Is polypropylene mesh safe and effective for repairing infected incisional hernia in renal transplant recipients?

doi:10.1016/j.urology.2005.04.072

Urology

Volume 66, Issue 4, October 2005, Pages 874-877

https://doi.org/10.1016/j.urology.2005.04.072 Get rights and content

Abstract

Introduction

Infected incisional hernias are common in kidney transplant patients. Treating them in immunosuppressed patients can take months, increasing costs and implying loss of working productivity. Abdominal wall prostheses have not been used in infected immunosuppressed patients because of poor infection control. We evaluated the outcome of the surgical treatment of these patients with polypropylene mesh to shorten the hospitalization time and patient recovery. The records of 462 consecutive kidney transplant patients (March 2000 to February 2004) were reviewed. Of these 462 patients, 13 (2.8%) had infected or contaminated herniations at the transplant incision. They developed between 2 and 60 days (mean 14) after transplantation. The racial distribution was not significant, but herniations were more common in patients from cadaveric donors (4.5% versus 0%, P = 0.005). Predisposing factors were found in 6 patients (46.2%) and included complications from transplant surgery in 2, obesity in 1, leukopenia in 3, sepsis in 1, diabetes mellitus in 1, and wall weakness in 1 patient (3 had more than one risk factor).

Technical Considerations

A prospective protocol of surgical correction with polypropylene mesh was established. After wound cleansing with normal saline, repair was done by primary fascial approximation and polypropylene mesh reinforcement. Broad-spectrum antibiotics and large-bore drains were used. Follow-up ranged from 1 to 40 months (mean 14.5). All patients did well except for one recurrence, 14 months after correction.

Conclusions

Surgical repair with polypropylene mesh is safe and effective in treating infected or contaminated herniations in kidney transplant patients, with an acceptable (9.1%) incidence of recurrence.

Section snippets

Material and methods

The records of 13 of 462 patients who underwent kidney transplantation from March 2000 to February 2004 who had infected hernias or evisceration were studied. Table I lists the demographic data. Infection was defined as the presence of clinical signs, such as pain, rubor, edema, and dehiscence with purulent secretion at the incision site, with positive culture for microorganisms. Contamination was considered in cases of evisceration with peritoneal content exposure.

We analyzed probable risk

Results

In 462 transplant cases, 13 (2.8%) infected or contaminated incisional hernias were identified. Table II lists the patient characteristics.

No patients had previously undergone any kind of incision at the current transplantation site. Of the 13 patients, 11 were kidney transplant patients in whom incision infection occurred with dehiscence in 5 and evisceration with omentum exposure in 6 (mean time between evisceration and operation 16 hours).

One patient underwent a simultaneous liver-kidney

Comment

Incisional hernias are a frequent problem in the general population, and about 70% of them develop within the first year after surgery.² Attempts to correct these hernias by repeating the closure with suture has resulted in recurrence rates of up to 50%. This rate has been reduced to less than 10% using mesh implantation.¹¹ Transplant patients are at additional risk of developing incisional hernias because of factors such as the chronic use of corticosteroids, other immunosuppressive drugs,

Conclusions

Incisional hernias are not rare after kidney transplantation, and some may become infected. When associated with wound infection, most develop within the first 3 weeks after transplant surgery. They are significantly more common in transplants of organs from a cadaveric source. Surgical complications of transplant surgery, such as wound hematoma and lymphocele, are important predisposing factors, underscoring the need for meticulous surgical technique. Surgical repair of infected or

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Cited by (43)

