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Triple-layer Mesh Plasty for Re-recurrent Ventral Hernia in a Liver Transplant Patient: A Case Report
Triple-layer Mesh Plasty for Re-recurrent Ventral Hernia in a Liver Transplant Patient: A Case Report D. Pisanielloa,*, G. Montib, A. Ceriellob, W. Santaniellob, F. Calisec, and O. Cuomob a Unit of Surgical Oncology, Saint Pio’s Hospital, Benevento, Italy; bHepatobiliary Surgical Unit, Liver Transplant Center, Cardarelli Hospital, Naples, Italy; and cHepatobiliary Surgical Unit, Pineta Grande Hospital, Castelvolturno, Italy
ABSTRACT Ventral hernias often occur in transplanted patients because of weakness of the abdominal wall, poor muscle mass, and ascitis. In this report we describe the case of a re-recurrent ventral hernia seen emergently in a liver transplant recipient, who was treated using a singular 3-layer approach by placement of an intraperitoneal mesh, stressing technical aspects of the plasty as well as the importance of a sublay technique in the reinforcement of a previous prosthetic plasty.
V
ENTRAL hernias are one of the most frequent complications after major abdominal surgery, accounting for 1%-19% of cases [1]. In liver transplant patients, the reported incidence of ventral hernias accounts for up to 34% of cases [2e4]. Large abdominal scars with midline and mono- or bilateral subcostal transverse incisions, as well as other factors, such as malnutrition and use of immunosuppressants, places these patients at high risk for developing ventral hernias [2e4]. In spite of the widespread use of prosthetic repair with absorbable and nonabsorbable meshes, the rate of recurrence of incisional hernias is as high as 10% [5] and short- and long-term complications are also seen. Herein we report the case of a recurrent abdominal obstruction occurring as a late complication after a double repair of a re-recurrent ventral hernia by placement of prosthetic mesh in a liver transplant recipient. The patient was treated (during the first 2 surgical operations) by placement of a double layer of meshes: one intraperitoneal (sublay positioned) and the other subcutaneous (onlay positioned). We describe the technique used for repair of the abdominal wall after conservative treatment of the intestinal obstruction. CASE REPORT This case report involved a 57-year-old man who underwent liver transplantation in 2008 because of hepatitis C, B, and D (HCVHBV-HDV)‒positive liver cirrhosis. There were no other comorbidities. He was administered everolimus at 1.5 mg/d. The patient underwent abdominal ventral hernia repair along the upper umbilical midline incision 3 years earlier, with placement of an intraperitoneal mesh. Two years after this operation, he had a small ª 2019 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 51, 589e592 (2019)
bowel obstruction due to encasement of a jejunal loop through a recurrent ventral hernia defect. At the time of reintervention, the intraperitoneal mesh was tied vertically along the midline and an urgent bowel resection was performed due to jejunal loop necrosis. After intestinal resection, the intraperitoneal mesh was closed by interrupted, nonabsorbable stitches, and a polypropylene mesh was placed subcutaneously (onlay) to “strengthen” the plasty (Fig 1). One year after this urgent laparotomy, the patient was urgently readmitted and referred to our institution due to onset of abdominal pain, clogging of a newly recurrent upper umbilical ventral hernia, and biliary vomit. On physical examination an incarcerated hernia was found. An abdominal X-ray scan was performed, showing bowel air-fluid levels. No fluid collections were found at ultrasonography. Computed tomographic abdominal scan showed marked small bowel obstruction with several air-fluid levels spreading up to the incarcerated large upper umbilical median ventral hernia, giving rise to a mechanical ileus. The patient underwent an urgent median laparotomy along the previous upper umbilical incision, extended to the subcostal previous right and left transverse incisions. Metronidazole (500 mg intravenously) was administered. Two prostheses placed during previous laparotomies were found: the first one (apparently polypropylene) was subcutaneous and the other was intraperitoneal (apparently a double-layer mesh). The intraperitoneal mesh was cut along its midline plane during the previous urgent laparotomy performed at another institution 1 year earlier (Fig 2). The mesh was not removed, because it appeared completely “epithelized,” and was kept in place and sutured on its midline by interrupted, nonabsorbable stitches. The hernia rose through a hole between 2 of these stitches (Fig 3). It was necessary to reopen along the
