Z Gastroenterol 2016; 54(05): 421-425
DOI: 10.1055/s-0042-103249
Originalarbeit
© Georg Thieme Verlag KG Stuttgart · New York

Ventral incisional hernia (VIH) repair after liver transplantation (OLT) with a biological mesh: experience in 3 cases

Biological mesh for ventral incisional hernia VIH repair after OLTNarbenhernien-Sanierung nach Lebertransplantation mit einem biologischen Mesh: Erfahrungen aus 3 Fällen
S. Schaffellner
1   Clinical Department for Transplantation Surgery, Medical University Graz, Austria
,
M. Sereinigg
1   Clinical Department for Transplantation Surgery, Medical University Graz, Austria
,
D. Wagner
2   General Surgery, Medical University Graz, Austria
,
E. Jakoby
1   Clinical Department for Transplantation Surgery, Medical University Graz, Austria
,
D. Kniepeiss
1   Clinical Department for Transplantation Surgery, Medical University Graz, Austria
,
P. Stiegler
1   Clinical Department for Transplantation Surgery, Medical University Graz, Austria
,
J. Haybäck
3   Pathology, Medical University Graz, Austria
,
H. Müller
1   Clinical Department for Transplantation Surgery, Medical University Graz, Austria
› Author Affiliations
Further Information

Publication History

01 October 2015

10 February 2016

Publication Date:
12 May 2016 (online)

Abstract

Background: Hernias after orthotopic liver transplant (OLT) occur in about 30 % of cases. Predisposing factors in liver cirrhotic patients of cases are ascites, low abdominal muscle mass and cachexia before and immunosuppression after OLT. Standard operative transplant-technique even in small hernias is to implant a mesh. For patients after liver transplantation a porcine non-cross linked biological patch being less immunogenic than synthetic and cross-linked meshes is chosen for ventral incisional hernia repair.

Methods: 3 patients (1 female, 2 male), OLT indications Hepatitis C, exogenous- toxic cirrhosis, median-age 53 (51 – 56) and median time to hernia occurrence after OLT were 10 month (6 – 18 m) are documented. 2 patients suffered from diabetes, 2 from chronic-obstructive lung disease. Maintenance immunosuppressions were Everolimus in 1 patient, Everolimus + MMF in the second and Everolimus +Tacrolimus in the third patient. The biological was chosen for hernia repair due to the preexisting risk- factors. Meshes, 10 × 16 cm were placed, in IPOM (Intra-Peritonel-Onlay-Mesh) -position by relaparatomy. Insolvable, monofile, interrupted sutures were used.

Results: All patients recovered primarily, and were dismissed within 10 d post OP. No wound healing disorders or signs of postoperative infections occurred. All are free of hernia recurrence in a mean observation time of 22 month (10 – 36).

Conclusion: The usage of porcine non-cross-linked biological patches seems feasible for incisional hernia repair after OLT. Wound infections in these patients have been observed with other meshes. Further investigation is needed to prove potential superiority of this biological to the other meshes.

Zusammenfassung

Hintergrund: Nach Lebertransplantation kommt es in ungefähr 30 % zur Entstehung von Hernien. Begünstigende Faktoren bei Patienten mit Leberzirrhose sind Ascites, wenig abdominale Muskelmasse und Kachexie vor und die Immunsuppression nach OLT. Die Standard-Operationstechnik auch bei kleinen Hernien ist die Implantation eine Netzes. Für die Patienten mit einer Narbenhernie nach Lebertransplantation wurde ein porcines nicht-cross-verlinktes Netz gewählt, da es als geringer Immunogen als cross-verlinkte und synthetische Netze angesehen wird.

Methode: 3 Patienten (1 weiblich, 2 männlich) mit den Indikationen zur Lebertransplantation Hepatitis C und exogen-toxischer Leberzirrhose, im mittleren Alter von 53 Jahren (51 – 64) und dem mittleren zeitlichen Abstand zur Hernien-Entwicklung nach OLT von 10 Monaten (6 – 18) werden dokumentiert. Zwei Patienten waren zusätzlich Diabetiker und litten auch an einer chronisch-obstruktiven Lungenerkrankung. Die Immunsuppression bei einem Patienten ist Everolimus, Everolimus und Mycophenolat-Mofetil beim Zweiten und beim Dritten Everolimus und Tacrolimus. Aufgrund der vorbestehenden Risikofaktoren wird ein biologisches Netz für die Hernien-Sanierung gewählt. Die Netze sind 10 × 16 cm groß und werden als IPOM (Intra-Peritoneal-Onlay-Mesh) im Rahmen einer Relaparatomie platziert. Monofile, nicht resorbierbare Einzelknopfnähte werden verwendet.

Ergebnisse: Die Patienten erholen sich komplikationslos und können 10 Tage nach der Herniatomie entlassen werden. Weder Wundheilungsstörungen noch Wundinfektionen treten auf. Alle sind frei von Hernien-Rezidiven in einem mittleren Überwachungszeitraum von 22 Monaten (10 – 36).

Schlussfolgerung: Narbenhernien-Verschlüsse mit einem porcinen nicht cross-verlinktem biologischen Netz nach OLT sind machbar. Wundinfektionen bei diesen Patienten mit anderen Netzen wurden beobachtet. Weitere Untersuchungen sind notwendig, um eine mögliche Überlegenheit des biologischen Materials gegenüber anderen Netzen zu beweisen.

