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
Department of General Surgery, Comprehensive Hernia Center, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA.
Department of Surgery, Washington University School of Medicine in St. Louis, 4590 Children's Place, Suite 9600, St. Louis, MO, 63110, USA.
Hernia. 2019 Apr;23(2):363-373. doi: 10.1007/s10029-019-01918-8. Epub 2019 Feb 21.
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.
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.
Forty-four patients were identified (mean age 60 ± 8, 75% male, median BMI 30.7 kg/m) 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.
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.
原位肝移植（OLT）后发生的切口疝（IH）具有挑战性，因为在终身免疫抑制的情况下，其同时存在中线和肋下缺损，且邻近骨性突出部位。迄今为止，尚无研究评估采用腹横肌松解（TAR）的后入路成分分离术修复OLT后复杂IH的效果。我们旨在报告在这种情况下TAR的治疗结果。
在美洲疝学会质量协作组（AHSQC）中，确定了在两个中心接受开放选择性TAR修复IH且至少随访1年的OLT患者。结果指标包括30天手术部位感染（SSI）、需要进行手术干预的手术部位事件（SSOPI）、非计划再入院、再次手术和疝复发。
在两个中心共确定了44例患者（平均年龄60±8岁，75%为男性，中位BMI为30.7kg/m²）。疝的中位宽度为20cm[四分位间距15 - 28cm]，98%（43例）为清洁手术病例。所有病例均使用了肌后合成补片，93%（41例）实现了筋膜闭合，术中无并发症。术后发生5例SSI（4例深部，1例浅表），6例SSOPI（4例伤口裂开，1例清创，1例血清肿引流），4例（9%）再入院，3例（7%）再次手术。1例患者发生补片感染，但无需切除补片。中位随访13个月[四分位间距12 - 17个月]后，有11例（25%）复发；8例是由于中央补片骨折（CMF）。7例复发病例已通过腹腔镜或外置补片修补。
在免疫抑制且患有大型IH的具有挑战性的患者队列中，TAR显示出可接受的中期结果，但CMF导致复发率较高。有必要进一步研究中央补片骨折的机制以减少这些复发。
