Incidence and management of abdominal wall defects after intestinal and multivisceral transplantation

BACKGROUND: Successful primary closure of the abdominal wall following visceral organ transplantation is not always feasible. Primary closure under tension can lead to fascial ischemia or necrosis, with subsequent dehiscence. Thus, alternate techniques to achieve abdominal wall closure are an important technical aspect in intestinal transplantation. The authors review their experience managing abdominal wall defects following intestinal or multivisceral transplantation. METHODS: A retrospective review of the transplant database revealed 28 intestinal transplants in 24 patients from program inception in 1991 to January of 2002. The management of six intestinal transplant recipients with giant posttransplant abdominal wall defects is reviewed, and a novel technique is described for initially managing defects with prosthetic grafts that were serially reduced in size until a clean granulating bed was established, at which time they underwent permanent coverage using a meshed split-thickness skin graft. RESULTS: Of the 28 transplants, primary fascial closure was possible in only 14. In the other 14 patients, the fascia could not be closed primarily at the time of transplantation. The donor weight-to-recipient weight ratio was significantly greater in patients with abdominal wall closure problems (0.64 versus 1.09; p < 0.005). The incidence of retransplantation was also higher in those with abdominal closure problems compared with those whose fascia could be closed primarily (five of 14 versus one of 14). The six patients managed with skin graft closure did not have any wound complications after grafting. CONCLUSIONS: Abdominal wall defect after intestinal and multivisceral transplantation is a common problem without an ideal solution. Use of a skin graft on granulating abdominal viscera frozen with adhesions is a simple and reasonable solution to a complex problem.