A mini review published in the Journal of Abdominal Wall Surgery synthesizes current evidence on elective incisional hernia repair in adult liver, kidney, and pancreas transplant recipients. The analysis addresses three primary clinical questions: whether transplant status independently predicts adverse outcomes, how immunosuppression relates to repair success, and how operative access, reconstruction, mesh plane, material, and fascial closure should be selected. The review concludes that while short-term wound morbidity and length of stay are generally similar to non-transplant patients, long-term recurrence rates vary widely, and the independent effect of transplantation on recurrence remains unproven due to limitations in observational data.

Incisional hernia is a frequent late complication following abdominal organ transplantation, with reported frequencies varying by organ and detection method. In a cohort of 3,460 transplants at a single institution, the Kaplan–Meier cumulative incidence at 10 years was 7.0% after kidney, 19.0% after liver, and 21.8% after pancreas transplantation. After liver transplantation specifically, cumulative incidence reached 28.5% at 5 years and 35.1% at a median of 76 months, while a cross-sectional study examining every patient found a prevalence of 43%. In contrast, the pooled proportion after kidney transplantation was 4% across 20 studies. These variations reflect differences in hernia definition, detection methods, and follow-up duration.

Concerns about wound failure, mesh infection, and recurrence often delay repair in immunosuppressed patients. In the Ventral Hernia Working Group system, immunosuppression places a recipient with a clean wound at least in grade 2, and previous wound infection or contamination raises the grade further. Reported recurrence after repair in these populations ranges from 0% to 76.9%, highlighting the uncertainty surrounding long-term outcomes. Better survival after repair compared to no repair has been observed, but this is open to selection and immortal-time bias, both of which are expected to favor the repaired group.

Short-term comparisons of repair outcomes are broadly reassuring but not uniform. In the Abdominal Core Health Quality Collaborative, 165 solid organ transplant recipients undergoing elective repair had an adjusted median length of stay similar to that of 13,452 non-transplant patients, at 2.8 versus 2.6 days. Surgical site infection rates were also similar, at 2.4% for transplant recipients versus 4.0% for controls. However, one propensity-matched laparoscopic series found that liver recipients had more surgical site occurrences than controls, at 19.0% versus 2.4%. Defect size was not matched in this study, so the excess may reflect hernia complexity rather than transplantation itself.

Recurrence estimates are study-specific and not interchangeable. In a case-matched cohort of mixed solid organ transplant recipients, recurrence was 12.1% in the transplant group versus 3.0% in controls at a mean of 13 months, though the difference was not statistically significant. In an analysis of 166 abdominal transplant recipients by the Americas Hernia Society Quality Collaborative, composite 2-year recurrence was 28%, but only 45% of patients contributed to this estimate due to low follow-up rates. After a first open repair in 141 liver recipients, recurrence occurred in 35.4%, with suture repair associated with higher recurrence compared to mesh repair. Pooled recurrence in kidney recipients was 16%, whereas registry data from the Abdominal Core Health Quality Collaborative showed a recurrence of 0.6%, which likely reflects under-ascertainment.

The role of immunosuppression, particularly mammalian target of rapamycin inhibitors like sirolimus, is a distinct area of concern. In the only randomised trial, wound complications including incisional hernia occurred in 47% of kidney recipients receiving sirolimus versus 8% of those receiving tacrolimus. Sirolimus was also associated with surgical site infection in a cohort of 1,398 kidney recipients. However, the association between maintenance sirolimus and recurrence after later repair rests on small, conflicting observational series. In one mixed solid organ transplant cohort, recurrence occurred in 2 of 5 patients taking sirolimus, 2 of 13 taking other regimens, and 0 of 29 taking tacrolimus. In contrast, neither sirolimus nor mycophenolate was associated with recurrence in a separate cohort of 141 liver recipients.

