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.

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].

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.

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).

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].

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.