Staged approach for abdominal wound closure following combined liver and intestinal transplantation from living donors in pediatric patients

Abstract

Primary closure of the abdominal wall after combined liver and intestine transplantation from a living donor into a pediatric patient is usually not possible, because of the size of the donor organ, graft edema, and preexisting scars or stomas of the abdominal wall. Closure under tension may lead to abdominal compartment syndrome with vascular compromise and necrosis of the transplanted organ. We describe our experience of abdominal wound closure after liver and intestinal transplant in the pediatric patient using a staged approach. From February 2003 to June 2006, we managed five pediatric liver and intestinal living donor transplant recipients. Because of the large post-transplantation abdominal wall defect, a staged technique of abdominal wound closure was utilized. Initially, an absorbable Polygalactin mesh was sutured around the layer of the defect. As soon as adequate granulation tissue was formed over the mesh a STSG was applied. From the wound stand point all five patients were managed successfully with staged wound closure after transplantation. Granulation tissue filled and covered the mesh within 7.6 wk. A STSG was then used to cover the defect. All infants recovered well and none had a significant wound complication in the immediate post-operative period following STSG. At a mean follow-up of 24 months only one patient developed an entero-cutaneous fistula five months post-transplant. Staged abdominal wall coverage with the use of Polygalactin mesh followed by STSG is a simple and effective technique. A closed wound is achieved in a timely fashion with protection of the viscera. Residual ventral hernia will need to be managed in the future with one of several reconstructive techniques.

Abdominal Decompression in Children

“…OA management is achieved by leaving the fascia and the skin open, and temporarily covering the viscera. An OA with temporary abdominal closure (TAC) may also be necessary following operations in which edematous viscera preclude easy fascial closure, management of abdominal wall defects or in which an adult size organ has been transplanted into a small child [22, 34, 52, 53, 55, 70, 71]. The ultimate goal of OA management is to achieve prompt primary fascial closure without complications.…”

Effect of small donor weight and donor–recipient weight ratio on the outcome of liver transplantation in children

“…For small infants receiving a cadaveric transplant in the United States, there is a preference to have a proportionately smaller donor based on the weight of recipient to be able to close the abdomen safely. These data suggest that such a preference may be misguided, leading to a higher risk of thrombosis, and that alternatively, consideration of abdominal closure with a mesh device or in a staged manner might actually be preferable .…”

Role of “reduced-size” liver/bowel grafts in the “abdominal wall transplantation” era

“…Alternatively, common used techniques include absorbable mesh[16]: Five pediatric liver and intestinal living-donor transplant recipients were treated by Chicago group initially through an absorbable Polygalactin mesh and later , once a granulated tissue was present, by a split-thickness skin graft. Sometimes the use of non-absorbable mesh[17] has also been reported: a prosthetic mesh alone was used in three patients from Bologna series to perform abdominal reconstruction , only in one case followed by a myocutaneous flap.…”