique. Swiss cheese defects and occult hernias, which are likely to be missed with open repair can be detected and repaired without any additional morbidity labroscopically. Because the abdominal cavity is entered remotely from prior incisions, there may be a reduction in the risk of enterotomy, and by avoiding previously manipulated or compromised skin incisions there may be a lower risk of wound infection. In addition, despite several hours of pneumoperitoneum, no graft dysfunction was reported in the transplant patients.
Because of a fear of wound-related complications and mesh infections, mesh repair was previously avoided in the transplant patients. Primary repair of hernias is known to have the highest recurrence rates (over 50%) among all types of hernia repair. Recent retrospective studies on open incisional hernia repair in kidney (2) and liver (10,32) transplant recipients showed that mesh repair is safe and effective with minimal postoperative and wound-related infectious complications. In addition, there are reports of LIHR in organ transplant patients with results comparable to nontransplant patients. Most of these studies either exclusively or predominantly involved the liver transplant patient population. To our knowledge, there are no studies in the literature on LIHR exclusively in the KP transplant patients and none comparing LIHR experience in KP transplant recipients with nontransplant population. We believe that our study is the first to meet those two objectives.
As with any new procedure there is a learning curve (33) as evidenced by our higher conversion rate in the transplant group compared to the nontransplant group. As mentioned earlier, the conversion rate 1 year after institution of the procedure reduced significantly and was comparable to the nontransplant group.
Despite the concern that some of the immunosuppression drugs may adversely affect the wound-related complications, mesh incorporation and subsequent recurrence rates, we did not notice any significant differences in outcomes between the transplant and the nontransplant groups. Incidence of infectious complications varied from 2% to 7.6% in transplant patients with open or laparoscopic approach (10,34). Incidence of seroma after LIHR varied from 3% to 21% in nontransplant patients (28,33) and up to 22% in the transplant patients (35). We encountered one patient in each group with mesh infection leading to mesh explant and 10% and 15% patients had seromas in the transplant and the nontransplant group, respectively. With the advances in management of immunosuppression and by avoiding mTOR inhibitors in the perioperative period, we confirm that prosthetic mesh is safe in KP patients.
Based on preclinical and clinical data, the incidence of adhesions and adhesion-related bowel obstructions are less in transplant patients (14–16). This led us to believe that LIHR in transplant recipients may be technically easier. It is difficult to draw any valid conclusions based on our data because we neither quantified the degree of peritoneal adhesions nor compared the operative times required for adhesiolysis. We did not notice any difference in bowel injury or conversion rates (both surrogate markers of peritoneal adhesions) between the groups. Further studies are warranted to confirm this hypothesis. We agree that preventing the bowel injuries is of utmost importance in LIHR and one should have a low threshold for conversion. Incidence of bowel injury during LIHR varies from 1% to 9.3%, which is comparable to 2–3% in our series.
Regarding the occurrence of incisional hernia, it was generally believed that transverse incisions fared better (36), but a recent large randomized study showed no difference in the occurrence of incisional hernia between midline and transverse incisions (37). As mentioned earlier, some KP transplant patients had both midline and lower abdominal hockey stick incisions, which theoretically double the risk for occurrence of incisional hernia and for recurrence after repair. We believe that with the laparoscopic approach, it may be technically easier to identify and fix occult hernias and the Swiss cheese defects of both incisions without any additional morbidity. In addition, KP patients have hernias close to bony prominences (from lower abdominal hockey stick incisions), which are notoriously difficult to repair. Recent technical advances in laparoscopic repair of such hernias supports the wider applicability of LIHR in KP patients (17). In a recent study of LIHR in organ transplant recipients, two out of two recurrences were due to difficulty in fixing the lateral margin of hernia in kidney transplant patients because of the proximity to bone (35). Surgeons need to be innovative in performing such repairs. Recently, we performed one such case and had no recurrence at 9 months follow-up (not included in this study because of <1 year postoperative follow-up).
Another important feature of our study is the high recurrence rate observed in patients with ADPKD. ADPKD patients have significantly higher incidences of all types of abdominal wall hernias compared with the general surgical population and patients with impaired renal function due to other etiologies (19). This is possibly caused by elevated intra-abdominal pressure due to enlarged kidney and liver cysts which lead to weakening of abdominal musculature. Higher recurrence rates are also anticipated because ADPKD is due to abnormal basement membrane or extracellular matrix production. So it is not surprising that 60% of recurrences in the transplant group are in ADPKD patients. Some of the patients had a prior history of multiple repairs and we also observed recurrences along the different parts of same incision at different points of time. Recently, safe and successful prophylactic mesh reinforcement of abdominal incisions in high-risk patients is reported in the literature (38). So, we believe, it is prudent to repair the entire incision and if possible both medial and lateral incisions at the same time to avoid future recurrences in these patients. Because of the limited number of ADPKD patients in the present study, larger studies are required to confirm our hypothesis.
Obesity is prevalent among KP transplant recipients and predicts increased risk of morbidity and mortality (20). Although earlier studies showed that the incidence of incisional hernias after laparotomy and subsequent recurrence rates after open (21,22) and laparoscopic incisional hernia (23,24) repair in obese patients was higher; several recent studies of LIHR in obese patients confirmed that LIHR is safe and effective with no significant difference in perioperative complications or recurrence rates between obese and nonobese patients (18,23,39–41). In this series, although there are a significant number of obese patients in the transplant and the nontransplant group, there is no statistically significant difference in recurrence rates in intragroup analysis. It appears that the degree of obesity will not influence the outcome (25,26). One caveat of the above studies as well as this study is that the follow-up period of LIHR in obese patients has been relatively short (42) and a difference in recurrence rates between obese and nonobese patients may become apparent over a longer follow-up and patients should be appropriately informed about this risk.
Several types of mesh are used for LIHR in literature. In this series, the majority of patients in the transplant group had LIHR with Parietex mesh and DualMesh was used with the majority in the nontransplant group. None of the studies or LIHR show one type of mesh to be better than another. We too believe that the type of mesh would not have influenced the outcome (1).
In a recent meta-analysis in the nontransplant population, recurrence rates with primary closure alone, open mesh repair and LIHR were 2–54%, 0–48% and 1–20%, respectively (43). Similar figures in organ transplant patients were 22–33% (10,44), 0–29% (3,32,34) and 0–23% (27,35,45). Recurrence rates of 7% and 16% in the nontransplant and transplant patients, respectively, in this study are comparable with the published data. Similarly the mean hospital stay of 1.3–9 days in nontransplant patients after LIHR (43) and 3.1–5.5 days after LIHR in transplant patients (34,45) are comparable to our study. Often transplant recipients require a longer hospital stay to ensure continued allograft function and adequate immunosuppression levels. But with adequate planning and perioperative management, hospital stay can be reduced as shown. The reported experience in organ transplant patients is limited to a few series when compared to the numerous studies reported in nontransplant population.
In this series, complications and recurrence rates are comparable to other published data in the transplant and the nontransplant groups. Despite the difference in patient and hernia characteristics between the groups, there are no statistically significant differences in both short and long-term results between the transplant and the nontransplant groups. Although there is a trend of higher recurrence rates in the transplant group, the retrospective nature and small sample size may not have picked up the actual difference in complication and recurrence rates. Multiple prospective studies with larger sample sizes and longer follow-up may be required to answer these questions. On the basis our experience, we conclude that LIHR is a safe and effective alternative to open incisional hernia repair in kidney and/or pancreas transplant recipients with results comparable to nontransplant patients.