Incisional hernia repair following liver transplantation: A meta-analysis

Abstract

BACKGROUND

Incisional hernia (IH) is a common complication following liver transplantation (LT), contributing to significant morbidity and impaired quality of life. The interplay of transplant-specific factors, patient comorbidities, surgical complexity, and immunosuppression presents considerable challenges in hernia repair, often accompanied by substantial risks.

AIM

To assess the incidence, risk factors, and outcomes of IH repair in LT recipients.

METHODS

A systematic literature search was conducted across MEDLINE, EMBASE, Scopus, CINAHL, the Cochrane Library, Google Scholar, and PubMed, yielding 493 results. In accordance with PRISMA guidelines, 39 studies reporting on IH following LT were included in the final analysis. Studies involving paediatric populations, hernias unrelated to transplant incisions, living liver donors, non-LT, and multi-organ transplants were excluded. Meta-analysis was performed using Cochrane RevMan software. The study has been registered with PROSPERO (CRD42024563398).

RESULTS

A review of 39 studies revealed incidence of post-LT IH ranging from 1.7% to upto 42.8%. Pooled analysis showed comparable demographics among groups and post-LT IH incidence was higher in older age recipients [mean difference (MD) = 2.39, 95%CI: 1.15-3.63, P < 0.001], male gender (relative risk = 1.42, 95%CI: 1.18-1.72, P < 0.001), high body mass index (BMI) (MD = 1.06, 95%CI: 0.82-1.29, P < 0.001), Mercedez-Benz incision type [odds ratio (OR) = 0.45, 95%CI: 0.21, 0.96, P = 0.04], and need for re-laparotomy (OR = 2.49, 95%CI: 1.05-5.93, P = 0.04). No significant differences were found in recurrence rates or wound complications between open and laparoscopic IH repairs.

CONCLUSION

Older recipient age, male gender, high BMI, Mercedes-Benz incision, and re-laparotomy after LT are significant risk factors for IH. In contrast, model for end-stage liver disease score, pre-LT ascites, acute rejection, and mammalian target of rapamycin inhibitor therapy do not appear to influence IH development. While open repair remains the predominant approach post-LT, no significant differences in recurrence or wound complication rates have been observed between open and laparoscopic repairs. However, open repair is associated with a shorter operative time.

Keywords: Liver transplant; Incisional hernia; Mesh repair; Biological mesh; Recurrence

Core Tip: This systematic review and meta-analysis provide a comprehensive evaluation of incisional hernia (IH) following liver transplantation, synthesizing evidence on risk factors, surgical techniques, and repair outcomes. It identifies high body mass index, male sex, older age, and re-laparotomy as key risk factors, and highlights a higher incidence of IH with Chevron and Mercedes-Benz incisions. While laparoscopic and open repairs show comparable outcomes, biological mesh may reduce complications in immunosuppressed patients. These findings emphasize the importance of individualized surgical planning and underscore the need for standardized outcome reporting and integration of quality-of-life measures in future research.