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.

Key Words: 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.

INTRODUCTION

Liver transplant (LT) is a life-saving intervention for patients with end-stage liver disease (ESLD), significantly improving survival rates and quality of life (QoL). However, it is not without complications, among which incisional hernia (IH) is one of the most common that can significantly impact on patients’ QoL. Studies estimate the incidence of IH following LT to range from 5% to 30%, with rates varying based on patient populations, surgical techniques, and follow-up durations[1]. Improvements in post-transplant immunosuppression and increasing long-term survival have led to a proportional increase in the incidence of IH in LT recipients[2-4].

In the LT population, IH often present with multiple defects, and in severe cases, may lead to loss of domain, necessitating complex abdominal wall reconstruction[5-7]. These patients frequently have multiple comorbidities, which are well-established risk factors for IH development and can complicate surgical management[8-11]. Additionally, the immunocompromised state of LT recipients further complicates perioperative management, making it challenging to identify the optimal candidates for IH repair and determine the ideal timing for surgical intervention[12,13].

While novel techniques utilizing biological mesh and autologous tissue have been explored for hernia repair, their outcomes have been mixed[5,14,15]. Laparoscopic and robotic approaches have demonstrated safety and efficacy for IH repair in LT recipients, offering minimally invasive options[16-18]. However, emergencies such as hernia incarceration, obstruction, or strangulation pose significant challenges, as inadequate medication optimization and immunosuppression can impair wound healing and hinder recovery[13,19].

Despite the high prevalence and significant implications of IH in LT recipients, there is a lack of comprehensive understanding regarding its risk factors, management strategies, and long-term outcomes. Previous studies have been constrained by small sample sizes, heterogeneity in study designs, and inconsistent reporting standards, limiting the strength of their conclusions. Addressing these gaps is crucial for enhancing patient outcomes and informing clinical decision-making. This systematic review and meta-analysis provide a comprehensive synthesis of existing literature on IH following LT, assessing its incidence, risk factors, and repair outcomes. By consolidating current evidence, this study aims to refine management strategies and optimize care for LT recipients with IH.

MATERIALS AND METHODS

This article follows the Meta-analyses Of Observational Studies in Epidemiology Checklist and the study is registered with PROSPERO (ID: CRD42024563398)[20]. Literature search was conducted in multiple databases including MEDLINE, EMBASE, Scopus, CINHAL, Cochrane library, Google Scholar and PubMed using keywords (“Incisional Hernia” OR “Ventral Hernia” OR “Postoperative Hernia”) AND (“Transplant Recipients” OR “Graft recipient” OR “Organ recipient” OR “Post “Transplant recipient”) AND (“Liver Transplantation” OR “Liver Transplant” OR “Hepatic Transplant” OR “Hepatic Transplantation”) by two members (Kannan SS and Sabapathy PK) of our review team and Royal College of Surgeons of England Library.

We supplemented our initial database search by incorporating additional studies from review articles and reference lists that were not initially identified. Only studies published in English and focused on adult LT recipients were included. Paediatric studies, hernias following non-transplant incisions, living liver donors, non-liver and multi-organ transplants were excluded from analysis. Three independent investigators (Kannan SS and Sabapathy PK and Kattil ALT) screened titles and abstracts following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines[21]. Data extraction was performed independently by all three reviewers using Excel sheets, and the extracted data were then consolidated for analysis (Figure 1). When no abstract was available or the abstract details were inadequate, the full article was reviewed. Differences between the three authors (Kannan SS and Sabapathy PK and Kattil ALT) in the selection of the studies were resolved by consensus with the fourth author (Hakeem AR), who independently reviewed all retrieved papers to make the selection of studies robust.

Figure 1 PRISMA flow diagram showing the number of studies reviewed, excluded, and included in the final analysis. RCT: Randomised controlled trial.

