Introduction: Patients undergoing liver transplantation are at increased risk of developing incisional hernia which can seriously affect their postoperative course and quality of life. This retrospective study identifies pre- and post-operative risk factors for incisional hernia development following liver transplantation.

Methods: We conducted a retrospective case-control study on 202 patients undergoing liver transplantation from 2007-2019. 101 selected patients who underwent liver transplantation followed by incisional hernia occurrence were compared with 101 age and date matched controls who did not form a hernia post-transplant.  Incisional hernias were repaired open with sublay or retrorectus mesh or by primary closure. Age, sex, body mass index (BMI), transplant indication, pre-operative MELD score, post-transplant complications and immunosuppressive medications were compared between the two groups.  Hernia repair outcomes including surgical site infection (SSI), other wound complications, length of hospital stay, and hernia recurrence were analyzed.

Results: Patient characteristics between the two groups were well matched.  The average time from liver transplantation to incisional hernia occurrence was 20 months. Significant risk factors for incisional hernia occurrence were transplant incision type, specifically midline incisions (0 vs 20 patients, p=0.01). There was a trend toward hernia occurrence with post-transplant take-back laparotomy (12 vs 22 patients, p= 0.06). When analyzing factors associated with recurrence after hernia repair, interestingly viral hepatitis had a significantly lower rate of hernia recurrence (p=0.03). Furthermore, hernia recurrence was impacted by a higher pre-transplant MELD score (score of 16 vs 22, p=0.05), takeback laparotomy post-transplant (17% vs 40%, p=0.03), retrorectus mesh repair of initial hernia repair (18% vs 50%, p=0.01), and post-hernia SSIs (11 vs 32%, p=0.02). No differences were observed for age, sex, BMI, immunosuppressive medications, and hernia defect size.

Conclusion: These results highlight important risk factors for hernia occurrence and recurrence post liver transplant including post-transplant takeback laparotomy, hernia repair technique, and SSIs. With regards to the repair technique, intraperitoneal sublay mesh reduces hernia recurrence and is a safe option for incisional hernia repair in this complex patient population.