Introduction: After pediatric left lateral segment (LLS) liver transplantation for small children, primary abdominal wall closure may not be possible or not recommended. Reduction of the graft, using a monosegment graft or deferred wall abdominal closure are possible alternatives. We describe our results with sequential abdominal closure (SAC) with polytetra-fluoroethylene mesh in pediatric LLS recipients.

Method: Retrospective review of patients who received LLS and CAS with polytetra-fluoroethylene mesh between 2010 and 2021. The mesh was placed and fixed with continuous polypropylene suture to the wall on both sides of the incision. Mesh flap approaches were performed in the PICU under sedation, with ultrasound control before and after, without requiring intubation. The mesh was removed in the operating room under general anesthesia after complete approximation of the flaps. The data were recorded from the patients' medical records after approval by the ethics committee.

Results: Of 198 who received an LLS, 86 (43.4%) required a SAC. Mean age was 2±3.1 years and mean weight 9.2±5.4 Kg. LLS was obtained from living donors (54.6%) and split (45.4%) with a mean graft weight of 324.1 grams. The graft weight/recipient weight ratio was 3.9±1.4%. The mesh was removed after 8.2±3.4 days, requiring 3.2±1.6 sequential approaches per patient. Six surgical wound infections and five wound dehiscence during the process were recorded. No systemic infection related to the mesh or compartment syndrome occurred. The mesh was directly removed in 81.4%, while 18.6% were reoperated for complications (vascular, biliary or intestinal) prior to its removal. After definitive closure, one (1.2%) patient had partial dehiscence and six (7%) suffered surgical wound infections. No grafts were lost due to sac procedure-related causes. The median follow-up time was 53 (15-84.3) months.

Conclusion: SAC with polytetra-fluoroethylene mesh offers a reproducible and safe solution for difficult or not advisable abdominal closure after pediatric liver transplantation of LLS. The presence of the mesh during the immediate postoperative period represents an advantage for the review of the graft status and possible complications in the immediate postoperative period. Hyper-reduction of the graft or the use of a monosegment could be avoided in most cases.