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Incisional Hernia after Liver Transplantation
Dear Colleague,
This survey is promoted by the European Society for Organ Transplantation (ESOT) — Interventional Working Group on post-liver-transplant abdominal-wall complications (Scientific Leads: Prof. Alessandro Anselmo, Tor Vergata, Rome · Muhammad Khurram, London).
The aim is to map current practice across European LT centres on the incidence, surveillance and prevention of post-LT IH.
Estimated completion time: 25 minutes.
▪ This survey complies with European data-protection law (GDPR). No identifying patient data are collected. Free-text comments are anonymised before analysis. Submission implies informed consent to inclusion in the aggregate dataset.
Section 1 — Respondent and centre profile
*
1.
Centre identification (kept confidential; used only for de-duplication).
(Required.)
Centre name:
Country:
City:
2.
Respondent name + e-mail (optional, for follow-up):
*
3.
Which best describes your role?
(Required.)
Lead transplant surgeon
Senior transplant surgeon (consultant / staff)
Hepatobiliary surgeon (with abdominal-wall expertise)
Abdominal-wall / hernia surgeon collaborating with the transplant unit
Hepatologist / transplant physician
Surgical fellow / trainee
Other (please specify)
*
4.
How many years of experience do you have in adult liver transplantation?
(Required.)
< 5 years
5–10 years
11–20 years
> 20 years
*
5.
How many adult liver transplants does your centre perform per year (most recent calendar year)?
(Required.)
< 25
25–50
51–100
101–150
> 150
*
6.
Case mix (approximate %, must sum to 100):
(Required.)
DDLT (deceased-donor) (%)
LDLT (living-donor) (%)
Split-liver (%)
Paediatric (%)
Section 2 — Incidence, surveillance and diagnostic protocol
*
7.
Is the incidence of post-LT IH systematically tracked at your centre?
(Required.)
Yes — prospective registry / database
Yes — retrospective extraction from clinical records
No — not formally tracked
Don't know
*
8.
Tracked incidence of post-LT IH at your centre over the last 5 years (if measured):
(Required.)
< 5%
5–10%
11–15%
16–20%
21–30%
> 30%
Don't know / not measured
*
9.
Perceived incidence of post-LT IH (your subjective estimate, even if not measured):
(Required.)
< 5%
5–10%
11–15%
16–20%
21–30%
> 30%
Don't know
*
10.
How is post-LT IH diagnosed at your centre? (select all that apply)
(Required.)
Routine clinical examination at all scheduled follow-up visits
Routine cross-sectional imaging (US / CT / MR) at scheduled intervals
Imaging only when symptomatic
Patient-reported outcome / self-report
Other (please specify)
*
11.
If imaging is used routinely, at which milestone(s)? (select all that apply)
(Required.)
3 months post-LT
6 months post-LT
12 months post-LT
Yearly thereafter
Only on indication
Not routinely
*
12.
In your opinion, the pooled incidence of 13.75% (from unpublished ESOT metanalysis) is:
(Required.)
An accurate reflection of true incidence
An underestimate (true incidence higher — likely with imaging surveillance)
An overestimate (true incidence lower — clinical-only surveillance suffices)
Highly heterogeneous and centre-dependent
Section 3 — Surgical technique at liver transplant
*
13.
Which abdominal incision do you use most often for adult LT?
(Required.)
Mercedes-Benz (inverted Y) — three-arm
Right subcostal
Right subcostal with extension to left rectus muscle
Bilateral subcostal (Chevron)
Makuuchi / J-shaped (vertical midline + oblique right component)
Modified Makuuchi / Reverse-T (vertical midline + horizontal subcostal component)
Midline laparotomy
Other (please specify)
*
14.
What abdominal closure technique is most commonly used at your centre? - Vertical component (if present). Select all that apply.
Type of suture:
(Required.)
Continuous fascial closure
Interrupted closure
Not applicable
*
15.
What abdominal closure technique is most commonly used at your centre? - Vertical component (if present). Select all that apply.
Bite size:
(Required.)
Small-bite technique (5mm)
Large-bite technique (1cm)
Not applicable
*
16.
What abdominal closure technique is most commonly used at your centre? - Vertical component (if present). Select all that apply.
Suture material most commonly used:
(Required.)
Slowly absorbable monofilament
Non-absorbable monofilament
Not applicable
Other (please specify)
*
17.
