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to the overlying fat and skin, leading to skin necrosis and its downstream sequelae. As mentioned above,
this dissection also creates large flaps, which often harbor enormous areas of dead space and associated
fluid collections. It should be noted that perforator-preserving ACS techniques have been described with
improved outcomes. A posterior component separation (PCS) allows for less subcutaneous dissection
and also may be preferred in patients who have undergone prior ACS repairs. In cases where patients lack
adequate retro-rectus space, a unilateral or bilateral transverse abdominis release (TAR) may be required to
minimize tension while avoiding the neurovascular bundles at the lateral border of the rectus muscle. As a
general rule, we recommend that the retro-rectus space be at least twice the size of the defect transversely
in order to undergo repair without the need for TAR. An advantage of TAR is the ability to create a wide
retro-muscular space that can extend to the psoas muscles, Cooper’s ligaments, and the central tendon of
the diaphragm.

A meta-analysis from 2018 comparing open ACS to PCS with TAR showed similar hernia recurrence rates
[23]
and wound complication rates; however, both larger and comparative studies still need to be performed .
It is difficult to discern which approach is superior. Ultimately, the choice of repair is multifactorial and will
vary based on patient comorbidities, hernia morphology, and surgeon experience.

Finally, robotic-assisted hernia repair can aid in abdominal wall reconstruction for complex and large-sized
hernias. A robotic approach may facilitate dissection and component separation in the setting of dense
adhesions and complicated post-transplant anatomy. It is our recommendation that such cases should be
performed at hernia centers that specialize in both complex hernia repair as well as transplant surgery such
that, if there are complications, the transplant team is readily available.

Significant variability exists between size criteria and the appropriateness of individual techniques among
surgeons; therefore, surgeon experience, patient factors, and hernia morphology must be considered when
choosing how to repair incisional hernia in solid organ transplant patients. Currently, there are no definitive
algorithms for hernia repair in this population for multiple reasons. First, a reparative approach can be
determined by size of fascial defect, patient risk factors, or even hernia stages. There is no consensus as to
which category is preferred in terms of stratifying patients to follow a certain algorithmic path. It is this
lack of a universal classification system that has prevented development of algorithms in the past and this
remains true today. Secondly, there is a great deal of variation in hernia repair technique that differs among
institutions and surgeons, based on individual operator preference, experience, and available resources.
What may be an acceptable approach at one institution may be deemed outdated, less desirable, or even
impossible at another. Finally, there is so much nuance regarding incisional hernias in transplant patients
- hernia size and location, degree of immunosuppression, comorbidities, loss of domain, and history of
previous surgeries and hernia repairs to name a few - that there are infinite possible approaches to repair.
Algorithms fail to be useful when they are too convoluted. This sentiment is best stated by Malangoni and
Rosen in the 20th Edition of the Sabiston Textbook of Surgery: “The absence of a universal classification
system has hindered comparisons within the literature and at meetings, indirectly delaying meaningful
conversations about repair techniques and prosthetic choice. The TNM model for cancer staging is an
[24]
enviable model to strive for in hernia repair” . As of now, a comparable model does not exist.

Autologous tissue flaps
While not common, some transplant patients’ hernias are so complicated, or have failed one or more
biological mesh repairs, that surgeons must turn to autologous tissue flaps such as tensor fascia lata or thigh
flaps. These autologous flaps were performed more frequently in the past and are now mostly of historical
interest because complicated hernias are so effectively managed by biological mesh and novel methods of
tissue expansion that complicated flap procedures are rarely necessary.