Temporary silastic mesh closure for adult liver transplantation: A safe alternative for the difficult abdomen

Abstract

Primary fascial closure is often difficult after adult orthotopic liver transplantation (OLT), complicated by donor-to-recipient graft size mismatch, post-reperfusion hepatic edema, coagulopathy, or intestinal edema. Attempts at closing the abdomen under these circumstances can cause increase in intra-abdominal pressures, resulting in significant complications, including graft loss. Temporary closure with silastic mesh has been used as a viable option in children receiving transplants, but there is no experience recorded with its use in adults. A retrospective review was conducted on 200 consecutive liver transplantations performed over 42 months (October 2002 to February 2006. Records were evaluated for patient and donor demographics, perioperative factors including Model for End-Stage Liver Disease and Child-Turcotte-Pugh scores, indications for OLT, ischemic times, blood product administration, and use of temporary silastic mesh closure. Patients requiring silastic mesh were further evaluated for indication, time to primary fascial closure, duration of intubation, length of stay, graft function, and complications (infectious, vascular, biliary, and hernia development). Comparisons were made with a cohort of patients undergoing OLT over the same time period but who were closed primarily, without the use of temporary silastic mesh. Fifty-one liver transplantations (25.5%) of the 200 total transplant cohort used silastic mesh closure. Comparison of the cohorts (primary closure vs. temporary mesh) revealed that no differences existed, except the requirement of all blood products was significantly greater in the silastic mesh group (P Ͻ 0.001). Bowel edema (47.1%) and coagulopathy (37.3%) were the most common indications for mesh closure, with less frequent reasons including donor to recipient size mismatch (11.8%), hemodynamic instability, and a large preexisting fascial defect (2.0% each). The average time from transplant to final fascial closure was 3.4 days (range 2-9 days). In the silastic cohort, 41 transplants where closed primarily, 3 required the addition of synthetic mesh, and 6 had component separation and flap closure. After fascial closure, the mean time to extubation was 1 day. The median length of follow-up was 1.3 years for the silastic closure group. Long-term wound complications in the silastic closure group included 1 instance of colonic fistula, 2 incisional hernias, and 2 wound infections. The 30-day and 1-year patient survival for this group were 93.6 and 82.4%, respectively, and the graft survival for those same periods were 90.2 and 77.7%, respectively. Wound complications, rates of hepatic artery thrombosis or stricture, portal vein thrombosis or stricture, biliary complications, and allograft and patient survival were no different than those in patients undergoing initial primary closure. In adult liver transplantation with a difficult (or potentially difficult) abdomen, temporary closure with silastic mesh was found to allow for uncomplicated fascial closure in a short period of time, wi...

Temporary abdominal coverage for adult liver transplantation

“…Nearly 50% of recurrences following hernioplasty do not appear until 5 yr after surgery; statistical significance is best determined with a 10-yr follow-up. 2 The very short follow-up in the Jafri et al 1 study does not permit sound conclusion as to the superiority of one approach over another. The authors also do not provide details about the closing method (continuous vs. single sutures) or suturing material (absorbable vs. nonabsorbable) used to oppose the fascia.…”

“…We read with great interest the recent article by Jafri et al 1 on temporary silastic mesh closure for adult liver transplantation, but would comment on some of the aspects of the study to help put the authors' large experience in perspective. A total of 51 (25.5%) out of 200 liver transplantations underwent temporary abdominal coverage with silastic sheeting reinforced with vacuum dressing on top.…”

“…Permanent fascial closure was established in 82% following resolution of the intraabdominal hypertension; component separation and absorbable polyglactin mesh became necessary to reconstruct the abdominal wall in 12% and 6%, respectively, with a 3.9% incidence of ventral hernia in that group. 1 Although the work makes a very important contribution to the understanding that temporary abdominal coverage can be performed safely in transplant patients, the following omissions detract somewhat from a full understanding of all aspects of the study.…”

“…The published randomized clinical trials and meta-analyses suggest that there is very little evidence for superiority of certain types of incisions, suture materials, or closure methods in decreasing the hernia incidence in the general population. 3 Recent trials suggest that a fundamental defect in the collagen metabolism plays a most important role in the formation of ventral hernias 4,5 ; unfortunately, this was not addressed in the work of Jafri et al 1 It will be extremely interesting to know how all these considerations are reflected in the liver transplantation population.…”

Use of the bilateral anterior rectus fascia turnover method and the components separation method for a difficult abdominal closure after transplantation

“…[1][2][3] A variety of techniques, including pedicle flaps, free fascia grafts, skin grafts, synthetic meshes, vacuum-assisted fascial closure with an open abdomen, and abdominal wall transplantation, have been used in this situation. Here we describe our positive experience with the use of plastic surgery techniques, including the anterior rectus sheath turnover (ART) method and the components separation (CS) method, for difficult abdominal closure after transplantation.…”