*Address correspondence to Donatella Pisaniello, PhD, Unit of surgical Oncology, Saint Pio’s Hospital, Via Presa Lanno, 27, 82011 Airola, Benevento, Italy. E-mail: [email protected] 0041-1345/19 https://doi.org/10.1016/j.transproceed.2018.12.020
589
590
PISANIELLO, MONTI, CERIELLO ET AL
Fig 1. Plasty after first laparotomy a) sublay intraperitoneal mesh cut along the midline b) onlay subcutaneous polypropylene mesh. midline stitches of the intraperitoneal mesh to free its content, which was an edematous and hemorrhagic jejunal loop (Fig 4). It was washed with hot water and soon resumed good color and peristalsis. Thus, it was not necessary to perform resection of the jejunal loop. Lysis of visceroparietal adhesions was performed to find a good plane below the former intraperitoneal prosthesis and for placement of another intraperitoneal double-layer mesh (19.6 24.6 cm; Bard Ventrio), fixed to the overlying prosthetic and muscoloaponeurotic planes by metal spiral tackers (Protack). Double high-vacuum drains (Redon-type) were inserted: one in close contact with the external layer of the Bard Ventrio mesh (Fig 5) and the other placed over the former intraperitoneal mesh, which was sutured once again along its midline incision (by way of a sheat) with nonabsorbable stitches (0 Prolene). Finally, the cut
Fig 3. The hole between stitches in the mesh previosuly placed, giving rise to recurrent hernia.
subcutaneous mesh was also closed on its median line by nonabsorbable stitches (2/0 Prolene). Thus, a 3-layer plasty was achieved (Fig 6). The postoperative period was uneventful, except for fever, which occurred only on the first day postoperatively (38.6 C). Immunosuppressants were stopped and the patient began a course of vancomycin 500 mg 3 times per day and tazobactam-piperacilline 4.5 g 3 times per day. Everolimus was readministered on postoperative day 3. On the third postoperative day, the patient had flatus and resumed oral feeding. He was discharged on postoperative day 8. At 36-month follow-up he remained in good clinical condition with no ventral hernia recurrence.
DISCUSSION
Incisional hernias are among the most frequent complications after major surgery and occur in up to 34% of patients following liver transplantation [4,5]. Ascitis, poor muscle mass, immunosuppressants (also steroids), and large incisions crossing vertical and transverse cuts can be predisposing factors [2,3,5]. Long-term tractions due to large
Fig 2. Defect between two stitches in the intraperitoneal mesh previously sutured along the midline.
Fig 4. The incarcerated oedematous jejunal loop.
RE-RECURRENT VENTRAL HERNIA
Fig 5. Final plasty.
retractors can also affect vascularization of the wall margins, causing transient ischemia of the incised walls and then wound and muscle healing [3,5]. Reinterventions can also be a cause of wall impairment [6], as can male sex, according to some studies [6]. Also, obesity (often occurring after liver transplantation) affects incidence and recurrence of ventral hernias. Large size and different orientation of incisions often require the use of larger meshes [7,8] to be placed intraperitoneally [9], such as for the patient in the case report. When the patient was first reoperated emergently because of jejunal loop ischemia, the surgeons cut and sutured the previous prosthesis along its midline by interrupted stitches. This may have weakened the deep prosthetic layer, causing a hole in the midline suture. Cutting the prosthesis, in fact, does not impair the tension along the abdominal wall. In our case, in fact, the prosthesis was completely epithelized. We believe it is mandatory to close using a running suture, placing stitches in close contact one another and passing through the full thickness of the mesh. In this case, the previous plasty should have been enough, especially because a jejunal resection was associated. The second prosthesis, which was placed as “onlay,” was not adequate to strengthen the abdominal wall.