Incisional Hernia Repaired Using Thigh Muscle Fascia After Kidney Transplantation: A Case Report
2022, Transplantation Proceedings
Citation Excerpt :
Now, a variety of meshes have been developed, and reliable data is available on their efficacy and safety [7,8,11]. Despite the wide use of meshes for IH after organ transplantation, serious complications such as mesh infection, migration to the intestine or bladder, and spermatic cord injury have been reported [8]. In our case, however, the use of mesh was also considered, and the final decision was to repair with autologous tissue because of the increased risk of infection in an unstable immunosuppressed situation.
Although monofilament mesh-based repair is a safe and effective procedure for incisional hernia (IH) in organ transplant patients, there is no definite evidence of IH treatment for patients with graft rejection and enhanced immunosuppressive therapy. We report a successful case of large IH repair using an autologous thigh muscle fascia sheet in a kidney transplant patient.
A 69-year-old man had IH from the incision of kidney transplantation, which was performed 6 years ago. He had a large right lower abdominal distension hanging down to the inguinal portion. A computed tomography scan revealed a large IH with a maximum abdominal defect diameter of 15 cm. The hernia sac contained the intestine, colon, and transplanted kidney, which had pulled out along with the retroperitoneum and protruded into the abdominal wall. He had chronic active acute antibody-mediated rejection, which required frequent steroid pulse therapy and additional or adjusted immunosuppressive drugs. After total circumferential exposure of the hernia sac and abdominal fascia, the abdominal wall defect was closed using a horizontal mattress suture. The sutured line was covered with a thigh muscle fascia sheet harvested from the patient's right femur and attached to the closed fascia. He was discharged on postoperative day 13 without any complications, and no IH recurrence was observed 10 months after surgery.
Hernia repair using autologous tissue could be a treatment option for post-transplant IH with a higher risk of infection.
Risk Factors and Optimal Methods for Incisional Hernias After Kidney Transplantation: A Single-Center Experience From Asia
2021, Transplantation Proceedings
For kidney transplant patients, incisional hernia (IH) is a major complication resulting from prolonged pretransplant dialysis, immunosuppressive drugs, and the high prevalence of diabetes. However, there have been relatively few studies of IH after kidney transplantation (KT) in Japan and in the greater Asian population. Additionally, operative methods for IH repair have not been established.
We retrospectively analyzed 465 consecutive patients who underwent KT at our hospital from April 2013 to March 2019. Patients who underwent incisional hernia repair were included in this study, and the follow-up time was extended to September 2020. We defined severe IH as an IH requiring surgical repair. We examine the risk factors for severe IH among KT patients and also discuss the operative methods of IH repair.
During the study period, 7 patients developed severe IH after KT. The cumulative occurrence rate for severe IH was 1.1% 1 year postoperatively. Multivariate logistic regression analyses showed that age at KT and dialysis duration (hazard ratio = 1.112, P = .016; hazard ratio = 1.106, respectively; P = .038) were independent risk factors for severe IH. We used polypropylene mesh for IH repair in all cases, with onlay repair performed in 5 of 7 cases. There was no recurrence or infection after mesh repair during follow-up.
In this study, age at KT and dialysis duration were independent risk factors for severe IH in the Japanese population. Onlay repair with a polypropylene mesh appeared to be a safe and acceptable operation for IH repair after KT.
Optimal surgical management in kidney and pancreas transplantation to minimise wound complications: A systematic review and meta-analysis
2018, Annals of Medicine and Surgery
Immunosuppression in transplant patients increases the risk of wound complications. However, an optimal surgical approach to kidney and pancreas transplantation can minimise this risk.
We performed a systematic review and meta-analysis to examine factors contributing to incisional hernia formation in kidney and pancreas transplant recipients. Bias appraisal of studies was conducted via the Newcastle-Ottawa scale. We considered recipient factors, surgical methods, and complications of repair.
