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

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.

Schlüsselwörter

Narbenhernie - Lebertransplantation - Biologikum - Immunsuppression

Key words

incisional hernia - liver transplantation - biological - immunosuppression

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