591
Usually, and particularly in this case, the second onlay mesh creates a barrier that is only superficial and this further reduces the space between the 2 layers, leading the recurrent ventral hernia to be incarcerated. In our case, the presence of the onlay mesh delayed the diagnosis of the small bowel obstruction because it hid the hernia. Thus, one should not try to reinforce the abdominal wall from the top (adding superficial layers onlay), but rather from below/inside (adding layers by an inlay technique) when an intraperitoneal mesh has already been put in place, at least whenever possible. The direction of reinforcement of the abdominal wall goes from the inside to the outside of the abdomen [7e13]. Thus, at the time of the first urgent laparotomy, if the surgeons considered it appropriate to place another mesh, then it would have been advisable to put it below, rather than above, the intraperitoneal one. Intraabdominal pressure indeed pushes tension toward the abdominal wall from the inside out [7e11,13]. Our experience has shown that cutting the integrity of the intraperitoneal mesh does not weaken it when it is completely epithelialized and a correct technique of closure is achieved [12]. In cases where the reported stitches are placed at a distance of greater than 1e2 cm, there is a risk of bulging of the intestinal viscera. Our decision to place another sublay mesh was due to the lack of associated intestinal resection and the fear that a new closure of an already cut mesh could weaken the plasty and inhibit collagen ingrowth over the ventral size of the mesh due to poor vascularization at its center [6,11]. Also, the patient received immunosuppressants who could have furtherly reduced a fast and wide healing so as growth of collagen fibers. Conversely, the mesh was placed underneath the previous intraperitoneal prosthesis with a wide overlap of healthy tissue in all directions [6,11]. Earlier studies have shown that meshes are usually placed intraperitoneally [7,9,10] in the repair of ventral hernias of liver transplant patients, because of the large and transverse incisions [2,3,5]. In this singular case of a re-recurrent ventral hernia, already treated by placement of a double layer of meshes, we emphasize the importance of a running suture with close stitches, passed in full thickness of the mesh when tying a cut mesh and/or a sublay approach with internal reinforcement of the intraperitoneal mesh in cases of recurrence. This treatment is particularly useful in cases of incarcerated hernia, whenever the intestinal approach is conservative. A wide overlap of meshes must be also implemented [6,11]. REFERENCES
Fig 6. Tryple mesh plasty (a) first intraperitoneal mesh sutured along the midline (b) subcutaneous mesh sutured along the midline (c) deep intraperitoneal mesh.
[1] Basoglu M, Yildirgan MI, Yilmaz I, Balik A, Celebi F, Atamanalp SS, et al. Late complications of incisional hernias following prosthetic mesh repair. Acta Chir Belg 2004;104:425e8. [2] Gomez R, Hidalgo M, Marques E, Marin K, Loinaz C, Gonzalez I, et al. Incidence and predisposing factors for incisional hernia in patients with liver transplantation. Hernia 2002;5: 172e6.
592 [3] Janssen H, Lange R, Erhard J, Malagò M, Eigler FW, Broelsch CE. Causative factors, surgical treatment and outcome of incisional hernia after liver transplantation. Br J Surg 2002;89:1049e54. [4] Fikatas P, Schoening W, Lee J-E, Chopra SS, Seehofer D, Guckelverger O, et al. Incidence, risk factors and management of incisional hernia in high volume liver transplant center. Ann Transplant 2013;18:2223e30. [5] Piardi T, Audet M, Panaro F, Gherza F, Cag M, Portolani N, et al. Incisional hernia repair after liver transplantation: role of the mesh. Transplant Proc 2010;42:1244e7. [6] Vardanian AJ, Farmer DG, Ghobrial RM, Busuttil RW, Hiatt JR. Incisional hernia after liver transplantation. J Am Coll Surg 2006;203:421e5. [7] Malik FI, Mirza TI. Intraperitoneal mesh plasty. Prof Med J 2010;17:360e5. [8] Cobb WS IV, Harris JB, Lokey JS, McGill ES, Klove K. Incisional herniorraphy with intraperitoneal composite mesh: a report of 95 cases. Am Surg 2003;69:784e7.
PISANIELLO, MONTI, CERIELLO ET AL [9] Korenkov M, Paul A, Sauerland S, Neugebauer E, Amdt M, Chevrel JP, et al. Classification and surgical treatment of incisional hernia. Lagenbeck Arch Surg 2001;386:65e73. [10] Klinge U, Conze J, Krones CJ, Schumpelick V. Incisional hernias: open techniques. World J Surg 2005;29:1066e72. [11] De Vries RTS, Van Geldere D, Langenhorst BLAM, de Jong D, van der Wilt GJ, van Goor H, et al. Repair of large midline incisional hernias with polypropylene mesh: comparison of three operative techniques. Hernia 2004;8:56e9. [12] Luijendijk RW, Hop WCJ, van den Tol MP, de Lange DCD, Braaksma MMJ, Izermans JNM, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 2000;343:392e8. [13] Rodriguez-Davalos MI, Ibarra C, Munoz-Abraham AS, Martinez AFH, Emre S. Surgical approach to abdominal wall defects and hernias in patients with end stage organ disease and transplantation. In: Latifi R, editor. Surgery of Complex Abdominal Wall Defects. Berlin: Springer; 2017.
