Ventral hernia repair following liver transplantation: outcome of repair techniques and risk factors for recurrence

Background: Patients undergoing liver transplantation are at increased risk of developing incisional hernia, which can seriously affect their postoperative course and quality of life. This retrospective study identified pre- and postoperative risk factors for incisional hernia development following liver transplantation. Methods: We conducted a retrospective case-control study on 202 patients undergoing liver transplantation between 2007 and 2019. We compared 101 selected patients who underwent liver transplantation followed by incisional hernia occurrence with 101 age- and date-matched controls who did not form a hernia post-transplant. Incisional hernias were repaired open with sublay or retrorectus mesh or by primary closure. Age, sex, body mass index (BMI), transplant indication, preoperative MELD score, post-transplant complications and immunosuppressive medications were compared between the 2 groups. Hernia repair outcomes including surgical site infections (SSIs), other wound complications, length of hospital stay, and hernia recurrence were analyzed. Results: Patient characteristics between the 2 groups were well matched. The average time from liver transplantation to incisional hernia occurrence was 20 months. Significant risk factors for incisional hernia occurrence were transplant incision type, specifically midline incisions (0 v. 20 patients, p = 0.01). There was a trend toward hernia occurrence with post-transplant take-back laparotomy (12 v. 22 patients, p = 0.06). When analyzing factors associated with recurrence after hernia repair, interestingly viral hepatitis had a significantly lower rate of hernia recurrence (p = 0.03). Furthermore, hernia recurrence was impacted by a higher pretransplant MELD score (score of 16 v. 22, p = 0.05), takeback laparotomy post-transplant (17% v. 40%, p = 0.03), retrorectus mesh repair of initial hernia repair (18% v. 50%, p = 0.01), and post-hernia SSIs (11% v. 32%, p = 0.02). No differences were observed for age, sex, BMI, immunosuppressive medications, and hernia defect size. Conclusion: These results highlight important risk factors for hernia occurrence and recurrence post-liver transplant, including post-transplant takeback laparotomy, hernia repair technique, and SSIs. With regards to the repair technique, intraperitoneal sublay mesh reduces hernia recurrence and is a safe option for incisional hernia repair in this complex patient population.