Incisional hernia repair following liver transplantation: A meta-analysis

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.