The data that were extracted include study details (title, author, year of publication, study design), incidence rates, time interval between transplant surgery and hernia diagnosis, follow-op period, risk factors, hernia characteristics, results of laparoscopic and open repair. Quality assessment was performed by the independent reviewers using Newcastle-Ottawa scale and Joanna Briggs Institute critical appraisal tool checklist for cohort studies and case series respectively[22,23]. Risk of Bias in Non-randomized Studies of Exposures (ROBINS-E) and ROBINS of Interventions (ROBINS-I) tools were utilized to assess risk of bias in included studies[24]. In risk factors analysis, ROBINS-E tool was used to assess bias with LT as exposure and, ROBINS-I tool was used to evaluate bias in studies comparing laparoscopic and open interventions for hernia repair. Egger test using funnel plots was used to analyse publication bias[25]. Any disagreements in judgement between the three reviewers were resolved by the senior author (Hakeem AR) and meta-analysis from the pooled data was performed with RevMan (5.4.1). Statistical analysis was performed using random-effects model to generate odds ratio and mean difference for categorical and continuous variable respectively and a P value of less than 0.05 represented statistical significance. When mean and standard deviation was not provided, it was derived from median and range using published method[26]. Heterogeneity between studies was assessed using I₂ value where < 25%, 25%-75%, > 75% corresponded to low, moderate and high degrees of heterogeneity.

RESULTS

The literature search identified 493 studies. After removing 164 duplicates and excluding 250 non-relevant studies during the initial screening, 79 abstracts were assessed for eligibility based on the inclusion and exclusion criteria. Of these, 53 articles were selected for full-text review, and ultimately, 39 studies comprising 2200 patients were included in the final analysis.

Incidence and demographics of IH post-LT

The overall incidence of IH after LT was reported in 32 studies, ranging from 1.7% to 42.8% (mean: 15.3%, SD: 10.8%). Among the 25 studies reporting recipient gender, 1190 males were affected, representing an average proportion of 76%, while 356 females developed IH. In six studies reporting Child-Pugh classification, 40.4% of transplanted patients were Child-Pugh C, while 22.3% and 37.3% were classified as Child-Pugh A and B, respectively. The incidence of IH in Child-Pugh A, B, and C patients was 10.0%, 13.3%, and 12.5%, respectively. Hepatocellular carcinoma was the most common indication for LT, followed by alcohol-related liver disease and viral hepatitis.

Risk factors for the development of IH post-LT

Data from 14 observational studies were pooled for a meta-analysis of risk factors for IH development. Significant risk factors included older age [mean difference (MD) = 2.39, 95%CI: 1.15–3.63, P < 0.001], male gender (RR = 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) (Figure 2A), Mercedes-Benz incision type (OR = 0.45, 95%CI: 0.21–0.96, P = 0.04), and the need for re-laparotomy (OR = 2.49, 95%CI: 1.05–5.93, P = 0.04) (Figure 2B). In contrast, pre-transplant ascites (P = 0.33), model for end-stage liver disease (MELD) score at the time of transplant (P = 0.34), acute rejection requiring high-dose steroids (P = 0.06), and mTOR-based immunosuppression (P = 0.29) were not associated with an increased risk of IH formation.

Figure 2 Forest plot. A: Comparing mean body mass index between patients with and without hernia; B: Odds ratios comparing hernia occurrence between patients with and without re-laparotomy. BMI: Body mass index.

Outcomes of IH repair post-LT

Analysis of four studies comparing laparoscopic and open repair of IH after LT found that age at the time of IH repair (P = 0.43), gender (P = 0.81), and BMI (P = 0.43) did not influence the choice of surgical approach. There were no significant differences between the two groups in terms of recurrence rates (P = 0.17), wound complications (P = 0.41), or length of hospital stay (P = 0.59). However, the open repair group had a significantly shorter operating time (MD = 53.9 minutes, 95%CI: 31.50–76.26, P < 0.001).

Funnel plots assessing publication bias for each comparison are available in the Supplementary material, along with additional forest plots for other risk factors and comparisons between laparoscopic and open surgery. Supplementary Tables also provide risk of bias and quality assessments of the included studies.

DISCUSSION

This systematic review and meta-analysis provide a comprehensive evaluation of the risk factors, surgical approaches, and outcomes associated with IH following LT. By analysing 39 studies and over 2200 patients, we offer valuable insights into the management of this complex post-transplant complication.

The incidence of IH post-LT varied widely across studies, ranging from 1.7% to 42.8%, with a pooled mean of 15.3%. Asymptomatic or small hernias may often go undetected in these group of patients, as most reported data reflect those requiring clinical intervention. On average, IH was diagnosed 19.6 ± 4.7 months after transplant, but the time to hernia development varied widely, with some studies reporting median durations exceeding 24 months. This highlights the importance of extended follow-up to identify late-onset hernias, which can cause chronic pain, discomfort, and functional limitations. Additionally, the studies lacked clarity on how many patients had multiple hernia defects, which is common in post-LT hernias.

