Role for biological meshes for delayed abdominal wall closure after pediatric liver transplantation?

GONDOLESI GABRIEL

PEDIATRIC TRANSPLANTATION.

WILEY-BLACKWELL PUBLISHING, INC

Lugar: Londres; Año: 2014 vol. 18 p. 554 - 555

1397-3142

In the current issue of the Journal, Caso Maestroet al. (1) describe their experience using abiological mesh for delayed abdominal wall closureafter pediatric liver transplantation. Theauthors should be congratulated on reviewingand presenting their excellent results. We fullyagree that tension-free abdominal closure at theend of a challenging procedure is mandatory.The importance of this problem in differentareas of the transplant field, such as liver, intestinal,and multivisceral transplantation, hasmotivated not only single center experiences,but also combined experiences and reviews (2?6). The proposed technique is an acceptableoption, but there are certain considerations thatrequire further discussion.Why should we delay a definitive closure today?Probably the only need for that decision todaymight be the unavailability of a biological meshat the time of the transplant. Currently, there areoptions to manage this problem. An importantadvantage in pediatric transplantation is the possibilityof having the estimated donor liver volumebefore the procedure either by imagingstudies during the donor evaluation in livingrelatedcases, or by using different available formulasat the time of accepting a cadaveric donorfor a split procedure (5). Therefore, it is recommendedthe ?graft to recipient weight ratio? becalculated while the transplant is being planned,predicting the need for a closure strategy. Thisapproach allows surgeons to request the biologicalmesh on the day a reduced size or split liverbecomes available or before a living donor transplant,or, if it is not available, to request the useof cadaveric fascia of the rectus muscle from thesame donor (2, 4). The fascia can be procuredfrom the same liver donor, or if a living donortransplant is being scheduled, it can be procuredfrom a different donor, prepared, and preservedfor the time of the living donor liver transplant.We have published results using the techniqueof use of abdominal rectus fascia forabdominal wall closure after liver, intestinal,and multivisceral transplantation with excellentresults with over 25 months of follow-up (2).This pre-emptive approach only requires a carefulplanning strategy and saves a second operationin most of those cases; this is more than aminor advantage.Skin closure and wound managementI certainly agree with the concept of having themesh covered by skin. Some surgeons proposeto do skin closure only or a staged approachusing a re-absorbable mesh (7). These are validalternatives, but they potentially cause fasciaretraction and/or leave the patient with a ventralhernia. In other cases, the reduction of theliver edema and the post-surgical fluid shiftsfacilitate to complete the skin closure in theearly post-transplant period, with the consequentneed for replacing or resizing the mesh;in those cases a negative pressure dressing canbe used after the transplant and before the finalskin closure, but this wound care is not recommendedto be used with all types of mesh. Certainly,it can be used if the fascia of the rectusmuscle is the elected one.Are all meshes resistant to wound infection?The authors have reported the absence of woundinfection, but infection has certainly beenreported. Not all the meshes resist wound infection,but the new biological meshes (7) and thefascia of the rectus muscle tend to. In superficialinfections requiring mesh exposure, wet to drydressings or negative pressure dressings can beused. In cases requiring re-exploration for intra-554Pediatr Transplantation 2014: 18: 554?555 © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons LtdPediatric TransplantationDOI: 10.1111/petr.12317abdominal infections, the fascia can be replacedby a new one from a different donor (2, 3).Costs and availabilityIn today?s complex medical procedures, costand worldwide availability are very importantqualifiers to consider when proposing the use ofa technique and/or supplies. Currently, the mostcost-effective option is the use of autologous tissueprocured at the time of a cadaveric donoroperation. Its origin makes it available worldwide.Not every biological mesh is availableworldwide (3?5).In summary, it is certainly recommended toperform a tension-free primary abdominal wallclosure whenever feasible. The closure needs tobe planned as part of the whole transplantoperation. The use of a biologic mesh or therectus muscle offers simplicity and resistance toinfection. But the fascia of the rectus musclebrings a better alternative for reoperation, iscost effective, is replaceable, and it is availableworldwide.