ABSTRACT Ventral hernias often occur in transplanted patients because of weakness of the abdominal wall, poor muscle mass, and ascitis. In this report we describe the case of a re-recurrent ventral hernia seen emergently in a liver transplant recipient, who was treated using a singular 3-layer approach by placement of an intraperitoneal mesh, stressing technical aspects of the plasty as well as the importance of a sublay technique in the reinforcement of a previous prosthetic plasty.
V
ENTRAL hernias are one of the most frequent complications after major abdominal surgery, accounting for 1%-19% of cases [1]. In liver transplant patients, the reported incidence of ventral hernias accounts for up to 34% of cases [2e4]. Large abdominal scars with midline and mono- or bilateral subcostal transverse incisions, as well as other factors, such as malnutrition and use of immunosuppressants, places these patients at high risk for developing ventral hernias [2e4]. In spite of the widespread use of prosthetic repair with absorbable and nonabsorbable meshes, the rate of recurrence of incisional hernias is as high as 10% [5] and short- and long-term complications are also seen. Herein we report the case of a recurrent abdominal obstruction occurring as a late complication after a double repair of a re-recurrent ventral hernia by placement of prosthetic mesh in a liver transplant recipient. The patient was treated (during the first 2 surgical operations) by placement of a double layer of meshes: one intraperitoneal (sublay positioned) and the other subcutaneous (onlay positioned). We describe the technique used for repair of the abdominal wall after conservative treatment of the intestinal obstruction. CASE REPORT This case report involved a 57-year-old man who underwent liver transplantation in 2008 because of hepatitis C, B, and D (HCVHBV-HDV)‒positive liver cirrhosis. There were no other comorbidities. He was administered everolimus at 1.5 mg/d. The patient underwent abdominal ventral hernia repair along the upper umbilical midline incision 3 years earlier, with placement of an intraperitoneal mesh. Two years after this operation, he had a small ª 2019 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 51, 589e592 (2019)
bowel obstruction due to encasement of a jejunal loop through a recurrent ventral hernia defect. At the time of reintervention, the intraperitoneal mesh was tied vertically along the midline and an urgent bowel resection was performed due to jejunal loop necrosis. After intestinal resection, the intraperitoneal mesh was closed by interrupted, nonabsorbable stitches, and a polypropylene mesh was placed subcutaneously (onlay) to “strengthen” the plasty (Fig 1). One year after this urgent laparotomy, the patient was urgently readmitted and referred to our institution due to onset of abdominal pain, clogging of a newly recurrent upper umbilical ventral hernia, and biliary vomit. On physical examination an incarcerated hernia was found. An abdominal X-ray scan was performed, showing bowel air-fluid levels. No fluid collections were found at ultrasonography. Computed tomographic abdominal scan showed marked small bowel obstruction with several air-fluid levels spreading up to the incarcerated large upper umbilical median ventral hernia, giving rise to a mechanical ileus. The patient underwent an urgent median laparotomy along the previous upper umbilical incision, extended to the subcostal previous right and left transverse incisions. Metronidazole (500 mg intravenously) was administered. Two prostheses placed during previous laparotomies were found: the first one (apparently polypropylene) was subcutaneous and the other was intraperitoneal (apparently a double-layer mesh). The intraperitoneal mesh was cut along its midline plane during the previous urgent laparotomy performed at another institution 1 year earlier (Fig 2). The mesh was not removed, because it appeared completely “epithelized,” and was kept in place and sutured on its midline by interrupted, nonabsorbable stitches. The hernia rose through a hole between 2 of these stitches (Fig 3). It was necessary to reopen along the
*Address correspondence to Donatella Pisaniello, PhD, Unit of surgical Oncology, Saint Pio’s Hospital, Via Presa Lanno, 27, 82011 Airola, Benevento, Italy. E-mail: [email protected] 0041-1345/19 https://doi.org/10.1016/j.transproceed.2018.12.020
589
590
PISANIELLO, MONTI, CERIELLO ET AL
Fig 1. Plasty after first laparotomy a) sublay intraperitoneal mesh cut along the midline b) onlay subcutaneous polypropylene mesh. midline stitches of the intraperitoneal mesh to free its content, which was an edematous and hemorrhagic jejunal loop (Fig 4). It was washed with hot water and soon resumed good color and peristalsis. Thus, it was not necessary to perform resection of the jejunal loop. Lysis of visceroparietal adhesions was performed to find a good plane below the former intraperitoneal prosthesis and for placement of another intraperitoneal double-layer mesh (19.6 24.6 cm; Bard Ventrio), fixed to the overlying prosthetic and muscoloaponeurotic planes by metal spiral tackers (Protack). Double high-vacuum drains (Redon-type) were inserted: one in close contact with the external layer of the Bard Ventrio mesh (Fig 5) and the other placed over the former intraperitoneal mesh, which was sutured once again along its midline incision (by way of a sheat) with nonabsorbable stitches (0 Prolene). Finally, the cut
Fig 3. The hole between stitches in the mesh previosuly placed, giving rise to recurrent hernia.