Older age, male gender, high BMI, and the need for re-laparotomy were all associated with increased IH risk. These findings are consistent with existing evidence and emphasize the importance of individualized pre- and post-operative care. High BMI, in particular, contributes to increased intra-abdominal pressure and impaired wound healing, reinforcing the value of preoperative weight optimization, even though achieving this in LT patients remains challenging due to underlying liver disease, immunosuppression, and lifestyle factors[27-30]. Due to the heterogeneity in classifications and definitions used across the included studies, particularly with respect to BMI thresholds and stratification methods, it was not feasible to derive a consistent or universally applicable cut-off point. Re-laparotomy reflects surgical complexity and its strong association with IH suggests a need for more cautious post-operative monitoring in these patients.

Mercedes-Benz incision was associated with a higher risk of IH compared to other incision types, including Chevron incisions, both of which were linked to increased IH rates in this review. In contrast, J-shaped and reverse L incisions were associated with lower IH risk. This supports current knowledge suggesting that incision geometry influences wound tension and tissue healing, particularly due to the involvement of the midline[29-33]. Although there is currently no consensus in the literature regarding the effectiveness of multi-layered abdominal wall closure, some studies suggest it may provide added strength and promote better tissue approximation, while others report no advantage over single-layer closure[32]. Tailoring incision type and closure technique to individual patient anatomy, risk factors, and procedural complexity may help minimize the risk of IH formation post-LT.

Our findings did not reveal a significant association between IH and factors such as pre-transplant ascites, MELD score, acute rejection requiring high-dose steroids, or mTOR-based immunosuppression. While mTOR inhibitors are widely recognized for their impact on wound healing, our analysis did not show a correlation with increased IH risk. This may be due to variations in their clinical application ranging from induction to maintenance therapy and the potential mitigating effect of individualized dose management. Kim et al[8] emphasized that mTOR-related risks may depend on trough levels, reinforcing the need for careful drug monitoring in transplant patients.

Although high-dose steroids in the postoperative period are generally associated with impaired wound healing and an increased risk of infection, our pooled analysis did not find a significant association between acute rejection after LT and IH formation[9,34,35]. This unexpected finding may be explained by inconsistent management strategies for acute rejection across studies, which complicate the ability to draw clear causal inferences. By comparing LT recipients with patients undergoing other hepatobiliary surgeries using similar incisions, Lam et al[36] demonstrated comparable IH incidence rates. These findings suggests that immunosuppression alone may not be the determining factor in hernia development.

Repair of IH post-LT presents significant technical challenges, largely due to the complexity of the initial transplant surgery. Surgical intervention is typically considered only for patients whose QoL will benefit from the repair[37]. For patients with asymptomatic hernias or those who have comorbidities that make surgical repair difficult, the general approach is to avoid surgical intervention. Because most are larger defects, risk of obstruction and strangulation of bowel is uncommon with these hernias. Many patients with IH post-LT are often hesitant to undergo major surgical procedures, as cosmetic concerns are generally not a priority for those who have already undergone life-saving operations. In these cases, the decision to proceed with surgery must carefully weigh the potential benefits against the associated risks[7,18].

The choice between open and laparoscopic repair techniques varies among different centers. In open surgery, primary repair is favoured for smaller hernias, and mesh is typically placed in a sublay position, rather than inlay or onlay[7,18,35,36]. While both approaches—open and laparoscopic—are used, laparoscopic repair has demonstrated advantages, such as shorter hospital stays and reduced postoperative pain[7,16-18]. However, recurrence rates and wound complications did not differ significantly between the two approaches in this review, suggesting that laparoscopic repair may be more appropriate for carefully selected patients, particularly those without extensive adhesions or large hernia defects.

Mesh reinforcement has emerged as a pivotal factor in improving outcomes of IH repair over the last decade. Techniques such as intraperitoneal onlay mesh (IPOM) and sublay placement demonstrated significantly lower recurrence rates compared to primary repair alone[7,17]. A consistent recommendation across studies was a minimum 5 cm mesh overlap to ensure a tension-free and durable repair[7,37]. Advancements in laparoscopic instruments, imaging, and surgical expertise have also broadened the feasibility of minimally invasive IH repair in post-transplant patients, including those with early postoperative complications. Moreover, the IPOM technique using composite mesh has become a widely accepted standard for laparoscopic repair, with studies showing improved outcomes when the hernia defect is closed before mesh placement[16,38,39]. However, the management of lateral hernias and the application of newer abdominal wall reconstruction techniques in LT patients have yet to be thoroughly reported[40,41].

