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Concurrent Umbilical Hernia Repair at the Time of Liver Transplantation: a Six-Year Experience from a Single Institution A

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Concurrent Umbilical Hernia Repair at the Time of Liver Transplantation: a Six-Year Experience from a Single Institution A Archive of SID Original Article Concurrent Umbilical Hernia Repair at the Time of Liver Transplantation: A Six-Year Experience from a Single Institution A. J. Perez1, I. N. Haskins1, 1Comprehensive Hernia Center, Digestive Disease and Surgery A. S. Prabhu1, D. M. Krpata1, Institute, The Cleveland Clinic Foundation, Cleveland, OH, 2 1 USA C. Tu , S. Rosenblatt , 2 3 3 Department of Quantitative Health Sciences, Lerner K. Hashimoto , T. Diago , Research Institute, The Cleveland Clinic Foundation, B. Eghtesad3, M. l. J. Rosen1* Cleveland, OH, USA 3Transplantation Center, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation, Cleveland, OH, USA ABSTRACT Background: Umbilical hernias are common in patients with end-stage liver disease undergoing liver transplantation. Management of those persisting at the time of liver transplantation is important to de- fine.Objective: To evaluate the long-term results of patients undergoing simultaneous primary umbilical her- nia repair (UHR) at the time of liver transplantation at a single institution. Methods: Retrospective chart review was performed on patients undergoing simultaneous UHR and liver transplantation from 2010 through 2016. 30-day morbidity and mortality outcomes and long-term her- nia recurrence were investigated. Results: 59 patients had primary UHR at the time of liver transplantation. All hernias were reducible with no overlying skin breakdown or leakage of ascites. 30-day morbidity and mortality included 5 (8%) su- perficial surgical site infections, 1 (2%) deep surgical site infection, and 7 (12%) organ space infections. Unrelated to the UHR, 10 (17%) patients had an unplanned return to the operating room, 16 (27%) were readmitted within 30 days of their index operation, and 1 (2%) patient died. With a mean follow-up of 21.8Conclusion: months, 7 (18%) patients experienced an umbilical hernia recurrence. - rent primary UHR resulted in an acceptable long-term recurrence rate with minimal associated morbid- ity. Despite the high perioperative morbidity associated with the transplant procedure, concur KEYWORDS: Cirrhosis; Clinical decision-making; Liver disease; Tissue injury and repair; Surgical technique; Umbilical hernia; Liver transplantation INTRODUCTION by the presence of liver cirrhosis, portal hy- pertension, and ascites, are the patients who hronic liver disease (CLD) affects progress to liver transplantation. Of those 4.5% to 9.5% of the general population patients being evaluated for liver transplanta- Cworldwide [1]. Those patients with tion, the incidence of umbilical hernia is esti- the most severe form of CLD, characterized mated to be 20% [2]. To put this in perspec- *Correspondence: Michael Rosen, MD, Clinical Fellow, tive, it is estimated that less than 1% of the Comprehensive Hernia Center, Digestive Disease and general population of the USA will develop an Surgery Institute, The Cleveland Clinic Foundation, 9500 umbilical hernia in their lifetime [3]. The dif- Euclid Avenue, A-100, Cleveland, OH 44195, USA Tel: +1-21-6445-0767 ference in the incidence of umbilical hernias Fax: +1-21-6444-2153 between these patient populations is likely re- E-mail: [email protected] lated to increased intra-abdominal pressure, International Journal of Organ Transplantation Medicine www.SID.ir Archive of SID Umbilical Hernia Repair and LTx weakening of the abdominal wall fascia, and currence rates in those patients undergoing muscle wasting due to poor nutritional status, concurrent primary umbilical hernia repair and portal hypertension leading to a dilated (UHR) at the time of orthotopic liver trans- umbilical vein enlarging the umbilical fascial plantation at a single institution. opening in patients with CLD [2, 4]. Never- theless, despite the relatively high incidence of umbilical hernias in the patient population PATIENTS AND METHODS with CLD, there remains a paucity of litera- ture directing the management of this com- Consecutive adult patients undergoing pri- mon problem in patients planning to undergo mary UHR at the time of liver transplanta- liver transplantation. tion from January 2010 through June 2016 at the Cleveland Clinic Foundation were identi- Approximately 7000 liver transplantations fied within a prospectively-maintained, in- were performed in the USA in 2015 [5]. It can stitutional liver transplantation database. All be estimated that 1400 of those liver trans- umbilical hernias were repaired primarily via plant patients will have developed an umbili- exposure from the Chevron incision used for cal hernia by the time of liver transplanta- the liver transplantation with the use of sim- tion. Repairing the umbilical hernia prior to ple interrupted or figure-of-eight permanent the transplantation may increase the risk of sutures by the transplant surgeon without ascites leakage, bleeding due to uncontrolled an additional incision over the site of the um- portal hypertension, mesh infections, and bilical hernia. Patients