Right Subcostal Incision in Liver Transplantation: Prospective Study of Feasibility

doi:10.1016/j.transproceed.2006.03.044

Transplantation Proceedings

Volume 38, Issue 4, May 2006, Pages 1109-1110

https://doi.org/10.1016/j.transproceed.2006.03.044 Get rights and content

Abstract

Little is known about incidence and risk factors for incisional hernia after liver transplantation (OLT). More frequently this problem occurs at the junction of midline and transverse incisions. We prospectively and consecutively used three different types of abdominal incisions in 47 OLTs. The results were compared in order to identify the type of incision and risk factors that determine herniae after OLT. The overall incidence was 17%. It occurred in 6 out of 19 patients (31.3%) with a transverse and right subcostal both with upper midline incision versus 2 out of 26 patients (7.7%) with only a right subcostal incision. In conclusion, a subcostal incision is sufficient to perform OLT and reduce hernia incidence after OLT.

Section snippets

Patients and methods

Between December 2002 and August 2005, 47 adult OLTs were prospectively and consecutively divided into three series according to the abdominal incision: bilateral subcostal with upper midline incision (M = 11 patients); right subcostal with upper midline incision (J = 9); and right subcostal incision (S = 27). Surgical technique was the same in all series. Hepatectomy with recipient caval preservation and cavo-cava laterolateral anastomosis without venous bypass. Closure of the abdominal

Results

Two patients (4.2%) died perioperatively; one in each group. They were excluded from the study. We analyzed 45 patients with least 3 months follow-up after OLT. There was no difference in previous abdominal surgery, BMI, operative time, perioperative use of blood products, ICU stay, wound hematoma, and infection between the two groups. No relaparotomy occurred. Immunosuppression treatment was similar in all patients: low-dose tacrolimus and steroids with or without mycophenolate mofetil. Two

Discussion

Cirrhotic patients are at high risk of hernia after OLT, at incidences ranging from 4.9% to 17%.2, 3, 4 Little is known about the causes of herniation. Many risk factors have been hypothesized in the pathogenesis of hernia occurrence: malnutrition and preoperative ascites, jaundice, thrombocytopenia, chronic steroid use, acute rejection, steroid pulse therapy, diabetes mellitus obesity, previous abdominal surgery, and relaparotomy all impair wound healing. Several studies reported a correlation

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V.J. Hesselink et al.
An evaluation of risk factors in incisional hernia recurrence
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There are more references available in the full text version of this article.

Cited by (16)

Low incisional hernia incidence using a large-bite, low-tension technique for celiotomy closure
2023, Surgery Open Science
Incisional herniae (IH) are reported in 5–>20 % of patients undergoing open celiotomy, and can be linked to closure technique. The STITCH randomized trial favors a small bite technique for midline celiotomy closure with a 1-year IH rate of 13 % over larger bites (23 %).
A continuous musculofascial mass closure with absorbable looped #1 PDS suture with 2-cm bite size was used for all open celiotomies. IH frequency and associated clinicopathologic factors were retrospectively analyzed from prospective data in 336 consecutive patients undergoing visceral resections by a single surgeon.
The study population included 192 men and 144 women, 81 % of whom had a cancer diagnosis, who underwent hepatobiliary, pancreatic, gastroesophageal, and colorectal resections, or a combination. The majority of patients (84 %) had subcostal incisions, and 10 % received a midline incision. At a median follow-up of 19.5 months, the overall IH rate was 3.3 %. Hernia rates were 2.5 % for subcostal margin, 2.9 % for midline, and 5.5 % for other incisions (p = 0.006). Median time to hernia detection was 492 days. Factors associated with IH were increased weight, abdominal depth/girth, male sex, spleen size, visceral fat, and body height (p ≤ 0.04 for all), but not type of resection, prior operations, underlying diagnosis, weight loss, adjuvant chemotherapy or radiation, incision length or suture to incision ratio.
The described technique leads to a low IH rate of <3 % in subcostal or midline incisions, and can be recommended for routine use. The observed results appear superior to those of the STITCH trial, even for the smaller midline incision cohort.
Prophylactic mesh can be used safely in the prevention of incisional hernia after bilateral subcostal laparotomies
2016, Surgery (United States)
Citation Excerpt :
In a study comparing transverse versus midline incisions, the incidence of IH was 8% at 1-year follow-up.4 Something similar occurs in the evaluation of IH after different operative incisions in liver transplantation, with a published incidence up to 43%.2,23-26 Nevertheless, liver transplantation series cannot be compared because immunosuppression impairs wound healing.
The use of prophylactic mesh to prevent incisional hernia is becoming increasingly common in midline laparotomies and colostomies. The incidence of incisional hernia after subcostal laparotomies is lower than after midline incisions. Nevertheless, the treatment of subcostal incisional hernia is considered to be more complex. Currently, there are no published data about mesh augmentation procedures to close these laparotomies.
This was a longitudinal, prospective, cohort study of patients undergoing a bilateral subcostal laparotomy in elective operations. The mesh group was a group of patients operated consecutively between 2011 and 2013 with a prophylactic self-fixation mesh. The control group was selected from a retrospective analysis of patients operated between 2009 and 2010 and closed with a conventional protocol of 2-layer closure. The incidence of incisional hernia was recorded both clinically and radiologically for 2 years.
A total of 57 patients were included in the control group and 58 in the mesh group. Most patients underwent gastric, hepatic, and pancreatic operations. Both groups were homogeneous in terms of their clinical and demographic characteristics. Operative time and hospital stay were similar in both groups. Both groups had a comparable rate of local and systemic complications. Ten patients (17.5%) in the control group developed an incisional hernia, and only 1 patient (1.7%) in the mesh group developed an incisional hernia (P = .0006).
The incidence of incisional hernia after a conventional closure of bilateral subcostal laparotomy is significant. The use of a mesh augmentation procedure for closing bilateral subcostal laparotomies is safe and may reduce the incidence of incisional hernia.
Optimal Technique for Abdominal Fascial Closure in Liver Transplant Patients
2010, Asian Journal of Surgery
The ideal technique for abdominal closure of a Mercedes-type incision, which is still a serious issue among surgeons, has yet to be demonstrated clearly. The purpose of this study was to explain our novel technique for abdominal fascial closure in liver transplant patients.
We analyzed retrospectively 180 consecutive adult-to-adult right lobe living donor liver transplants. The patients were divided into two groups based on two abdominal closure types used. Group A consisted of 78 patients who were submitted to abdominal closure with our new technique using three synthetic absorbable loop suture materials, and group B consisted of 102 patients whose abdominal closure was performed with another type of closure technique.
There were no significant differences between the demographic characteristics of the two groups. The mean closure time was significantly lower in group A than in group B (p <0.05). The incidence rates of ascites leakage and hernias were also significantly lower in group A (p <0.05).
Our results indicate that the novel technique used in this study contributed to overcoming early and late postoperative complications associated with closure of the abdominal fascia in liver transplant patients. In addition, this new technique has proven to be easily applicable, faster, safer and efficient in these patients; it is also potentially useful for conventional surgery.
Is the incision type important for the development of hernia in liver transplant patients?
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Incisional hernia after liver transplantation: mesh-based repair and what else?
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Liver transplantationOutcomeRight Subcostal Incision in Liver Transplantation: Prospective Study of Feasibility

Abstract

Section snippets

Patients and methods

Results

Discussion

Transplant Proc

An evaluation of risk factors in incisional hernia recurrence

Surg Gynecol Obstet

Liver transplantation
Outcome
Right Subcostal Incision in Liver Transplantation: Prospective Study of Feasibility