subcutaneous mesh was also closed on its median line by nonabsorbable stitches (2/0 Prolene). Thus, a 3-layer plasty was achieved (Fig 6). The postoperative period was uneventful, except for fever, which occurred only on the first day postoperatively (38.6 C). Immunosuppressants were stopped and the patient began a course of vancomycin 500 mg 3 times per day and tazobactam-piperacilline 4.5 g 3 times per day. Everolimus was readministered on postoperative day 3. On the third postoperative day, the patient had flatus and resumed oral feeding. He was discharged on postoperative day 8. At 36-month follow-up he remained in good clinical condition with no ventral hernia recurrence.
DISCUSSION
Incisional hernias are among the most frequent complications after major surgery and occur in up to 34% of patients following liver transplantation [4,5]. Ascitis, poor muscle mass, immunosuppressants (also steroids), and large incisions crossing vertical and transverse cuts can be predisposing factors [2,3,5]. Long-term tractions due to large
Fig 2. Defect between two stitches in the intraperitoneal mesh previously sutured along the midline.
Fig 4. The incarcerated oedematous jejunal loop.
RE-RECURRENT VENTRAL HERNIA
Fig 5. Final plasty.
retractors can also affect vascularization of the wall margins, causing transient ischemia of the incised walls and then wound and muscle healing [3,5]. Reinterventions can also be a cause of wall impairment [6], as can male sex, according to some studies [6]. Also, obesity (often occurring after liver transplantation) affects incidence and recurrence of ventral hernias. Large size and different orientation of incisions often require the use of larger meshes [7,8] to be placed intraperitoneally [9], such as for the patient in the case report. When the patient was first reoperated emergently because of jejunal loop ischemia, the surgeons cut and sutured the previous prosthesis along its midline by interrupted stitches. This may have weakened the deep prosthetic layer, causing a hole in the midline suture. Cutting the prosthesis, in fact, does not impair the tension along the abdominal wall. In our case, in fact, the prosthesis was completely epithelized. We believe it is mandatory to close using a running suture, placing stitches in close contact one another and passing through the full thickness of the mesh. In this case, the previous plasty should have been enough, especially because a jejunal resection was associated. The second prosthesis, which was placed as “onlay,” was not adequate to strengthen the abdominal wall.
