Lucian Panait, MD, Robert L Bell, MD, Kurt E Roberts, MD, Andrew J Duffy, MD. Yale School of Medicine
Introduction: The incidence of hernias at the transplantation incision following renal transplantation is reported to be 4%. These incisions are usually located in the right lower quadrant (RLQ) and create hernias close to the pelvic bones. Incisional hernia repairs in this location are hindered by limited residual abdominal wall tissue in the region and the proximity of the renal graft. Recurrence following standard operative techniques is up to 22% at 2 years. We present early results with a new technique for laparoscopic preperitoneal incisional hernia repair (LPIHR) in renal transplant recipients which addresses the difficulties in treating this condition.
Methods: Three patients underwent RLQ LPIHR at our institution. Average age was 61.3 years and average BMI 24.6 kg/m2. One patient had had two previous attempts at open repair. One other patient had had a prior intraperitoneal laparoscopic repair and had developed a recurrence inferior and lateral to the intraperitoneal mesh. All were right lower quadrant transplant incisions. Laparoscopic repair was undertaken. The time from the kidney transplantation to the LPIHR averaged 19 months.
Results: All procedures were completed laparoscopically. After adequate enterolysis and exposure of the fascial defect, a peritoneal flap is created at the arcuate line, and carried to the superior pole of the renal graft. The bladder is mobilized inferiorly in order to expose the pubic tubercle and Cooper’s ligaments on both sides. The region of the ureteral implant is carefully avoided. Dissection is continued anterior and laterally to the kidney graft, taking care not to violate the renal capsule. This enables medial mobilization of the graft and allows positioning of a dual-sided polyester mesh, appropriately sized to the defect, anterior and lateral to the kidney and bladder. Helical titanium tacks are used to anchor the mesh to the Cooper’s ligaments. Transfascial sutures are utilized through healthy tissues as able. Length of hospital stay in our case series averaged 3 days (1-5 days). Median follow-up was 50.6 days. All patients developed postoperative seromas, but these decreased in size after the intial postoperative period. No early recurrences have developed. Graft function was not compromised in any of the patient.
Conclusions: Laparoscopic preperitoneal incisional hernia repair following renal transplantation is a safe and effective repair, associated with minimal complications and good short term results. The procedure holds promise to become standard of care in this category of patients.
Session Number: ResFel – Residents/Fellows Scientific Session
Program Number: S139