undergoing only liver eventual delay of liver transplantation due to transplantation and those patients undergoing complications. However, if the hernia is not ad- repair of abdominal wall hernias other than dressed at the time of transplantation, it could umbilical hernias, including ventral/incisional result in acute incarceration of the hernia con- hernia repair or inguinal hernia repair, were tents, as a result of the rapid resolution of the excluded from this analysis. ascites post-transplantation. Furthermore, the most appropriate approach to repairing an After obtaining Institutional Review Board umbilical hernia during liver transplantation approval, retrospective chart review was per- is complicated by the contamination inherent formed on all identified patients. Patient de- to the procedure and the burst of immunosup- mographic information, operative details, 30- pression, both of which are felt to be relative day post-operative outcomes, and long-term contraindications for synthetic mesh place- hernia recurrence outcomes were collected. At ment. Most transplant surgeons, therefore, ei- our institution, all patients undergoing liver ther avoid repairing these hernias at the time transplantation are followed at the transplant of transplantation or perform a primary repair clinic at one week, one month, three months, at the time of transplantation. six months, nine months, and one year, post- operatively and then annually, thereafter. The management of umbilical hernias in pa- tients on the liver transplant list is controver- Disease severity was assessed by the Charl- sial, with little published data to guide trans- son Comorbidity Index, the Model for End- plant and general surgeons. Stage Liver Disease (MELD) score, and the Sodium-Adjusted MELD Score [6-8]. These Our institution is a high-volume transplanta- scores were calculated at the time the patients tion center with significant experience with admitted to the hospital for liver transplanta- this patient population. Our group prefers to tion to most accurately reflect their associated perform a primary tissue repair of the um- comorbidities and extent of CLD. Thirty-day bilical hernia defect when present at the time outcomes of interest included the incidence of of liver transplantation. The objective of this superficial surgical site infection (SSI), deep study was to evaluate 30-day morbidity and surgical site infections, organ space infections, mortality outcomes and long-term hernia re- wound dehiscence, unplanned return to the op- www.ijotm.com Int J Org Transplant Med 2018; Vol. 9 (1) 21 www.SID.ir Archive of SID A. J. Perez, I. N. Haskins, et al Table 1: Patients characteristics (n=59) RESULTS Mean±SD Variable Approximately 135 patients are transplanted or n (%) at our institution annually. From January 2010 Age (yrs) 58.0±9.8 through June 2016, 59 patients underwent pri- Sex mary UHR at the time of liver transplanta- Male 52 (88%) tion at our institution (Table 1). The majority of the patients were Caucasian (84%) and male Female 7 (12%) (88%). With respect to the severity of illness, Race patients had an average Charlson Comorbid- Caucasian 48 (81%) ity Index of 5.2, a MELD Score of 18.1, and African-American 5 (9%) a Na-MELD Score of 21.3. Of note, 19 (32%) Other 6 (10%) patients had hepatocellular carcinoma at the time of liver transplantation. Charlson Comorbidity Index Score 5.2±1.6 Age Adjusted Charlson Comorbid- 6.5±1.9 In terms of 30-day morbidity and mortality ity Index outcomes, five (9%) patients experienced a su- MELD Score 18.1±9.1 perficial SSI, one (2%) patient experienced a Na-MELD Score 21.3±8.6 deep SSI, and seven (12%) patients experienced Presence of HCC 19 (32%) an organ space infection (Table 2). Of the five Presence of ascites 57 (97%) patients who developed a superficial SSI, one was at the site of the umbilical hernia repair; erating room (OR), unplanned readmission to this patient went on to develop an umbilical the hospital, and death. Long-term outcomes hernia recurrence. No deep or organ space in- of interest included hernia recurrence, addi- fections occurred at the site of the UHR. tional abdominal surgeries, and death. Hernia recurrence was defined as a defect in the fascia Ten (17%) patients experienced an unplanned at the site of the umbilicus either on physical return to the OR; eight (80%) patients re- examination or radiographic imaging at any of turned to the OR for coagulopathy-related the above-mentioned follow-up appointments. intra-abdominal hemorrhage, one (10%) pa- Kaplan-Meier survival anlaysis was used to tient returned to the OR for repair of a bili- determine the length of time to hernia recur- ary duct anastomotic leak, and one (10%) pa- rence, taking into account those patients who tient returned to the OR for emergent repair were lost to follow-up and those who died. All of an incarcerated inguinal hernia. Sixteen statistical analyses were performed using SAS (27%) patients had an unplanned readmission (ver 9.4, Cary, NC, USA). to the hospital, all of which were unrelated to the UHR, and one (2%) patient died within 30 days of their index procedure due to multior- Table 2: 30-day outcomes (n=59) gan system failure following a biliary anasto- motic leak.
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