591
Usually, and particularly in this case, the second onlay mesh creates a barrier that is only superficial and this further reduces the space between the 2 layers, leading the recurrent ventral hernia to be incarcerated. In our case, the presence of the onlay mesh delayed the diagnosis of the small bowel obstruction because it hid the hernia. Thus, one should not try to reinforce the abdominal wall from the top (adding superficial layers onlay), but rather from below/inside (adding layers by an inlay technique) when an intraperitoneal mesh has already been put in place, at least whenever possible. The direction of reinforcement of the abdominal wall goes from the inside to the outside of the abdomen [7e13]. Thus, at the time of the first urgent laparotomy, if the surgeons considered it appropriate to place another mesh, then it would have been advisable to put it below, rather than above, the intraperitoneal one. Intraabdominal pressure indeed pushes tension toward the abdominal wall from the inside out [7e11,13]. Our experience has shown that cutting the integrity of the intraperitoneal mesh does not weaken it when it is completely epithelialized and a correct technique of closure is achieved [12]. In cases where the reported stitches are placed at a distance of greater than 1e2 cm, there is a risk of bulging of the intestinal viscera. Our decision to place another sublay mesh was due to the lack of associated intestinal resection and the fear that a new closure of an already cut mesh could weaken the plasty and inhibit collagen ingrowth over the ventral size of the mesh due to poor vascularization at its center [6,11]. Also, the patient received immunosuppressants who could have furtherly reduced a fast and wide healing so as growth of collagen fibers. Conversely, the mesh was placed underneath the previous intraperitoneal prosthesis with a wide overlap of healthy tissue in all directions [6,11]. Earlier studies have shown that meshes are usually placed intraperitoneally [7,9,10] in the repair of ventral hernias of liver transplant patients, because of the large and transverse incisions [2,3,5]. In this singular case of a re-recurrent ventral hernia, already treated by placement of a double layer of meshes, we emphasize the importance of a running suture with close stitches, passed in full thickness of the mesh when tying a cut mesh and/or a sublay approach with internal reinforcement of the intraperitoneal mesh in cases of recurrence. This treatment is particularly useful in cases of incarcerated hernia, whenever the intestinal approach is conservative. A wide overlap of meshes must be also implemented [6,11]. REFERENCES
Fig 6. Tryple mesh plasty (a) first intraperitoneal mesh sutured along the midline (b) subcutaneous mesh sutured along the midline (c) deep intraperitoneal mesh.
[1] Basoglu M, Yildirgan MI, Yilmaz I, Balik A, Celebi F, Atamanalp SS, et al. Late complications of incisional hernias following prosthetic mesh repair. Acta Chir Belg 2004;104:425e8. [2] Gomez R, Hidalgo M, Marques E, Marin K, Loinaz C, Gonzalez I, et al. Incidence and predisposing factors for incisional hernia in patients with liver transplantation. Hernia 2002;5: 172e6.
592 [3] Janssen H, Lange R, Erhard J, Malagò M, Eigler FW, Broelsch CE. Causative factors, surgical treatment and outcome of incisional hernia after liver transplantation. Br J Surg 2002;89:1049e54. [4] Fikatas P, Schoening W, Lee J-E, Chopra SS, Seehofer D, Guckelverger O, et al. Incidence, risk factors and management of incisional hernia in high volume liver transplant center. Ann Transplant 2013;18:2223e30. [5] Piardi T, Audet M, Panaro F, Gherza F, Cag M, Portolani N, et al. Incisional hernia repair after liver transplantation: role of the mesh. Transplant Proc 2010;42:1244e7. [6] Vardanian AJ, Farmer DG, Ghobrial RM, Busuttil RW, Hiatt JR. Incisional hernia after liver transplantation. J Am Coll Surg 2006;203:421e5. [7] Malik FI, Mirza TI. Intraperitoneal mesh plasty. Prof Med J 2010;17:360e5. [8] Cobb WS IV, Harris JB, Lokey JS, McGill ES, Klove K. Incisional herniorraphy with intraperitoneal composite mesh: a report of 95 cases. Am Surg 2003;69:784e7.
PISANIELLO, MONTI, CERIELLO ET AL [9] Korenkov M, Paul A, Sauerland S, Neugebauer E, Amdt M, Chevrel JP, et al. Classification and surgical treatment of incisional hernia. Lagenbeck Arch Surg 2001;386:65e73. [10] Klinge U, Conze J, Krones CJ, Schumpelick V. Incisional hernias: open techniques. World J Surg 2005;29:1066e72. [11] De Vries RTS, Van Geldere D, Langenhorst BLAM, de Jong D, van der Wilt GJ, van Goor H, et al. Repair of large midline incisional hernias with polypropylene mesh: comparison of three operative techniques. Hernia 2004;8:56e9. [12] Luijendijk RW, Hop WCJ, van den Tol MP, de Lange DCD, Braaksma MMJ, Izermans JNM, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 2000;343:392e8. [13] Rodriguez-Davalos MI, Ibarra C, Munoz-Abraham AS, Martinez AFH, Emre S. Surgical approach to abdominal wall defects and hernias in patients with end stage organ disease and transplantation. In: Latifi R, editor. Surgery of Complex Abdominal Wall Defects. Berlin: Springer; 2017.