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Page 6 of 13 Singh et al. Plast Aesthet Res 2020;7:39 I http://dx.doi.org/10.20517/2347-9264.2019.76
[9]
development. Depending on the score from zero to six, the risk for hernia ranges from 5.5% to 55% .
The HERNIAscore has also been improved to include length of incision, COPD, and prior abdominal
[10]
operations .
VHRS is an additional tool available for risk assessment of surgical site infection (SSI). Based on VHRS,
risk factors for SSI include concomitant hernia repair, raising of skin flaps, wound Class 4 (i.e., dirty), BMI
[11]
greater than 40, and ASA Class 3 or greater . Both the HERNIAscore and VHRS have been externally
validated and shown to be more effective in identifying SSI/SSO risk when compared to other risk models.
Overall, while some models are helpful, not all have been internally and externally validated. Validated
grading scales can help counsel patients and set realistic expectations for possible complications following
ventral hernia repair.

CURRENT TECHNIQUES IN HERNIA MANAGEMENT
Abdominal wall closure in transplant patients
Surgical closure of an abdomen following solid organ transplant is a critical aspect of the transplant, as a
failure of closure greatly increases the risk for graft failure and infection. Primary closure of the abdominal
[12]
wall is, of course, ideal, however cannot be achieved in approximately 20% of patients . A common reason
for failure of primary closure is lack of intra-abdominal domain. Some initial loss of domain is transient
from edema and resolves with diuresis, etc. A rush to primary closure only increases the risk of dehiscence
and wound breakdown. Patients may also present with presence of fistulae, ostomies, extensive scar
tissue, significant skin lesions from healed fistulae/wounds, or even a frozen abdomen secondary to dense
adhesions from multiple prior procedures, thus making primary closure challenging or even impossible to
perform. In these patients with such anatomic complexities, an open approach may be favorable.

Significant tension on the abdominal wall from closure in patients with loss of domain can also lead to
abdominal compartment syndrome, which in a newly transplanted graft can lead to graft failure. Foley
catheters are commonly left in place postoperatively, often to monitor urine output, but also to monitor
bladder pressures in the setting of possible abdominal compartment syndrome. It is imperative that the
patient is intubated, paralyzed, and fully supine in order to obtain accurate bladder pressures. Increased
abdominal pressure that does not cause compartment syndrome can still impede flow within the inferior
vena cava and decrease portal venous flow to the liver. This is a known risk factor for graft failure following
liver transplantation. Low flow states can also lead to poor venous return, resulting in decreased cardiac
output and perfusion. Increased abdominal pressure after fascial closure can also lead to respiratory
compromise, especially in patients with loss of domain. Thus, it is important to communicate with the
anesthesia team intraoperatively to monitor peak pressures after closure, as some patients may require
continued intubation in the immediate postoperative period. Elevated ventilatory pressure or changes in
peak pressures may also serve as a real time indication of impending compartment syndrome so our group
routinely solicits feedback from anesthesia throughout closure.

Panniculectomy and transplantation
Obesity remains a significant risk factor for morbidity after abdominal surgery. Transplantation in
general carries a higher degree of morbidity among obese patients. Large overhanging skin folds create
a moist environment that increases the risk of postoperative infection. Furthermore, the large amount of
subcutaneous tissue that must be traversed and potentially undermined in patients undergoing transplant
has a higher risk of necrosis and infection. A large pannus may also create additional tension and
[13]
stress on the incision, which may lead to separation of wound edges . Individual centers have specific
protocols and regulations regarding optimal BMI prior to transplantation. While there is no consensus,
[14]
some centers suggest having a BMI less than 30 to decrease the risk of perioperative complications . A
prophylactic panniculectomy can be performed prior to transplant to enable obese patients to meet criteria