The rate of incisional hernia formation in recipients of kidney and pancreas transplants was 4.4% (CI 95% 2.6–7.3, p < 0.001). Age above or below 50 years did not predict hernia formation (Q (1) = 0.09, p = 0.77). Body mass index (BMI) above 25 (10.8%, CI 95% 3.2–30.9, p < 0.001) increased the risk of an incisional hernia. Mycophenolate mofetil (MMF) use significantly reduced the risk of incisional hernia from 11.9% (CI 95% 4.3–28.7, p < 0.001) to 3.8% (CI 95% 2.5–5.7, p < 0.001), Q (1) = 4.25, p = 0.04. Sirolimus significantly increased the rate of incisional hernia formation from 3.7% (CI 95% 1.7–7.1, p < 0.001) to 18.1% (CI 95% 11.7–27, p < 0.001), Q (1) = 13.97, p < 0.001. While paramedian (4.1% CI 95% 1.7–9.4, p < 0.001) and Rutherford-Morrison incisions (5.6% CI 95% 2.5–11.7, p < 0.001) were associated with a lower rate of hernia compared to hockey-stick incisions (8.5% CI 95% 3.1–21.2, p < 0.001) these differences were not statistically significant (Q (1) = 1.38, p = 0.71). Single layered closure (8.1% CI 95% 4.9–12.8, p < 0.001) compared to fascial closure (6.1% CI 95% 3.4–10.6, p < 0.001) did not determine the rate of hernia formation [Q (1) = 0.55, p = 0.46].
Weight reduction and careful immunosuppression selection can reduce the risk of a hernia. Rutherford-Morrison incisions along with single-layered closure represent a safe and effective technique reducing operating time and costs.
Surgical complications of renal transplantation
2016, Progres en Urologie
Rapporter la nature, l’incidence, les outils diagnostiques et les moyens thérapeutiques des complications chirurgicales de la transplantation rénale.
Une recherche bibliographique exhaustive à partir de Medline (http://www.ncbi.nlm.nih.gov/) et Embase (http://www.embase.com/) a été réalisée entre 1960 et 2016 en utilisant les mots clés suivants « complications chirurgicales ; fistule ; lymphocèle ; sténose ; thrombose » en combinaison avec le mot clef « transplantation rénale » dans le champ « Titre/Résumé ». Les articles obtenus ont ensuite été sélectionnés sur leur méthodologie. Ainsi 7618 articles ont été identifiés dont plus spécifiquement 981 pour les complications vasculaires, 1016 pour les complications urinaires et 239 pour les lymphocèles. Après élimination des doublons et sélection, 190 articles ont été revus et sélectionnés.
L’incidence des complications chirurgicales de la transplantation rénale varie de 1 à 30 % selon les séries ; elles sont souvent rapportées de façon incomplète et leur prise en charge est rarement consensuelle. Les techniques d’angioplastie ont apporté une amélioration sensible du traitement des complications vasculaires du transplant à moyen et long terme. Les facteurs de risque de thromboses des vaisseaux du transplant sont le rein droit, la présence d’artères multiples du transplant, l’existence d’une artériopathie chez le donneur ou le receveur, les troubles hémodynamiques per-procédure, la présence d’une néphropathie diabétique ou un antécédent d’accident thromboembolique chez le receveur. Les complications urinaires et la lymphocèle, si elles ne mettent pas en jeu la survie du transplant, sont responsables d’une morbidité conséquente pour le receveur. L’anastomose pyélo-urétérale d’emblée ou de rattrapage fait partie des principales options thérapeutiques des sténoses et fistules urétérales.
La prévention des complications chirurgicales de la transplantation nécessite une préparation minutieuse du transplant, et un respect rigoureux des bonnes pratiques chirurgicales. Les comorbidités de plus en plus importantes des receveurs sélectionnés, et des donneurs marginaux, n’ont pas permis de diminuer significativement la morbidité globale de la transplantation rénale.
To report the nature, incidence, diagnosis and treatment options of surgical complications after renal transplantation.
Relevant publications were identified through Medline (http://www.ncbi.nlm.nih.gov/) and Embase (http://www.embase.com/) database from 1960 to 2016 using the following keywords “fistula; lymphocele; stricture; thrombosis”, in association with “renal transplantation” in Title/Abstract field. Articles were selected according to methods, language of publication and relevance. A total of 7618 articles were identified including specifically 981 for vascular complications, 1016 for urologic complications and 239 for lymphocele; after careful selection 190 publications were eligible for our review.
Surgical complications occur in 1 to 30% of renal transplantations while being incompletely reported without consensual management. Angioplasty techniques led to a significant improvement of short- and long-term vascular complications outcome. Risk factors for transplant thrombosis are a right allotransplant, multiple renal arteries or vasculopathy in the donor, diabetes, arterial disease or thrombophilia in the recipient and hemodynamic changes during procedure. Urinary complications and lymphocele significantly impair overall outcome and recipients quality of life with no demonstrated impact on allotransplant survival. Immediate or salvage pelvi-ureterostomy is a main treatment option for ureteral strictures and fistula.