The effectiveness of hernia repair is influenced not only by mesh placement technique but also by the type of mesh used. Biological meshes have demonstrated lower rates of postoperative complications, particularly those related to infection, which is a critical consideration in immunosuppressed transplant recipients. Their higher cost compared to synthetic alternatives remains a limitation, but the trend toward adopting biological prostheses underscores their clinical value in reducing infection risks. Biologic materials such as non-vascularized transplanted tissue, porcine dermal collagen, and Permacol mesh have been explored as viable options, especially in urgent scenarios like bowel strangulation and cases involving loss of domain[14,15,42].

In summary, our findings offer several key implications for clinical practice (Table 1). First, recognizing high-risk patients—such as those with elevated BMI, advanced age, and a history of re-laparotomy—can help guide preoperative planning and targeted risk reduction strategies. Second, repair techniques and mesh types should be selected based on individual patient profiles, balancing the complexity of the hernia with risks of recurrence and infection. Third, while laparoscopic repair and biological meshes show promise in selected cases, particularly among immunosuppressed patients, their higher cost and longer operative time warrant careful consideration. Future research should prioritize prospective, standardized studies with patient-centered outcomes, including long-term recurrence and QoL, to better inform surgical decision-making. Establishing consensus guidelines will be essential to ensure consistent, evidence-based care across transplant centers.

Table 1 Characteristics, aims and outcomes of the included studies.

