Fig. 16.1
Incisions used in transplant surgery
As mentioned previously in the author’s experience we also encounter frequently umbilical, inguinal, and ventral hernia in patients with ESOD especially patients with CLD.
Factors such as the location of the defect and the surrounding areas influence can add to the complexity of the hernia. Even though the techniques used in the reconstruction of the abdominal wall are changing constantly, the goal for all abdominal reconstructions continues to be the same: obtain a good healing scar of the affected area with healthy tissues to allow for restoration of rigidity, resistance, and functional support of the abdominal wall in order to prevent herniation, a challenging process when it comes to a patient with ESOD or after transplantation.
In order to understand the approach to this complex group it’s important to review previous classifications and grading, we will then underline in which of these apply to our patients.
Hernia Classification and Grading
Grading
Efforts to increase successful outcomes and minimize recurrence have led the Ventral Hernia Working Group (VHWG) to stratify and grade hernias according to the risk of developing a surgical site infection (Table 16.1) [9]. Unfortunately, there is no universal grading system that has been established to effectively evaluate surgical outcomes. The lack of ambiguity along with a wide mixture of incisional hernias (IH) and ventral hernias has not permitted standardization. This table proposes a classification with criteria that helps clinicians predict risk of developing surgical site infections (SSI). Grade 1 proposes a “low risk” and no history of wound infections. Grade 2 includes “co-morbidities” and considers patients who smoke, are obese, diabetic, immunosuppressed, or have been diagnosed with COPD. Grade 3 includes patients who are “potentially contaminated” and patients who have had a previous wound infection, a stoma, or violation of the gastrointestinal (GI) tract. Lastly, Grade 4 takes into consideration “infected” mesh and septic wound dehiscence. Most of the hernias on patients with ESOD and after organ transplantation fall into Grade 2 and in rare occasions Grades 3 and 4.
Table 16.1
Hernia grading system
Grade 1
Low risk |
Grade 2a
Co-morbid |
Grade 3
Potentially contaminated |
Grade 4
Infected |
---|---|---|---|
Low risk of complications
No history of wound infection |
Smoker
Obese
Diabetic
Immunosuppressed
COPD |
Previous wound infection
Stoma present
Violation of the
gastrointestinal tract |
Infected mesh
Septic dehiscence |
Classification
Abdominal hernias can be classified differently depending on their location, size, reducibility, recurrence, and symptoms. In the year 2000, Chevrel and Rath proposed a simple classification for IH for the comparison and study between similar groups. The aim of this classification is to direct the assessment of multiple techniques for the different types of ventral hernia repairs (Table 16.2) [10].
Table 16.2
Hernia classification
According to localization (modified Chevrel) |
According to size |
According to recurrence |
According to the situation at the hernia gate |
According to symptoms | |
---|---|---|---|---|---|
Vertical |
Midline above or below umbilicus
Midline including umbilicus right or left
Paramedian right or left |
Small (<5 cm in width or length) |
Primary incisional hernia |
Reducible with or without obstruction |
Symptomatic |
Transversal |
Above or below umbilicus right or left
Crossed midline or not |
Medium (5–10 cm in width or length) |
Recurrence of an incisional hernia (1, 2, 3, etc., with type of hernioplasty:
adaptation
Mayo-duplication
prosthetic implantation
autodermal
etc. |
Irreducible with or without obstruction |
Asymptomatic |
Oblique |
Above or below umbilicus right or left
Combined
midline + oblique
midline + parastomal
etc. |
Large (≥10 cm in width or length) |
End Stage Organ Disease
End Stage Organ Diseases (ESOD) such as end stage liver disease (ESLD) in chronic liver disease (CLD) and end stage renal disease (ESRD) are the terms used to refer to diseases in which the organ functions are completely abolished or severely damaged. In both cases, organ transplantation has shown to be the definitive treatment when medication therapy can no longer control the complications or progression of ESOD. Unfortunately, many of these patients will not meet criteria for listing, but due to the complexity of their medical disease they are often referred to transplant centers where a multidisciplinary approach and collaboration with hepatology, nephrology, registered dietitians, specialized nurses and interventional radiology offer hope to the patient with ESOD and this difficult population can be managed appropriately by these teams. Patients with ESOD and hernias are referred to these centers since most of the time only transplant surgeons are skilled enough to manage these cases, and in the postoperative period they will have the support of the multidisciplinary team. In the following section the characteristics and approaches to the ESOD patients with hernias are described.
Liver
Compensated Chronic Liver Disease
The complications related to CLD make it one of the major causes of death in the USA. Such complications include ascites, hepatic encephalopathy, renal failure, and variceal hemorrhage; in consequence, patients with CLD require increasingly complex medical care and treatment, which has a direct impact on their quality of life, survival, and economy [11].