Prevention of surgical complications following renal transplantation relies on careful allotransplant preparation and strict respect of surgical best practices. Increasing comorbidities in recipients as well as marginal donors are significant limits for the improvement of post-transplant surgical outcome.
Transversus abdominis muscle release for repair of complex incisional hernias in kidney transplant recipients
2015, American Journal of Surgery
Citation Excerpt :
Unfortunately, the use of mesh has become the standard-of-care for all but the smallest incisional hernias.17 Importantly, the safety of prosthetic mesh in renal transplant recipients has been reported, supporting synthetic mesh reinforcement.2,18 Still, efforts should be maintained to minimize potential complications.
Incisional hernias in kidney transplant recipients (KTRs) can be complex because of adjacent bony structures, proximity of the allograft/transplant ureter, and context of immunosuppression. We hypothesized that our novel posterior component separation with transversus abdominis muscle release (TAR) and retromuscular mesh reinforcement offers a safe and durable repair.
KTRs with incisional hernias repaired using the aforementioned technique were identified within our prospective database (2007 to 2013) and analyzed.
Eleven patients were identified (median age 49 years, body mass index 32). The median hernia size was 30 cm² (range 88 to 1,040 cm²) and 8 of the 11 patients were recurrent. Intraoperative morbidity consisted of one transplant ureter injury repaired primarily over a stent. Postoperative morbidity consisted of 2 superficial surgical site infections that resolved and 1 readmission for a blood transfusion. There were no instances of mesh infection, explantation, graft loss, or graft dysfunction. With a median follow-up of 12 months (range 3 to 69), 1 (9%) lateral recurrence has been documented.
For complex incisional hernias in KTRs, TAR is associated with low perioperative morbidity and durable repair.
Abdominal wall closure after a stomal reversal procedure
2014, Cirugia Espanola
Revertir un estoma temporal implica 2 procedimientos quirúrgicos diferentes: la reconstrucción del tránsito intestinal y el cierre de la pared abdominal en el sitio del estoma. Este último presenta diferentes aspectos que deben ser analizados: a) la infección del sitio quirúrgico (ISQ), b) el manejo de una hernia coincidente en el sitio del estoma en el momento de su cierre, c) la prevención del desarrollo de una hernia incisional posterior, d) el cierre del estoma en el caso de que se realice la reconstrucción del tránsito por vía laparoscópica, o e) el cierre de la piel del sitio del estoma. El objetivo de este trabajo es analizar estos aspectos en relación con la reconstrucción de la pared abdominal por la que emerge un estoma temporal cuando se procede al cierre de este.
The closure of a temporary stoma involves 2 different surgical procedures: the stoma reversal procedure and the abdominal wall reconstruction of the stoma site. The management of the abdominal wall has different areas that should be analyzed such us how to avoid surgical site infection (SSI), the technique to be used in case of a concomitant hernia at the stoma site or to prevent an incisional hernia in the future, how to deal with the incision when the stoma reversal procedure is performed by laparoscopy and how to close the skin at the stoma site. The aim of this paper is to analyze these aspects in relation to abdominal wall reconstruction during a stoma reversal procedure.

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Surgical techniques in urologyIs polypropylene mesh safe and effective for repairing infected incisional hernia in renal transplant recipients?

Abstract

Introduction

Technical Considerations

Conclusions

Section snippets

Material and methods

Results

Comment

Conclusions

J Urol

Transplant Proc

J Am Coll Surg

Transplant Proc

Surg Clin North Am

Use of Marlex mesh in the repair of recurrent incisional hernia

Br J Surg

Reconstructive surgery with polypropylene mesh associated with kidney transplant

Actas Urol Esp

Repair of incisional hernia

Surg Gynecol Obstet

Recent trends in the management of incisional herniation

Arch Surg

Prosthetic repair of incisional hernia in kidney transplant patientsa technique with on-lay polypropylene mesh

Hernia

Surgical techniques in urology
Is polypropylene mesh safe and effective for repairing infected incisional hernia in renal transplant recipients?