Ref.	Year	Study design	Study aim	Study period	No. of patients	No. of patients with hernia	Incidence	Incision used for transplant	Results summary
Risk factor analysis
Ayvazoglu Soy et al[6]	2017	Retrospective cohort	Risk factor analysis	1988-2016	245	22	9.0%	Mercedes = 245	Male = 17 (77%), female = 5 (23%); < 5 cm = 5, 5-10 cm = 12, > 10 = 5; primary repair 5/22, prolene 17/22; sublay 3/17, onlay 14/17; 2-3 cm mesh overlap
Kim et al[8]	2024	Retrospective cohort	Risk factor analysis	2015-2021	878	28	3.2%	Not reported	Risk factors = BMI > 25, mTOR inhibitor within 1 month of LT
Cos et al[9]	2020	Retrospective cohort	Risk factor analysis	2003-2015	1019	166	16.3%	Mercedes = 1019	Male = 136 (83.4%), female = 27 (16.6%); risk factors = male gender, acute cellular rejection; 70/163 underwent surgical repair; 62/70 underwent mesh repair with minimum 2 cm overlap; no difference in recurrence between open and laparoscopy group
Yassein et al[10]	2020	Retrospective cohort	Risk factor analysis	2004-2017	239	35	14.6%	J/Mercedes	Male = 30 (85.7%), female = 5 (14.3%); risk factors = HCC as indication, small graft weight, prolonged waiting time, bile leak, surgical site infection; midline = 23, right subcostal = 9, left subcostal = 3
Dominguez Bastante et al[34]	2023	Retrospective cohort	Risk factor analysis	2002-2021	400	101	25.3%	Chevron = 400	Male = 83 (82.1%), female = 18 (17.9%); risk factors = obesity, platelet transfusion, smoking, mTOR
Fikatas et al[35]	2013	Prospective cohort	Risk factor analysis	2002-2009	810	77	9.5%	Not reported	Male = 52 (67.5%), female = 25 (32.5%); Risk factors = age, BMI, and re-laparotomy; primary repair = 13, mesh repair = 62; onlay = 5, sublay = 44, IPOM = 13; Approx 5 cm overlap
Vardanian et al[37]	2006	Retrospective cohort	Risk factor analysis	1999-2004	959	44	4.6%	Mercedes = 959	central = 31, right subcostal = 28, left subcostal = 28, upper midline = 13; onlay patch = 25, inlay patch = 4, primary repair = 15; single = 29, multiple = 14; recurrence- primary repair = 5/15, mesh repair = 2/29; time to hernia = 15.48 months
Ferri et al[43]	2022	Retrospective cohort	Risk factor analysis	2004-2020	261	71	27.2%	Mercedes = 261	Male = 52 (73%), female = 19 (27%); risk factors = diabetes, male gender, acute cellular rejection; onlay 20, sublay 4, inlay 1, intraperitoneal 1
de Goede et al[44]	2014	Retrospective cohort	Risk factor analysis	2004-2010	140	60	43.0%	J incision = 140	Male = 90 (64%), female = 50 (36%); risk factors = advanced age, surgical site infection, prolonged ICU stay; 21/60–sub-xyphoidal, 18/60-middle, 9/60-lateral, 12/60-multiple locations; IH has impact on physical, mental and social HR-QoL
Gómez et al[45]	2001	Retrospective cohort	Risk factor analysis	1986-1997	465	54	11.61%	J incision = 465	Male = 46 (85.1%), female = 8 (14.9%); risk factors = male gender, acute rejection and previous laparotomy; midline incision = 15, transverse = 8, at crosspoint = 11, several segmental defects = 20; primary = 3/40, prolene mesh = 37/40
Janssen et al[46]	2002	Retrospective cohort	Risk factor analysis	1990-2000	290	50	17.24%	Mercedes = 266, Chevron = 24	Male = 29 (58%), female = 21 (42%); risk factors = low mean platelet count during first 10 days after transplantation, early acute rejection, transverse incision with upper midline incision; trifurcation = 30/50, upper midline = 6, right transverse = 8, left transverse = 6
Kahn et al[47]	2007	Retrospective cohort	Risk factor analysis	1998-2005	90	17	23.3%	Chevron = 90	Male = 14 (82%), female = 3 (18%); risk factors = end-stage liver cirrhosis, Sirolimus, and MMF
Lee et al[48]	2019	Retrospective cohort	Risk factor analysis	2000-2015	1044	79	7.57	Mercedes = 1044	Male = 62 (78.5%), female = 17 (21.5%); risk factors = age, male gender, BMI, hypertension, acute cellular rejection; Time to hernia = 23.74 months
Montalti et al[49]	2012	Retrospective cohort	Risk factor analysis	2000-2009	373	121	32.4%	J incision/Mercedes	Male = 99 (81.8%), female = 22 (18.2%); risk factors = male gender, BMI > 29, LT era, MELD score > 22, HBV positive, deceased donor, type of induction therapy; < 10 cm diameter = sublay, > 10 cm diameter = inlay
Ozgor et al[50]	2014	Retrospective cohort	Risk factor analysis	2006-2010	173	44	25.4%	reverse T	Male = 31 (70%), female = 13 (30%); Risk factors = re-laparotomy; < 5 cm = 1, 5-10 cm = 12, > 10 cm = 1 with onlay polypropylene mesh, 3 cm overlap; Time to hernia = 17.6 months
Piardi et al[51]	2010	Retrospective cohort	Risk factor analysis	2000-2005	422	36	8.5%	Mercedes/Chevron	Male = 34 (94.5%), female = 2 (5.5%); risk factors = ascites, COPD, DM, BMI > 25, female gender; trifurcation = 11, upper midline = 8, right subcostal = 12, left subcostal = 5; < 5 cm = 10, 5-10 cm = 24, > 10 cm = 2; primary repair = 5, polypropylene mesh = 25, dual mesh = 6 with 2-3 cm overlap in subfascial location
Piazzese et al[52]	2004	Retrospective cohort	Risk factor analysis	1986-2002	623	31	4.97%	Mercedes/J	junction of transverse and midline = 18, upper midline = 6, right subcostal = 7, left subcostal = 2, other = 4; < 5 cm = 25, 5-10 cm = 8, > 10 cm = 4; primary repair = 17, mesh repair = 20
Shi et al[53]	2003	Retrospective cohort	Risk factor analysis	1986-2000	410	26	6.3%	Mercedes = 410	Male = 15 (57.7%), female = 11 (42.3%); right subcostal = 10, central wound = 9, vertical limb = 6, left subcostal = 2, drain site = 2 (23 single +3 dual defects); Time to hernia = 19.07 months
Laparoscopy vs open