Some complications of CLD may predispose or lead to abdominal wall pathology. The development of ascites in these patients increases the tension on the abdominal wall. This, along with the decreased synthetic function of the liver that affects protein synthesis can end up weakening the layers of the abdominal wall with herniation as an end result. Also, these patients often require paracentesis, a procedure that alleviates the ascitic burden but may increase the risk of hernia complication as reported by some authors [12] this is particularly important in individuals listed for liver transplantation in which a potential incarceration could complicate their candidacy. It is estimated that approximately 10% if patients with CLD will require a surgical procedure within the last 2 years of life, and up to 20% with ascites will develop an umbilical hernia. These hernias might eventually become symptomatic, grow in size, and will require surgical repair [13–15]. Once the hernia has already developed, thorough evaluation before intervention is required, to assess their functional status, synthetic function, and risk of perioperative complications [12, 16].
The management of hernias in patients with CLD varies according to the situation and each patient health status; thus, different systems have been developed to assess the severity of disease and predict the morbidity and mortality in this complex population. These systems can aid in decision-making algorithms for the treatment of CLD patients that have developed a hernia. Defining, stratifying, and classifying the stage of liver disease and the type of hernia are necessary for planning its appropriate treatment (Table 16.3).
Table 16.3
Hernias in CLD and post-transplant patients
Eker et al. |
Marsman et al. |
Leonetti et al. |
Mekeel et al. |
Harold et al. | |
---|---|---|---|---|---|
Risk factors |
Ascites
Cirrhosis
Increased intra-abdominal pressure
Weakening of the abdominal fascia
Muscle wasting
Poor nutritional status |
Ascites
Cirrhosis
Increased intra-abdominal pressure
Weakening of the abdominal fascia
Muscle wasting
Poor nutritional status |
Ascites
Poor liver function
Malnutrition
High intra-abdominal pressure |
Male gender
Steroid Immunosuppression
Reoperation
Living donor
Prolonged ICU
Acute rejection
BMI > 25
Severe post-transplantation ascites |
Malnutrition
Immunosuppression
Systemic steroid use
Abdominal ascites |
Management |
Elective surgery
Open technique |
Elective surgery
Primary suturing |
Elective and emergent
Open technique |
Laparoscopic hernia repair |
Laparoscopic hernia repair |
Recurrence |
7% |
24% |
16% |
7.6% |
7.9% |
Risk Stratification
In order to have a proper evaluation of the patient with liver disease that presents with a hernia, an assessment of the severity of disease, the type of hernia, and other co-morbidities need to be determined. Although liver disease patients are complicated, fortunately, in the present era and with advancements in the field of transplantation, the multidisciplinary management of transplantation centers allows the cirrhotic patient to have enough time to undergo a proper evaluation of the need for surgery to be performed while the liver disease complications are controlled. Pre-transplant patients are expected to undergo a preoperative evaluation, and their conditions should be optimized prior to elective surgery. This type of evaluation can also be performed in CLD that require hernia repair.
It is imperative to mention that there are contraindications for hernia repair or any abdominal surgery with liver disease, such as acute liver failure, acute renal failure, acute hepatitis, coagulopathy, hypoxemia and alcoholic hepatitis, or active alcohol abuse [17] thus, in this chapter, we are focusing on CLD, where the patient is expected to have synthetic function of the liver. It is also always important to consider that patients found to have CLD may benefit from conservative management [17]. However, some series have shown that conservative management can lead to more complications such as incarcerated hernias [18], for that reason, the preoperative assessment and workup for potential repair should be performed in a timely manner.
Many decades ago, predictor scales were developed to determine the mortality risk in patients with cirrhosis; such scales have proven their utility to assess surgical risk as well [19]. Two commonly tools used by most centers in the USAs including ours are the Child-Turcotte-Pugh (CTP) score and the Model for End Stage Liver Disease (MELD).
The Child-Turcotte-Pugh score , developed in the 1960s (Child CGG) and modified in the 1970s [20], bases its classification criteria on the following parameters: Total bilirubin, serum albumin, prothrombin time, and ascites and hepatic encephalopathy. Each parameter is scored 1–3, 3 indicating the most severe alteration on that parameter. The interpretation is based on the added score, and can be divided into Class A (5–6 points) associated with a 100% one-year survival rate, Class B (7–9 points) with an 81% one-year survival rate, and Class C (10–15 points) with a 45% one-year survival rate [21].
In elective surgery, it is well known that Child A patients can tolerate the procedure well and surgery is permissible on Child B patients if compensated and with a platelet count preferably higher 100,000. In our experience at the Yale New Haven Transplantation Center we are mainly using the MELD score and portal hypertension assessment as described later in this section.
Hernia repair should be contraindicated in Child C; some exceptions have been done in cases of incarcerations by some teams in which an adequate informed consent and a clear understanding of the high mortality of patients should be discussed. Park et al. [22] demonstrated that when it comes to hernias, CTP Class A and B are safe and the recurrences rate is low.
