Posterior component separation with transversus abdominis release (TAR) for repair of complex incisional hernias after orthotopic liver transplantation

L. Tastaldi; J. A. Blatnik; D. M. Krpata; C. C. Petro; A. Fafaj; H. Alkhatib; M. Svestka; S. Rosenblatt; A. S. Prabhu; M. J. Rosen

doi:10.1007/s10029-019-01918-8

Posterior component separation with transversus abdominis release (TAR) for repair of complex incisional hernias after orthotopic liver transplantation

L. Tastaldi^*, J. A. Blatnik, D. M. Krpata, C. C. Petro, A. Fafaj, H. Alkhatib, M. Svestka, S. Rosenblatt, A. S. Prabhu, M. J. Rosen

^*Corresponding author for this work

Surgery, Gastrointestinal/Endocrinology Division

Research output: Contribution to journal › Article › peer-review

25 Scopus citations

Abstract

Background: Incisional hernias (IH) after orthotopic liver transplant (OLT) are challenging due to their concurrent midline and subcostal defects adjacent to bony prominences in the context of lifelong immunosuppression. To date, no studies evaluated the posterior component separation with transversus abdominis release (TAR) to repair complex IH after OLT. We aim to report the outcomes of TAR in this scenario. Study Design: OLT patients who underwent open, elective IH repair with TAR performed at two centers and with a minimum of 1-year follow-up were identified in the Americas Hernia Society Quality Collaborative (AHSQC). Outcomes included 30-day surgical site infections (SSI), surgical site occurrences requiring procedural intervention (SSOPI), unplanned readmissions, reoperations, and hernia recurrence. Results: Forty-four patients were identified (mean age 60 ± 8, 75% male, median BMI 30.7 kg/m ² ) at two centers. Median hernia width was 20 cm [IQR 15–28] and 98% (43) were clean cases. Retromuscular synthetic mesh was used in all cases, and 93% (41) achieved fascial closure with no intraoperative complications. Postoperatively, there were 5 SSIs (4 deep, 1 superficial), 6 SSOPIs (4 wound opening, 1 debridement, 1 seroma drainage), four (9%) readmissions, and 3 (7%) reoperations. One patient developed a mesh infection that did not require mesh excision. After a median follow-up of 13 months [IQR 12–17], there were 11 (25%) recurrences; 8 due to central mesh fractures (CMF). Seven recurrences have been repaired either laparoscopically or using an onlay. Conclusions: In a challenging cohort of immunosuppressed patients with large IH, TAR was shown to have acceptable medium-term results, but high recurrence rate driven by CMF. Further studies investigating the mechanism of central mesh fractures are necessary to reduce these recurrences.

Original language	English (US)
Pages (from-to)	363-373
Number of pages	11
Journal	Hernia
Volume	23
Issue number	2
DOIs	https://doi.org/10.1007/s10029-019-01918-8
State	Published - Apr 1 2019

Funding

Conflict of interest LT and AF declare resident research grants from the AHSQC that are not related to the submitted work. JAB has received: grants from the Americas Hernia Society, Intuitive Surgical Inc., and Colorado Therapeutics and personal fees from Colorado Therapeutics, Bard Davol Inc., Medtronic Inc., Intuitive Surgical Inc., and Cook Biomedical. None of these conflicts of interest are related to the submitted work. DMK has received an educational grant from W.L Gore that is not related to the submitted work. ASP has received a research grant from Intuitive Inc. and personal fees from Intuitive Inc. and Medtronic Inc. that are not related to the submitted work. MJR declares to receive salary support from the AHSQC, research grants from Intuitive Inc. and Pacira Pharmaceuticals Inc., and to be a board member and have stock options from Ariste Medical; none of these conflicts of interest are related to the submitted work. CCP, HA, MS, and SR declare no conflicts of interest.

Keywords

Incisional hernia
Liver transplant
Mesh fracture
TAR
Transversus abdominis release
Ventral hernia

ASJC Scopus subject areas

Surgery

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10.1007/s10029-019-01918-8

Cite this

Tastaldi, L., Blatnik, J. A., Krpata, D. M., Petro, C. C., Fafaj, A., Alkhatib, H., Svestka, M., Rosenblatt, S., Prabhu, A. S., & Rosen, M. J. (2019). Posterior component separation with transversus abdominis release (TAR) for repair of complex incisional hernias after orthotopic liver transplantation. Hernia, 23(2), 363-373. https://doi.org/10.1007/s10029-019-01918-8

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title = "Posterior component separation with transversus abdominis release (TAR) for repair of complex incisional hernias after orthotopic liver transplantation",

abstract = " Background: Incisional hernias (IH) after orthotopic liver transplant (OLT) are challenging due to their concurrent midline and subcostal defects adjacent to bony prominences in the context of lifelong immunosuppression. To date, no studies evaluated the posterior component separation with transversus abdominis release (TAR) to repair complex IH after OLT. We aim to report the outcomes of TAR in this scenario. Study Design: OLT patients who underwent open, elective IH repair with TAR performed at two centers and with a minimum of 1-year follow-up were identified in the Americas Hernia Society Quality Collaborative (AHSQC). Outcomes included 30-day surgical site infections (SSI), surgical site occurrences requiring procedural intervention (SSOPI), unplanned readmissions, reoperations, and hernia recurrence. Results: Forty-four patients were identified (mean age 60 ± 8, 75% male, median BMI 30.7 kg/m 2 ) at two centers. Median hernia width was 20 cm [IQR 15–28] and 98% (43) were clean cases. Retromuscular synthetic mesh was used in all cases, and 93% (41) achieved fascial closure with no intraoperative complications. Postoperatively, there were 5 SSIs (4 deep, 1 superficial), 6 SSOPIs (4 wound opening, 1 debridement, 1 seroma drainage), four (9%) readmissions, and 3 (7%) reoperations. One patient developed a mesh infection that did not require mesh excision. After a median follow-up of 13 months [IQR 12–17], there were 11 (25%) recurrences; 8 due to central mesh fractures (CMF). Seven recurrences have been repaired either laparoscopically or using an onlay. Conclusions: In a challenging cohort of immunosuppressed patients with large IH, TAR was shown to have acceptable medium-term results, but high recurrence rate driven by CMF. Further studies investigating the mechanism of central mesh fractures are necessary to reduce these recurrences.",