Ealing et al[7]	2023	Retrospective cohort	Laparoscopy vs open	2010-2021	1877	240	12.79%	Reverse L or J/Mercedes/Midline	Male = 112 (81.7%), female = 25 (18.3%); primary repair = 17, mesh repair = 121; Laparoscopic = epigastric 28, right subcostal 6, periumbilical 6, < 5 cm 17, > 5 cm 20, IPOM 40; open = open (98): Epigastric 51, right subcostal 23, left subcostal 4, periumbilical 19, < 5 cm 45, > 5 cm 25, sublay 60, onlay 15, inlay 6; no difference in recurrence rates and post-operative complications
Kuo et al[17]	2017	Retrospective cohort	Laparoscopy vs open	2015-2016	NR	35	NR	Not reported	Male = 31 (88.6%), female = 4 (11.4%); median size of hernia laparoscopy = 39.07 cm2, open = 62.83 cm2; minimum overlap 2 cm; open procedure had less operating time and long post-operative stay; time to hernia = 12.75 months
Kurmann et al[18]	2010	Prospective cohort	Laparoscopy vs open	1993-2007	225	57	25.0%	Mercedes/Chevron	Male = 31 (70.5%), female = 13 (29.5%); risk factors = male gender and BMI > 25; open procedure = long operative time; open- right subcostal = 11, left subcostal = 5, midline = 17, open polypropylene(pre-peritoneal) = 25/31, open primary closure = 6/31; lap- right subcostal = 6, left subcostal = 6, midline = 9, dual composite IPOM
Mekeel et al[38]	2007	Retrospective cohort	Laparoscopy vs open	1999-2007	NR	27	NR	Mercedes	Male = 21 (77.8%), female = 6 (22.2%); majority at trifurcation or midline portion of incision; laparoscopic repair mean size = 55.7 cm2 using dual mesh; open mean size = 400.7 cm2 underlay = 3/14, onlay = 10/14, primary = 1/14
Incision type
Adani et al[54]	2009	Retrospective cohort	Incision type (J vs Mercedes Incision)	2005-2008	115	14	12.1%	J = 62; Mercedes = 53	No difference in incisional hernia between J and Mercedes incision
Donataccio et al[55]	2006	Prospective cohort	Incision type (J vs Mercedes Incision)	2002-2005	47	8	17.02%	J = 9; Mercedes = 11; Chevron = 27	At junction of midline and oblique incisions in J and Mercedes, laterally in subcostal incision; higher incidence in former group
Gastaca et al[56]	2010	Retrospective cohort	Incision type (Bilateral subcostal)	1998-2007	626	11	1.7%	Chevron = 626	Lowest reported incidence of hernia
Heisterkamp et al[57]	2008	Prospective cohort	Incision type (J vs mercedes incision)	2002-2008	118	20		Mercedes = 58, J = 60	Reduced post-operative wound infection and incisional hernia in J incision group
Zarbaliyev et al[58]	2022	Retrospective Cohort	Incision type (J vs mercedes incision)	2015-2019	208	81	38.9%	J/Reverse T/Chevron	Lower incisional hernia rates in J group compared to chevron and reverse T
Surgery type
Gianchandani et al[59]	2020	Retrospective cohort	Laparoscopic repair	1998-2018	750	46	6.13%	J incision/Mercedes	Male = 32 (86.5%), female = 5 (13.5%); laparoscopic = 37; lateral = 1, vertical = 17, trifurcation = 14, all = 5; < 4 cm = 2, 4-10 cm = 9, > 10 cm = 26; IPOM-composite bard; approx. 5 cm overlap; time to hernia = 26.5 (14-57.5) months
Hegab et al[60]	2016	Retrospective cohort	Laparoscopic repair	2001-2012	488	33	6.9%	Mercedes = 488	Male = 25 (75%), female = 8 (25%); risk factors = male gender, BMI, reoperation; open repair stayed longer than laparoscopic repair; 5 cm mesh overlap
Weiss et al[61]	2015	Retrospective cohort	Laparoscopic repair	1995-2007	755	54	7.1%	NR	Male = 42 (77.7%), female = 12 (22.3%); trifurcation = 20, right subcostal = 15, left subcostal = 13, upper midline = 6; IPOM; no difference between two groups
Han et al[16]	2023	Retrospective cohort	Laparoscopic repair	2007-2020	NR	89	NR	Mercedes/Chevron	Male = 73 (82%), female = 16 (18%); 5 cm overlap IPOM mesh; Ileus and seroma were frequent complications; time to hernia = 16 months
Lam et al[36]	2016	Retrospective cohort	Transplant vs HPB surgery	2001-2014	NR	82	NR	J/Chevron	No significant difference in hernia occurrence in post LT compared to other HPB surgeries. Recurrence after hernia repair was more when steroids and immunosuppressants were taken; primary closure = 2, onlay = 1, sublay = 42, intraperitoneal = 10
Heise et al[39]	2019	Retrospective cohort	Open repair	2010-2015	218	25	11.5%	Mercedes = 218	Male = 21 (84%), female = 4 (16%); no difference between defect only overlap and complete incision overlap; Time to hernia = 18.3 +/- 11.8 months
Nielsen et al[62]	2022	Prospective cohort	Retro-rectus mesh repair	2010-2017	517	26	5.02%	Reverse L/Chevron	Peritoneal flap mesh hernioplasty; 1/26 developed collection requiring re-operation; no recurrence
Quality of life
Perrakis et al[63]	2021	Prospective cohort	Quality of life	NR	239	29	13%	Reverse L	Male = 12 (41%), female = 17 (59%); risk factors = re-laparotomy; majority hernias occurred at junction of horizontal and vertical incisions; dual mesh repair with IPOM; QoL improved in all patients after hernia repair
Novel methods
Ayuso et al[5]	2021	Retrospective cohort	Biological prosthesis	2017-2020	NR	17	NR	NR	No hernia recurrence after follow-up of 21.6 ± 11.6 months. 3 of 17 developed wound complications
Justo et al[14]	2024	Prospective cohort	Non-mesh repair	2019-2023	NR	8	NA	Not reported	Abdominal wall transplantation with no post-operative sequalae of mesh repair
Vennarecci et al[15]	2017	Case series	Biological prosthesis	2001-2016	270	78	28.8%	Mercedes/J	Giant hernias 8 to 20 cm; reinforced with biological mesh without recurrence in all 5 cases
Werkgartner et al[42]	2015	Prospective cohort	Giant hernia-biological prosthesis	NR	NR	63	26.0%	Chevron	Defect > 10 cm; Direct closure = 19 vs porcine dermal collagen = 16; less recurrence and increased wound complication with PDC

