Comments to “PRevention of INCisional hernia after liver transplantation (PRINC trial): study protocol for a randomized controlled trial.”

Dear Editor

I read the article by Kniepeiss et al. with great interest. It describes the first attempt to significantly reduce the rate of postoperative hernia in patients who undergo liver transplantation [1]. The technique of primary wound augmentation with the use of mesh was first described in 2002 in a group of patients subjected to a bariatric procedure [2]. Four years later, the results of the first randomized clinical trial of hernia prophylaxis were published [3]. The effectiveness of laparotomy closure, with the use of a non-absorbable mesh, in reduction of the rate of incisional hernia has been confirmed by many studies, among them a multicenter, double-blind, randomized controlled trial by Jairam et al. [4].

The authors of the article published in Trials emphasize the risk of using the mesh in patients undergoing immunosuppressive therapy. A large study comparing the use of a mesh in repairing an incisional hernia in patients who underwent liver transplantation or pancreatoduodenectomy showed similar results in both groups, although only patients with transplanted liver were receiving immunosuppressive therapy [5].

According to data obtained from the Americas Hernia Society Quality Collaborative, immunosuppression in patients subjected to open elective ventral hernia repair is associated with an increased risk of 30-day surgical site occurrence, mostly seromas, but not surgical site infection or an additional 30-day morbidity or mortality [6].

To reduce the risk of using the mesh in immunosuppressed patients, the authors chose a long-absorbing mesh, which maintains the mechanical strength of the wound for up to 18 months. Various studies have shown that postoperative hernia is a lifelong risk. Juvany and colleagues have found that, in half of the patients who developed incisional hernia, it occurred more than 3 years from the original procedure [7]. Kockerling et al. proved that in a complex abdominal hernia repair, biologic and biosynthetic meshes do not provide a superior alternative to synthetic meshes [8]. The use of poly-4-hydroxybutyrate mesh to repair incisional hernia in a high-risk group of patients, resulted in a 9% recurrence rate in the 18-month follow-up [9]. There is no evidence to support the use of biologic/biosynthetic meshes for prevention of incisional hernias [8].

I am afraid that the choice of an absorbable mesh may reduce the potential success rate of incisional hernia prevention in patients who undergo liver transplantation.

Yours sincerely,

Janusz Strzelczyk, MD, PhD.