Intraabdominal, Preperitoneal And Interstitial Hernioplasty Of Incisional Hernia After Kidney Transplantation Is Safe And Effective Even When The Abdominal Wall Defect Is Large

Background: Preferred surgical technique for incisional hernia repair following kidney transplantation is unknown. In the few publications available a high risk of recurrence (>20%) has been reported. A program for incisional hernia repair following kidney transplantation was started at our transplant center in 2015. The strongest incentive for the program was a reluctance to accept kidney recipients for hernioplasty at secondary care centers. Although the incisional hernias caused significant disability the risk of complications was deemed too high.We herein present the longterm results of 20 consecutive incisional hernia repairs after kidney transplantation. Materials and Methods: Between 2010 to 2017 633 adult patients underwent kidney transplantation with a modified Gibson approach at our institution. Of those, 25 patients (3,9%) were diagnosed with symptomatic incisional hernia and 20 underwent surgery. A surgical team consisting of a specialist in hernia repair and a transplant surgeon undertook the hernioplasties, using polypropylene or polyester mesh. The hernioplasties were either performed with sublay, interstitial or intraabdominal mesh placement. Onlay hernioplasty was assumed to carry a high risk of recurrence and was therefore avoided. Results: Follow-up was 2,9 ±1,2 years. Patients with incisional hernias were generally older (59.9 ±6.3 years) than patients without incisional hernia (50 ±14 years) (p=0.01). Deceased donor kidney transplantation was also a risk factor (p=0.002). Most patients (68%) had large abdominal wall defect (>100 cm2) (mean 171 cm2 +/-149 cm2) and in 12 (60%) operations mesh bridging was needed. Mean operating time was 204 min (±62 min) and hospital stay 5,3 (±4) days. All patients underwent a 1-month postoperative assessment and were later on reassessed as part of the regular post-transplant follow-up. Symmetry and function of the abdominal wall was restablished after hernioplasty and no one had a recurrence of hernia during follow-up.One-year patient and graft survival was 100% but there was one (5%) Clavien-Dindo grade IV and one (5%) grade IIIa complication. Transient postoperative respiratory insufficiency ± pneumonia was common (25% of patients). For one patient an impairment of kidney function was observed. Discussion: The results in this study indicate that the surgical techniques used were effective. An alternative surgical approach, not evaluated in this study, would be onlay hernioplasty, a more straightforward procedure. If onlay hernioplasty is equally effective should therefore be evaluted in further studies. Conclusion: With intraabdominal, preperitoneal or interstitial mesh, successful incisional hernioplasty following kidney transplantation can be accomplished with a low risk of kidney injury even when the abdominal wall defect is large. Experience in kidney transplant surgery is most probably a necessity.