BMI: Body mass index; mTOR: Mammalian target of rapamycin; LT: Liver transplantation; HCC: Hepatocellular carcinoma; IPOM: Intraperitoneal onlay mesh; ICU: Intensive care unit; IH: Incisional hernia; HR-QoL: Health-related quality of life; MMF: Mycophenolate mofetil; MELD: Model for end-stage liver disease; HBV: Hepatitis B virus; COPD: Chronic obstructive pulmonary disease; DM: Diabetes mellitus; HPB: Hepato-pancreato-biliary; PDC: Porcine dermal collagen.

This review offers a comprehensive synthesis of the risk factors, surgical approaches, and outcomes associated with IH following LT, presenting a more integrated understanding than previous fragmented studies. It consolidates evidence on the role of incision type, evaluates the limited influence of immunosuppressive therapies, and highlights the emerging clinical relevance of biological meshes in managing high-risk transplant populations. These contributions support more individualized, evidence-based decision-making and emphasize the importance of aligning surgical strategies with patient-specific factors.

However, several limitations should be acknowledged. Significant heterogeneity in study design, definitions of symptomatic hernia, and outcome reporting across the included studies limits the comparability and generalizability of findings. This inconsistency likely contributed to the broad range in IH incidence and constrained the ability to conduct robust subgroup analyses. The predominance of retrospective data further introduces potential bias and limits causal inference, while incomplete reporting and variation in follow-up duration reduce data reliability. Additionally, the scarcity of studies reporting patient-centered outcomes—particularly QoL—prevents a comprehensive assessment of the broader clinical impact of IH and its repair. Moving forward, high-quality prospective research incorporating standardized diagnostic criteria, consistent outcome reporting, and validated QoL measures will be essential to strengthen the evidence base and inform best practices.

CONCLUSION

IH remain a common and significant complication following LT. This review emphasizes key risk factors, surgical approaches, and the potential benefits of novel techniques in optimizing patient care. Advances in minimally invasive repair techniques, mesh reinforcement, and perioperative optimization strategies hold promise for reducing hernia-related morbidity and improving long-term outcomes. However, the limitations inherent in current evidence underscore the need for well-designed, prospective studies to further refine best practices in hernia management. A personalized, evidence-based approach will be crucial for enhancing both the survival and QoL of LT recipients, ultimately improving the outcomes of this challenging post-transplant complication.