 
  • References

  • 1 den Hartog D, Dur AH, Tuinbreijer WE et al. Open surgical procedures for incisional hernias. Cochrane Database Syst Rev 2009; CD006438
  • 2 Hodgson NC, Malthaner RA, Ostbye T. The search for an ideal method of abdominal fascial closure: A meta-analysis. Ann Surg 2000; 231: 436-442
  • 3 Vardanian AJ, Farmer D, Ghobrial R et al. Incisional hernia after liver transplantation. J Am Coll Surg 2006; 203: 421-425
  • 4 Gomez R, Hidalgo M, Marques E et al. Incidence and predisposing factors for incisional hernia in patients with liver transplantation. Hernia 2001; 5: 172-176
  • 5 Skipworth JR, Vyas S, Uppal L et al. Improved outcomes in the management of high-risk incisional hernias utilizing biological mesh and soft-tissue reconstruction: A single center experience. World J Surg 2014; 38: 1026-1034
  • 6 Lovecchio F, Famer R, Souza J et al. Risk factors for 30-day readmission in patients undergoing ventral hernia repair. Surgery 2014; 155: 702-710
  • 7 Kalmuk S, Neuhaus P, Pascher A. Surgery and organ transplantation. Chirurg 2013; 84: 937-944
  • 8 Janssen J, Lange R, Erhard J et al. Causative factors, surgical treatment and outcome of incisional hernia after liver transplantation. Br J Surg 2002; 89: 1049-1054
  • 9 Muller V, Lehner M, Klein P et al. Incisional hernia repair after orthotopic liver transplantation: A technique employing an inlay/onlay propylene mesh. Langenbecks Arch Surg 2003; 388: 167-173
  • 10 Porrett PM, Hsu J, Shaked A. Late surgical complications following liver transplantation. Liver Transplant 2009; 15: S12-S18
  • 11 Burger JW, Luijendijk RW, Hop WCJ et al. Long term follow up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 2004; 240: 578-585
  • 12 Muysoms FE, Miserez M, Berrevoet F et al. Classification of primary incisional abdominal wall hernias. Hernia 2009; 13: 407-414
  • 13 Breuing K, Butler CE, Ferzoco S. The Ventral Hernia Working Group et al. Incisional ventral hernias: Review of the literature and recommendations regarding the grading and technique of repair. Surgery 2010; 148: 544-558
  • 14 Burger JW, Lange JF, Halm JA. Incisional hernia: Early complication of abdominal surgery. World J Surg 2005; 29: 1608-1613
  • 15 Itani KMF, Hur K, Kim L et al. Comparison of laparoscopic and open repair with mesh for the treatment of ventral incisional hernia. Arch Surg 2010; 145: 322-328
  • 16 Coccolini F, Catena F, Bertuzzo VR et al. Abdominal wall defect repair with biological prosthesis in transplanted patients: Single center retrospective analysis and review of the literature. Updates Surg 2013; 65: 191-196
  • 17 Grehan JF, Levay-Young BK, Benson BA et al. Alpha Gal ligation of pig endothelial cells induces protection from complement and apoptosis independently of NK-kappa B and inflammatory changes. Am J Transplant 2005; 5: 712-719
  • 18 Gentile P, Colicchia GM, Nicoli F et al. Complex abdominal wall repair using a porcine dermal matrix. Surg Innov 2011; Epub ahead of print.
  • 19 Kaplan KM, Chopra K, Feiner J et al. Chest wall reconstruction with strattice in an immunosuppressed patient. Eplasty 2011; Epub ahead of print.
  • 20 Deeken CR, Melman L, Jenkins E et al. Histologic and biomechanical evaluation of cross-linked and non-cross-linked biologic meshes in a porcine model of ventral incisional hernia repair. J Am Coll Surg 2011; 212: 880-888
  • 21 Breuing K, Butler CE, Ferzoco S et al. Incisional ventral hernias: Review of the literature and recommendations regarding the grading and technique of repair. Surgery 2010; 148: 544-558
  • 22 Bisgaard T, Kehlet H, Bay-Nielsen MB et al. Nationwide study of early outcomes after incisional hernia repair. Br J Surg 2009; 96: 1452-1457
  • 23 Jin J, Voskerician G, Hunter S et al. Human peritoneal membrane controls adhesion formation and host tissue response following intra-abdominal placement in a porcine model. J Surg Res 2009; 156: 297-304
  • 24 Harth KC, Broome AM, Jacobs MR et al. Bacterial clearance of biologic grafts used in hernia repair: An experimental study. Surg Endosc 2011; 25: 2224-2229
  • 25 Mulier KE, Nguyen AH, Delaney JP et al. Comparison of PermacolTM and StratticeTM for the repair of abdominal wall defects. Hernia 2011; 15: 315-319
  • 26 Melman L, Jenkins ED, Hamilton NA et al. Early biocompatibility of crosslinked and non-crosslinked biologic meshes in a porcine model of ventral hernia repair. Hernia 2011; 15: 157-164
  • 27 Itani KM, Rosen M, Vargo D et al. Prospective study of single-stage repair of contaminated hernias using a biologic porcine tissue matrix: The RICH Study. Surgery 2012; 152: 498-505
  • 28 Gao D, Wei S, Zhai C et al. Clinical research of peritoneal drainage after endoscopic totally extraperitoneal inguinal hernia repair. Hernia 2014; Epub ahead of print.
  • 29 Klosterhalfen B, Klinge U. Retrieval study at 623 human mesh explants made of polypropylene – impact of mesh class and indication for mesh removal on tissue reaction. J Biomed Mater Res B Appl Biomater 2013; 101: 1393-1399
  • 30 Cevasco M, Itani KM. Ventral hernia repair with synthetic, composite, and biologic mesh: Characteristics, indications, and infection profile. Surg Infect (Larchmt) 2012; 13: 209-215