Non-vascularized Abdominal Rectus Fascia for Abdominal Closure after Transplantation, Single Center Report and Long-Term Follow-Up

Introduction: Closure of the abdominal wall after intestinal (ITx), combined liver-intestine (cL-ITx), multivisceral (MVT) or liver re-transplantation (L-reTx) usually can be a major challenge because those patients usually have a history of multiple abdominal surgeries, significant scarring and loss of abdominal domain. A variety of techniques, including anatomic closure (component separation) and use of surgical mesh or even abdominal wall transplantation have been described in order to overcome this challenge. We aim to report our experience using Non-vascularized Abdominal Rectus Fascia (NVARF) for abdominal wall closure. Patients and Methods: Retrospective report of a series of 24 recipients of NVARF after ITx, cL-ITx, MTV or L-reTx performed between January 2006 and December 2022 at a single transplant center. Results: 772 liver transplants (including 79 L-reTx), and 52 ITx, cL-ITx or MVT were performed in our center during the cited period. In 24 of them (3%) NVARF was used (12 in adult patients) 15 (62%) being on ITx graft recipients, 4 (17%) cL-ITx, 3 (13%) were MVT and 2 (8%) were L-reTx). Seventeen patients (71%) required re-operations: 11 (65%) before the 30th post-op day: 5 (45%) required 1 exploratory laparotomy, 2 (12%) underwent 2 re-operations, 2 (12%) patients had 3, 1 (6%) patient had 4 and 1 (6%) patient had 7. The most frequent indication for exploratory laparotomy were intra-abdominal collections (5, 45%) and abdominal hematoma (4, 36%). Eight patients required late re-operations (>30 days): 4 of them (57%) underwent total enterectomy due to graft rejection. Two patients had both early and late re-operations. During re-operations, NVARF was transected and no internal adhesions were found. After the surgical procedures, we closed the NVARF using running sutures. Only in 4 cases (17%) we had to remove the NVARF, and use a different abdominal wall closer technique: in 3 cases we replaced it for a synthetic mesh (2 of them due to a ventral hernia) and in 1 case, a second NVARF was used. At a mean follow up of 48 month, 20 patients still have the original NVARF (83%), without developing chronic ventral defects, nor developing adhesions to the non-vascularized graft. Conclusion: The use of a NVARF has become an efficient, economic reproducible alternative to overcame defects or compromised abdominal walls after complex liver or intestinal containing transplants. The NVARF can be re-sutured after being transected, it doesn’t increase the risk of ventral defects, nor generates intra-abdominal adhesions. The potential risk for developing donor specific antibodies, remained to be studied in order to expand its use to non-transplant patients.