Management of incisional hernias in renal transplant patients

Background

Incisional hernia (IH) remains one of the most common complications following abdominal organ transplantation with no consensus on the optimal management. This study is a narrative review of the incidence, risk factors, diagnosis, and management of IH post-transplantation.

Methods

A literature search using the EMBASE and MEDLINE from 1.1.2016 to 15.8.2002 was conducted. Included studies reported on IH after open abdominal organ transplantation. The outcomes included in our analysis were the incidence of IH, significant patient risk factors, the diagnostic approach used to detect IH, and proposed strategies for the management of IH. 54 publications that involved 9336 transplant patients who developed IH were included.

Results

The incidence of IH ranged from 1.7 % to 43 % in liver transplant patients and was lower following kidney transplantation (1.1 %-7.0 %). Patient risk factors predisposing to IH were body mass index>30, age (>50), smoking history, previous open abdominal surgery, open surgical repair, a Mercedes or inverse T incision and surgical site infections. The most common diagnostic approach for IH is clinical examination, followed by US or CT imaging in cases of complex IH. Following IH repair, recurrence rates ranged from 0 to 76.9 %, and complication rates from 12 % - 52.9 %, the most common of which were surgical site occurrences (11.0–79.2 %) including infection (0 - 65.4 %) and seroma formation (0–8 %). Management of IH should include preoperative optimisation of patients through weight reduction, smoking cessation and adjustment of immunosuppression using a multidisciplinary (MDT) approach. Mesh repair, either open or laparoscopic, is the gold standard for the treatment of IH, resulting in a significantly lower recurrence rate than primary closure. There is no consensus on the type and positioning of mesh, and very limited studies have reported on other perioperative factors such as wound closure.

Conclusions

Prehabilitation and MDT approach are important in ensuring good outcomes following IH repair. Further prospective studies and the establishment of a relevant registry are required to propose a consensus pathway for IH repair in the transplanted population.