What abdominal closure technique is most commonly used at your centre? - Horizontal component (if present). Select all that apply.
Type of suture:
(Required.)
Continuous fascial closure
Interrupted closure
Not applicable
*
18.
What abdominal closure technique is most commonly used at your centre? - Horizontal component (if present). Select all that apply.
Bite size:
(Required.)
Small-bite technique (5mm)
Large-bite technique (1cm)
Not applicable
*
19.
What abdominal closure technique is most commonly used at your centre? - Horizontal component (if present). Select all that apply.
Suture material most commonly used:
(Required.)
Slowly absorbable monofilament
Non-absorbable monofilament
Not applicable
Other (please specify)
20.
What abdominal closure technique is most commonly used at your centre? - Horizontal component (if present). Select all that apply.
Layers:
One layer
Two layers
Three layers
Other (please specify)
Section 4 — Prophylactic mesh placement
*
21.
Do you use prophylactic mesh reinforcement in LT recipients?
(Required.)
Routinely in all
Selectively (criteria specified in next questions)
Never
Within a clinical trial only (e.g., PRINC, NCT04512469 / Skaro, or Prometheus)
*
22.
Are you familiar with the Prometheus Patient Selection Algorithm (an Italian Multi-Center Study) for prophylactic mesh placement after LT?
(Required.)
Yes — currently used in our centre
Yes — aware of it but not yet adopted
No — first time I hear of it
Other (please specify)
*
23.
Preoperative risk factors — for each, indicate how routinely you assess it in your LT workup.
▪ Mark one column per row.
(Required.)
Never
Rarely
Sometimes
Often
Routinely
Age > 60 years
Never
Rarely
Sometimes
Often
Routinely
Male sex
Never
Rarely
Sometimes
Often
Routinely
BMI > 30
Never
Rarely
Sometimes
Often
Routinely
Active smoker
Never
Rarely
Sometimes
Often
Routinely
Diabetes mellitus
Never
Rarely
Sometimes
Often
Routinely
Chronic kidney disease (CKD)
Never
Rarely
Sometimes
Often
Routinely
MELD > 22
Never
Rarely
Sometimes
Often
Routinely
COPD
Never
Rarely
Sometimes
Often
Routinely
Moderate / large ascites at time of transplant
Never
Rarely
Sometimes
Often
Routinely
Sarcopenia (radiologically defined)
Never
Rarely
Sometimes
Often
Routinely
Umbilical hernia (if incision passes through umbilical area)
Never
Rarely
Sometimes
Often
Routinely
Previous upper-quadrant laparotomy
Never
Rarely
Sometimes
Often
Routinely
*
24.
Which threshold of preoperative risk factors would trigger prophylactic mesh in your practice?
(Required.)
≥ 1 (any factor)
≥ 2
≥ 3
≥ 4
≥ 5
Patient-specific multidisciplinary decision
Not applicable — never use prophylactic mesh
*
25.
Intraoperative gating criteria — which must be satisfied before placing a prophylactic mesh? (select all that you require)
(Required.)
Good reperfusion of the transplanted liver after portal declamping
Hemodynamic stability without large doses of inotropes
Satisfactory hemostasis
Lactate < 10 mmol/L or reduction across 2 consecutive samples (30 min after portal declamping)
No skin / abdominal-wall / intraperitoneal infection or contamination
Primary fascial closure achievable (no need for bridging)
In case of secondary abdominal-wall closure after removal of a bridge mesh
*
26.
Which mesh type, if any, is used for prophylaxis at LT? (select all that apply)
(Required.)
Synthetic non-absorbable (polypropylene / polyester)
Slowly-absorbable biosynthetic — (e.g. Phasix™ BD / Bio-A® GORE-Bio, …)
Biological (e.g. Permacol™ Medtronic, Strattice AbbVie, …)
Composite or coated mesh
None
Other (please specify)
27.
If you use prophylactic mesh, in which plane is it placed? (select all that apply)
Onlay
Sublay — retrorectus
Sublay — preperitoneal
IPOM (intraperitoneal)
Other (please specify)
*
28.
In your view, what would be an absolute contraindication to prophylactic mesh placement at LT? (select all that apply)
(Required.)
Unsatisfactory graft reperfusion after portal declamping
Hemodynamic instability requiring large doses of inotropes
Unsatisfactory hemostasis
Lack of lactate clearance 30 min after portal declamping (or lactate ≥ 10 mmol/L without trend)
Skin / abdominal-wall / intraperitoneal infection or contamination
All of the above
None of the above
*
29.
