Objectives: Primary abdominal wound closure is performed at the completion of liver transplant in most patients. However, this is not always possible in pediatric recipients. The shortage of size-matched donor organs for pediatric patients means that occasionally it is necessary to use whole livers that are larger than can be accommodated comfortably in the child’s abdomen. The present report outlines our experience with temporary patch closure after pediatric liver transplant of the abdominal wall.
Materials and Methods: Our team performed the first liver transplant in Turkey in 1988. Since 1988, we have performed 629 liver transplant (336 adult and 293 pediatric) procedures at our center. We evaluated data of 191 liver transplants performed in recipients who were under 10 years of age. Left lateral lobe grafts were used in 169 patients (88%), and whole grafts were used in 22 patients (12%).
Results: Temporary closure with the Bogota bag patch was necessary in 31 transplant procedures (16.2%), 3 of which involved whole livers and 28 of which involved left lateral lobe grafts. The age range of recipients was 5 months to 10 years (median, 30 mo). The temporary abdominal closure technique was preferred in 22 patients because the abdomen could not be closed during surgery.
Conclusions: In pediatric patients with difficult abdominal closure after liver transplant, temporary patch closure is the treatment of choice. Our preference has been reinforced silicone sheeting, which allows minimal adhesion formation between the patch and abdominal viscera; in addition, the transparent nature of the material provides a window for inspection of the donor liver.
Key words : Bogota bag, Graft-to-body weight ratio, Temporary patch closure
Liver transplant has been successful in treating children with end-stage liver disease and offers the opportunity for a long healthy life. However, liver transplant remains an intricate surgery with significant morbidity and mortality. About 40% of pediatric recipients may present with postoperative complications, which can range from minor to major.1 The ratio between the liver graft mass and the recipient’s body weight is important for living-donor liver transplant. The ideal graft mass-to-body weight ratio is unknown, but it is believed that the graft must weigh 0.8% to 2.0% of the recipient’s body weight. When this ratio is greater than 4%, the graft is termed a large-for-size graft, and problems caused by a large-for-size graft are termed large-for-size syndrome.2
Primary abdominal wound closure is performed at the completion of liver transplant in most patients. However, this is not always possible in pediatric recipients. Closure of the abdomen after pediatric orthotopic liver transplant can often be challenging and sometimes dangerous as a result of donor-to-recipient allograft size mismatch, postreperfusion hepatic edema, and intestinal edema due to venous engorgement or lactulose therapy, in addition to ongoing hemorrhage (Figure 1).3
Tense fascial closure may lead to a multitude of problems. These include the following: (1) respiratory compromise and difficulty with ventilation, (2) decreased cardiac output, (3) vascular compromise to the allograft, (4) delayed graft function, (5) oliguria, (6) impaired abdominal wall nutrient blood supply, (7) enterocutaneous fistula, (8) entrapment of intestinal contents in the closure, and (9) hernia.
The pathology of abdominal hypertension resulting from abdominal compartment syndrome has been well described in the literature. Standard diagnostic criteria have been established and widely validated, including evaluation of bladder pressure as a relatively noninvasive estimation of intra-abdominal pressure, as well as clinical findings of oliguria, increased pulmonary pressure, hypoxia, hypotension, and decreased cardiac output, all improving with abdominal decompression.4
The recognition of the potential for abdominal hypertension is most obvious in the pediatric population, in which graft size mismatch is a relatively common problem. Correspondingly, the literature is replete with reports of temporary abdominal wound closure in children who receive liver transplants. There are 2 approaches to solve this problem: further reduction of the graft (monosegmentation or hyperreduction) or leaving the abdomen temporarily open.4,5
We describe our technique and rationale for temporary closure using delayed primary closure of the abdominal wall after liver transplant. The objectives of the study were to evaluate the safety, efficacy, and short- and long-term complications of temporary abdominal closure after liver transplant and to determine situations where this practice would most benefit the recipient.
Materials and Methods
Our team performed the first liver transplant of Turkey in 1988. Since 1988, we have performed 629 (336 adult and 293 pediatric) liver transplant procedures at our centers. We evaluated the data of 191 liver transplants performed in patients under 10 years of age. Left lateral lobe grafts were used in 169 patients (88%) and whole grafts in 22 patients (12%).
During temporary closure time, a sterilized saline bag, tailored to the shape of the abdominal wall defect, was sutured to the skin for temporary closure without tension by the surgical team. Medical records from recipients were reviewed. We analyzed recipient and donor demographics, graft ischemic times, operative blood product and fluid requirements, postoperative days to final abdominal closure and extubation, hospital and intensive care unit lengths of stays, indication for temporary closure, postoperative complications (including hepatic artery thrombosis and biliary and infectious complications), and allograft and patient survival (Table 1).