The MELD system, created to predict mortality after transjugular intrahepatic portosystemic shunt (TIPS), at the Mayo clinic more than two decades ago [16, 23], and since February of 2002 is used in the United States as a stratification system and organ allocation for liver transplantation (modified MELD-Na is currently utilized by the United Network of Organ Sharing). The system is utilized by many as described by Befeler et al. to predict perioperative mortality in CLD patients undergoing elective and urgent procedures, not only in hepatobiliary surgery, but also in any intervention that may require anesthesia. The MELD system focuses on the following criteria: Bilirubin, creatinine, and International Normalized Ratio (INR). The MELD formula allows assessment of 3-month mortality.
The risk of an additional operation for patients who have high MELD scores is considered greater than the risk of waiting until transplantation in which cases the hernia would be corrected during the transplantation procedure, for that reason, hernias in patients with a MELD score of more than 22 or a close date to transplant are not recommended to be treated unless they present signs of incarceration, due to the high risk of complications in CLD patients [12, 24]. Saleh et al. developed a nomogram that included MELD score to predict 30-day postoperative mortality in patients with ascites undergoing umbilical hernia repair. In their study MELD score, low albumin, high WBC, and low platelet count were found to be significant predictors of mortality. With the use of their nomogram it was noted that mortality begins to increase at a MELD score of 12, and the non-survivor patients had an average MELD of 19 [25]. In our group based on the experience obtained we rarely performed a hernia repair open or laparoscopically in patients with MELD over 14 (average MELD of 12). Also, when the patient meets criteria for transplantation, a discussion in a multidisciplinary fashion takes place prior to repair.
This algorithm represents the previously suggested management of hernias in which factors such as signs of incarceration, cirrhosis, ascites, and transplant possibility are taken into account in the process of decision making (Fig. 16.2).
Fig. 16.2
Guidelines of surgical approach in ESOD and transplant patients
Kidney
Patients with end stage renal disease (ESRD) that need peritoneal dialysis have increased intra-abdominal pressures and increased risk for developing abdominal wall complications such as peritonitis, wound infections, and hernias [24].
Literature shows patients being treated with continuous ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD) have a higher rate of hernia development in the first 3 months following initiation of CAPD/CCPD with a subsequent rapid decrease. Patients not eligible for peritoneal dialysis (PD) may be those with massive kidneys, abdominal hernias, or previous episodes of diverticular disease. In theory, transplant patients are at an increased risk for incisional hernia due to the time they spend on dialysis before transplantation, the use of immunosuppressors and co-morbidities. We have in our experience seen this to be a particular issue with PKD patients in pre and post-transplantation setting.
Transplantation and immunosuppressive therapy have shown to increase the risk of hernias in patients with ESRD. In order to minimize risks and treat pre-transplant hernias it is recommended the place a tenckhoff catheter for peritoneal dialysis through minimally invasive surgery (MIS), which is a surgical technique with proven superior outcomes related to wound complications, hospital stays, infections, scarring, and pain compared to the open technique [24].
Post Transplant Hernia Repair
Liver
Even though much improvement has been made in surgical techniques and immunosuppressive therapy, hernias in the post-transplant setting are still common, which influence patient and graft survival. The incidence of incisional hernias after liver transplantation can range from 1.7 to 34.3% [25]. Recent literature reports 350,000 incisional hernia repairs each year in the USA and close to 200,000 are associated with a previous surgery. Among potential complications are abdominal pain, skin necrosis, and intestinal incarceration and perforation [26–28].
Risk factors such as increased age, smoking, persistent ascites, obesity (BMI > 30), diabetes, malnutrition, connective tissue disorders [29–31], and immunosuppression therapy can increase the risk of developing incisional hernias. Among the most influential agents of immunosuppression Cortisone and Sirolimus have demonstrated negative outcomes in relation with post-transplant wound complications [32]. Conditions such as (SSI’s) may increase the possibility of developing an incisional hernia by up to 25%.
The group of Modena, Italy, suggests a safe approach towards cessation of mTORs one month before surgery and reinstating 3 months’ post-surgery. At the Yale New Haven transplantation center our current practice is to stop the use of mTOR inhibitors 1 week prior to surgical repair, especially in the cases of open procedures in which we use biological materials. At that time, we would switch or adjust the dose of Tacrolimus, which is the most common Calcineurin Inhibitors (CNI) used in our program. Therapy is reinitiated 3–4 weeks after the repair, except in the cases where we suspect SSI [26]. Systemic use of Sirolimus in animal studies has proven to decrease tensile strength of wound healing and the deposit of collagen.
Patients who are tobacco users will see their wound healing mechanisms altered, predisposing them to complications, and recurrence of incisional hernias. This was confirmed by Moller et al. [33] who observed smoking cessation, at least 3 weeks before surgery, produced an improved post-surgical healing wound due to the recovery of collagen structure and the immune system in general. Evidence shows cigarette smoking may contribute to poor graft function, cardiovascular disease, and secondary malignancies post-transplantation. In current practice unfortunately we observe 40% of patients will resume smoking habits soon after their liver transplant.