In your opinion, what level of evidence is needed before wider adoption? (select all that apply)
(Required.)
Randomized controlled trials
Registry data
International guidelines
Meta-analysis
Cost-effectiveness data
Current evidence is sufficient
Other (please specify)
Section 5 — Immunosuppression & pharmacologic management
▪
Post-LT IH is one of the few wound complications where the pharmacologic regimen materially modifies risk. This section captures how the immunosuppression strategy interacts with the wound-healing imperative.
*
30.
What is your default immunosuppression regimen in the first 6 months post-LT?
Please specify for each type of patient
(Required.)
Standard Patient:
Impaired Renal Function:
Oncological Risk:
IH high-risk patient:
Other / individualised — please specify
*
31.
How does your centre weigh the trade-off between mTOR-i exposure and post-LT IH risk?
(Required.)
Avoid mTOR-i in general — wound-healing priority
Avoid mTOR-i only when renal function is preserved (no CNI-sparing need)
Avoid mTOR-i only when there is no oncologic indication (no HCC antiproliferative need)
Use mTOR-i routinely — IH risk is not a deciding factor
No formal policy — clinician-level decision
*
32.
How does your centre weigh the trade-off between corticosteroid exposure (maintenance immunosuppression + rejection-treatment pulses) and post-LT IH risk?
(Required.)
Avoid corticosteroids in general — wound-healing priority (steroid-free or rapid-taper protocol within 30 days)
Avoid corticosteroids only when there is no autoimmune indication (no maintenance need for autoimmune hepatitis, PBC, or overlap syndromes)
Avoid corticosteroids only when there is no high-rejection-risk profile
Use corticosteroids routinely — IH risk is not a deciding factor in the IS regimen
No formal policy — clinician-level decision
*
33.
Do you routinely modify immunosuppression around the time of IH repair?
(Required.)
No modification
Reduce mTOR-i (± switch to CNI)
Stop mTOR-i (± switch to CNI)
Reduce steroid dose
Stop steroid dose
Other (please specify)
*
34.
In your view, the evidence on mTOR-i as a risk factor for post-LT IH is:
(Required.)
Convincing — antiproliferative effect on wound healing is established
Suggestive but not conclusive — small-study effect / confounding by indication
Not convincing — overestimated by selection bias
Don't know / no opinion
Section 6 — Elective repair of post-LT incisional hernia (Optional completion)
35.
Does a dedicated abdominal-wall surgeon collaborate with your transplant unit for IH repair?
Yes — as a routine part of the transplant team
Yes — on consultation when needed
No — IH managed entirely by transplant surgeons
No — IH referred to general surgery outside the transplant unit
36.
Preferred elective approach when the defect CAN be primarily closed:
Open suture-only repair (any size)
Open suture-only repair (small defects 2–3 cm)
Open mesh repair — onlay
Open mesh repair — sublay retrorectus
Open mesh repair — sublay preperitoneal
Open mesh repair — intraperitoneal
Laparoscopic / robotic IPOM-plus
Robot-assisted (eTEP / robotic Rives–Stoppa)
Hybrid approach (laparoscopic + open)
Other (please specify)
37.
Preferred elective approach when the defect CANNOT be primarily closed:
Open mesh repair — inlay (bridging)
Open component separation (anterior or posterior, TAR)
Laparoscopic / robotic IPOM
Laparoscopic / robotic component separation (TAR)
Hybrid approach (laparoscopic + open)
Preoperative botulinum toxin administration
Other (please specify)
38.
Mesh choice when placed OUTSIDE the peritoneal cavity, in a CLEAN or CLEAN-CONTAMINATED field (class I-II):
Polypropylene — heavyweight
Polypropylene — lightweight / mid-weight
Polyester / PET
ePTFE
Slowly-absorbable biosynthetic (Phasix™ BD / Bio-A Gore-Bio)
Biological mesh
Composite / coated
No mesh
Other (please specify)
39.
Mesh choice when placed OUTSIDE the peritoneal cavity, in a CONTAMINATED or DIRTY field (class III-IV):
Polypropylene — heavyweight
Polypropylene — lightweight / mid-weight
Polyester / PET
ePTFE
Slowly-absorbable biosynthetic (Phasix™ BD / Bio-A Gore-Bio)
Biological mesh
Composite / coated
No mesh
Other (please specify)
40.