Operative approach and prosthesis selection involve five dimensions that are often conflated: access, release or reconstruction technique, mesh plane, prosthesis material, and fascial closure versus bridging. Early comparative series favored laparoscopic intraperitoneal onlay mesh repair, with no recurrence after 12 laparoscopic repairs compared to recurrence or serious mesh infection after 7 of 15 open repairs in immunosuppressed patients. A proportional meta-analysis of 546 mesh repairs after liver transplantation pooled complications of 23% for open and 20% for laparoscopic repair, but overlapping confidence intervals do not establish equivalence. Robotic repair is reported only in small series, and comparisons of laparoscopic and open repair have only been made against historical or unmatched controls.

Extraperitoneal reconstructions report widely varying results. Peritoneal flap hernioplasty with large retromuscular and intermuscular mesh produced no recurrence or infection in 26 liver recipients at a median of 54 months. Open transversus abdominis release with retromuscular synthetic mesh through a midline incision in 44 liver recipients was followed by recurrence in 25% at a median of 13 months, with 8 recurrences from central mesh fracture. In contrast, open transversus abdominis release through the existing subcostal incision with medium-weight polypropylene mesh was followed by no recurrence in 23 liver recipients at a median of 53 months, compared with 36.7% after other, mostly intraperitoneal, techniques. These differences suggest that incision, defect size, and mesh may matter as much as the release technique itself.

Diaphragmatic tack fixation should be avoided in subxiphoid defects. Of 25 reported severe penetrating cardiac injuries after mesh fixation, 23 followed diaphragmatic tacks, and 12 patients died. Manufacturers contraindicate tack deployment in the diaphragm, and tacks should not be used for diaphragmatic fixation above the costal arch. Extraperitoneal dissection into the retroxiphoid space without costal or diaphragmatic fixation avoids this hazard, but has not been formally compared in transplant recipients. This safety concern is distinct from the efficacy of the repair itself and highlights the need for careful technique selection in this population.

Systemic morbidity, particularly acute kidney injury, is a separate concern. In 172 liver recipients, acute kidney injury defined as a creatinine rise greater than 0.3 mg/dL within 24 hours occurred in 48% after repair and was associated with longer stay and lower intraoperative fluid administration. This incidence is specific to that cohort and definition, and the association with fluid administration does not show that restrictive enhanced recovery protocols cause acute kidney injury or that liberal fluid prevents it. It supports baseline renal assessment, attention to calcineurin inhibitor levels, avoidance of dehydration, and joint planning with the transplant team.

Research gaps remain significant. Recurrence is defined inconsistently, and post-repair follow-up is often two years or less, although median time to recurrence after repair was 8.8 months in one cohort and 29 months in another. Graft function and rejection are seldom reported, and patient-reported outcomes after repair come from a single pilot study. Pancreas and combined-organ recipients appear mainly within mixed cohorts, and UK data are limited to two single-centre series. The evidence does not yet support firm practice recommendations, and further research is needed to clarify the independent effect of transplantation on recurrence and the optimal management of immunosuppression around repair.

Two randomised trials of prophylactic mesh at transplant closure are registered, without published results. The PRINC trial of onlay poly-4-hydroxybutyrate mesh after liver transplantation is listed as terminated after enrolling 36 patients, with no results posted. A kidney transplant trial of onlay self-gripping polyester mesh is listed as recruiting, with primary completion expected in December 2026. Evidence on prophylactic mesh in transplant recipients is therefore absent rather than negative, and trials after midline laparotomy in non-transplant patients may not transfer to immunosuppressed recipients with transverse or iliac fossa incisions.

Subject of Research: Evidence on elective incisional hernia repair in adult liver, kidney, and pancreas transplant recipients

Article Title: Incisional hernia repair after abdominal organ transplantation: current evidence, controversies and research gaps

Article References: Vivek, K., Paß, M., Köckerling, F., & Papalois, V. (2026). Incisional hernia repair after abdominal organ transplantation: current evidence, controversies and research gaps. Journal of Abdominal Wall Surgery, 5, Article 17970. https://doi.org/10.3389/jaws.2026.17970

Image Credits: AI Generated

DOI: 10.3389/jaws.2026.17970

Keywords: incisional hernia, organ transplantation, immunosuppression, sirolimus, surgical outcomes, mesh repair, abdominal wall surgery, clinical review, Incisional, hernia, repair, abdominal