In cases in which it was obvious that undue compression would occur if primary wound closure was attempted, partial closure of the wound was performed initially, until some tension was evident.
Preference was given to closure of the vertical midline section of the wound when this extension of the bilateral subcostal incision had been used. A sterilized saline bag, tailored to the shape and size of the abdominal wall defect, was sutured to the skin layer with continuous 3-0 polypropylene, to provide temporary closure without tension. In the immediate posttransplant period, dressing changes were performed daily unless leakage of excessive peritoneal fluid prompted more frequent wound care. Temporary abdominal closure was changed every 48 hours (Figure 2). In each operation, reduced abdominal wall defect and graft perfusion were checked with Doppler ultrasonography until abdominal closure was achieved with normal graft perfusion. Delayed wound closure was deemed appropriate when palpation showed a relaxed abdominal wall.
Between October 2000 and June 2019, we evaluated 191 liver transplant procedures in pediatric recipients. The age range of recipients was 5 months to 10 years (median, 30 mo). Left lateral lobe grafts were used in 169 recipients (88%), and whole grafts were used in 22 recipients (12%). Temporary closure with the Bogota bag patch was necessary in 31 liver transplant procedures (16.2%), 3 of which involved whole livers and 28 of which involved left lateral lobe grafts. Temporary abdominal closure technique was preferred in 22 patients because the abdomen could not be closed during surgery. The procedure was also used in 9 other patients who had primary abdominal wall closure but who required a posttransplant laparotomy (3 for thrombectomy of portal vein thrombosis and 6 for wound dehiscence associated with ileus and marked abdominal distension). Five patients died due to sepsis or bleeding in the early postoperative period. Removal of the patch and delayed wound closure were achieved in 26 patients. This was achieved in a single operation in 12 patients. Gradual reduction in the size of the wound patch was necessary in the other 14 patients. Temporary abdominal closure technique was performed 9 times in 7 patients, 7 times in 4 patients, and 4 times in 3 patients. Wound closure was completed within 12 days for 8 patients and within 20 days for the other 6 patients.
In pediatric patients with difficult abdominal closure after liver transplant, temporary patch closure is the treatment of choice. A shortage of size-matched organs for pediatric patients has meant the use of whole livers or reduced-size grafts that are larger than can be accommodated comfortably in the available abdominal space of pediatric patients.1,6 Although these measures have been advantageous in providing organs for children who otherwise would have died while on wait lists, transplant is often accompanied by an inability to perform primary wound closure.2,7 Our preference has been a sterilized saline bag, which allows minimal adhesion formation between the patch and abdominal viscera; in addition, the transparent nature of the material provides a window for inspection of the donor liver.
When we compared the temporary abdominal closure technique with primary abdominal closure technique, we observed (1) no differences in graft and patient survival, (2) shorter overall hospital stays with primary abdominal closure after liver transplant, and (3) no differences in vascular complications.
The problem of achieving reconstitution of the abdominal wall when it is not possible to perform primary wound closure is most common after pediatric liver transplant procedures. The lack of intra-abdominal space related to an oversized liver, bowel distension, and edema after liver transplant require a bridging wound patch to allow abdominal closure without tension.8 Temporary wound closure with a sterilized saline bag is a standard surgical technique. The use of a temporary patch permits low-pressure abdominal closure without compression and without compromising the liver’s vascular perfusion. It also avoids the high central venous pressure and increased ventilatory support that inevitably would result from abdominal closure under tension. The disadvantages are leakage of intra-abdominal fluid, additional postoperative wound care, interference with ultrasonographic examination, and the necessity to perform surgical procedures to gain final closure.9
Although our results were not statistically significant, our experiences showed that, in recipients with body weight under 7 kg, graft-to-body weight ratio of more than 4 g/kg (a large for size graft), and anhepatic phase more than 100 minutes, temporary abdomen closure should be preferred.
Volume : 18
Issue : 1
Pages : 32 - 35
DOI : 10.6002/ect.TOND-TDTD2019.O6
From the Departments of 1Transplantation and 2Anesthesiology, Baskent
University, Ankara, Turkey
Acknowledgements: The authors have no sources of funding for this study and have no conflicts of interest to declare.
Corresponding author: Mahir Kırnap, Department of General Surgery, Baskent University Hospital, Maresal Fevzi Cakmak Cad. No: 10, Ankara 06490, Turkey
Figure 1. Closure of Abdomen After Pediatric Liver Transplant
Figure 2. Closure Techniques
Table 1. Demographic Characteristics of Patients