Mesh choice when placed INSIDE the peritoneal cavity (direct visceral contact), CLEAN / CLEAN-CONTAMINATED:
Polypropylene — heavyweight
Polypropylene — lightweight / mid-weight
Polyester / PET
ePTFE
Slowly-absorbable biosynthetic (Phasix™ / Bio-A)
Biological mesh
Composite / coated
No mesh
Other (please specify)
41.
Mesh choice when placed INSIDE the peritoneal cavity, CONTAMINATED / DIRTY:
Polypropylene — heavyweight
Polypropylene — lightweight / mid-weight
Polyester / PET
ePTFE
Slowly-absorbable biosynthetic (Phasix™ / Bio-A)
Biological mesh
Composite / coated
No mesh
Other (please specify)
42.
Minimum interval from LT to elective IH repair at your centre:
≥ 6 months
≥ 12 months
≥ 24 months
Decided case-by-case based on IS / clinical status
No fixed interval
Section 7 — Complications, outcomes & patient-reported outcomes (Optional completion)
43.
Annual incarcerated / strangulated post-LT IH presentations at your centre:
0–1
2–5
6–10
> 10
Don't know
*
44.
Tracked 5-year recurrence rate after IH repair in LT recipients:
(Required.)
< 10%
10–20%
21–30%
> 30%
Don't know / not measured
*
45.
Perceived 5-year recurrence rate after IH repair in LT recipients:
(Required.)
< 10%
10–20%
21–30%
> 30%
Don't know
*
46.
Most frequent complications after IH repair in LT recipients (select up to 3):
(Required.)
Surgical site infection (SSI)
Seroma
Hematoma
Mesh infection requiring explantation
Wound dehiscence
Recurrent hernia
Bowel injury
Acute kidney injury
Cardiopulmonary complications
Death within 30 days
Other (please specify)
*
47.
Do you measure patient-reported outcomes / quality of life around IH repair?
(Required.)
Yes — generic instrument (SF-36, EQ-5D)
Yes — hernia-specific (HerQLes, Carolinas Comfort Scale)
Yes — both
No
Section 8 — Burden, costs, research priorities & participation
*
48.
On a 1–5 scale, post-LT IH represents a CLINICALLY relevant burden at our centre.
(Required.)
strongly disagree
1 star
disagree
2 stars
neutral
3 stars
agree
4 stars
strongly agree
5 stars
*
49.
On a 1–5 scale, post-LT IH represents an ECONOMIC burden at our centre.
(Required.)
strongly disagree
1 star
disagree
2 stars
neutral
3 stars
agree
4 stars
strongly agree
5 stars
*
50.
Approximate mean length of hospital stay for elective post-LT IH repair (days):
(Required.)
*
51.
Approximate mean number of post-LT IH repairs performed at your centre per year:
(Required.)
*
52.
Are post-LT IH repairs counted in your transplant programme's activity (e.g., DRG / GDP) separately from the LT episode?
(Required.)
Yes
No
Don't know
*
53.
Do you perceive that post-LT IH repairs compete with the LT waiting list for OR / bed availability?
(Required.)
Yes — frequently
Yes — occasionally
No
Don't know
*
54.
Which research priorities would your centre most strongly support? (select up to 3)
(Required.)
European prospective registry of post-LT IH (ESOT-coordinated)
Multicentre RCT of prophylactic mesh in high-risk LT recipients (PRINC / Prometheus design)
Convergence with the registered (status: not yet recruiting) NCT04512469 (Skaro, London ON) on shared core-outcome set
RCT comparing closure techniques (small-bites vs large-bites) in LT
RCT comparing repair strategies (open sublay vs robotic) in post-LT IH
Health-economic analysis of prophylaxis vs treatment
Standardisation of definition / classification of post-LT IH
Patient-reported outcome / QoL studies
Other (please specify)
*
55.
Would your centre participate in an ESOT-coordinated prospective registry on post-LT IH?
(Required.)
Yes
Possibly — needs further information
No
*
56.
Would your centre participate in a multicentre RCT (e.g., on prophylactic mesh under Prometheus / PRINC design)?
(Required.)
Yes
Possibly — needs further information
No
57.
Any additional comments, observations or unmet needs we should be aware of?
Thank you for your time and expertise.
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