keywords = "Incisional hernia, Liver transplant, Mesh fracture, TAR, Transversus abdominis release, Ventral hernia",

author = "L. Tastaldi and Blatnik, {J. A.} and Krpata, {D. M.} and Petro, {C. C.} and A. Fafaj and H. Alkhatib and M. Svestka and S. Rosenblatt and Prabhu, {A. S.} and Rosen, {M. J.}",

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T1 - Posterior component separation with transversus abdominis release (TAR) for repair of complex incisional hernias after orthotopic liver transplantation

AU - Tastaldi, L.

AU - Blatnik, J. A.

AU - Krpata, D. M.

AU - Petro, C. C.

AU - Fafaj, A.

AU - Alkhatib, H.

AU - Svestka, M.

AU - Rosenblatt, S.

AU - Prabhu, A. S.

AU - Rosen, M. J.

PY - 2019/4/1

Y1 - 2019/4/1

N2 - Background: Incisional hernias (IH) after orthotopic liver transplant (OLT) are challenging due to their concurrent midline and subcostal defects adjacent to bony prominences in the context of lifelong immunosuppression. To date, no studies evaluated the posterior component separation with transversus abdominis release (TAR) to repair complex IH after OLT. We aim to report the outcomes of TAR in this scenario. Study Design: OLT patients who underwent open, elective IH repair with TAR performed at two centers and with a minimum of 1-year follow-up were identified in the Americas Hernia Society Quality Collaborative (AHSQC). Outcomes included 30-day surgical site infections (SSI), surgical site occurrences requiring procedural intervention (SSOPI), unplanned readmissions, reoperations, and hernia recurrence. Results: Forty-four patients were identified (mean age 60 ± 8, 75% male, median BMI 30.7 kg/m 2 ) at two centers. Median hernia width was 20 cm [IQR 15–28] and 98% (43) were clean cases. Retromuscular synthetic mesh was used in all cases, and 93% (41) achieved fascial closure with no intraoperative complications. Postoperatively, there were 5 SSIs (4 deep, 1 superficial), 6 SSOPIs (4 wound opening, 1 debridement, 1 seroma drainage), four (9%) readmissions, and 3 (7%) reoperations. One patient developed a mesh infection that did not require mesh excision. After a median follow-up of 13 months [IQR 12–17], there were 11 (25%) recurrences; 8 due to central mesh fractures (CMF). Seven recurrences have been repaired either laparoscopically or using an onlay. Conclusions: In a challenging cohort of immunosuppressed patients with large IH, TAR was shown to have acceptable medium-term results, but high recurrence rate driven by CMF. Further studies investigating the mechanism of central mesh fractures are necessary to reduce these recurrences.

AB - Background: Incisional hernias (IH) after orthotopic liver transplant (OLT) are challenging due to their concurrent midline and subcostal defects adjacent to bony prominences in the context of lifelong immunosuppression. To date, no studies evaluated the posterior component separation with transversus abdominis release (TAR) to repair complex IH after OLT. We aim to report the outcomes of TAR in this scenario. Study Design: OLT patients who underwent open, elective IH repair with TAR performed at two centers and with a minimum of 1-year follow-up were identified in the Americas Hernia Society Quality Collaborative (AHSQC). Outcomes included 30-day surgical site infections (SSI), surgical site occurrences requiring procedural intervention (SSOPI), unplanned readmissions, reoperations, and hernia recurrence. Results: Forty-four patients were identified (mean age 60 ± 8, 75% male, median BMI 30.7 kg/m 2 ) at two centers. Median hernia width was 20 cm [IQR 15–28] and 98% (43) were clean cases. Retromuscular synthetic mesh was used in all cases, and 93% (41) achieved fascial closure with no intraoperative complications. Postoperatively, there were 5 SSIs (4 deep, 1 superficial), 6 SSOPIs (4 wound opening, 1 debridement, 1 seroma drainage), four (9%) readmissions, and 3 (7%) reoperations. One patient developed a mesh infection that did not require mesh excision. After a median follow-up of 13 months [IQR 12–17], there were 11 (25%) recurrences; 8 due to central mesh fractures (CMF). Seven recurrences have been repaired either laparoscopically or using an onlay. Conclusions: In a challenging cohort of immunosuppressed patients with large IH, TAR was shown to have acceptable medium-term results, but high recurrence rate driven by CMF. Further studies investigating the mechanism of central mesh fractures are necessary to reduce these recurrences.

KW - Incisional hernia

KW - Liver transplant

KW - Mesh fracture

KW - TAR

KW - Transversus abdominis release

KW - Ventral hernia

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Posterior component separation with transversus abdominis release (TAR) for repair of complex incisional hernias after orthotopic liver transplantation

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