We read with great interest the recent article by Jafri et al. 1 on temporary silastic mesh closure for adult liver transplantation, but would comment on some of the aspects of the study to help put the authors' large experience in perspective. A total of 51 (25.5%) out of 200 liver transplantations underwent temporary abdominal coverage with silastic sheeting reinforced with vacuum dressing on top. Permanent fascial closure was established in 82% following resolution of the intraabdominal hypertension; component separation and absorbable polyglactin mesh became necessary to reconstruct the abdominal wall in 12% and 6%, respectively, with a 3.9% incidence of ventral hernia in that group. 1 Although the work makes a very important contribution to the understanding that temporary abdominal coverage can be performed safely in transplant patients, the following omissions detract somewhat from a full understanding of all aspects of the study.
The authors report a median follow-up of 1.3 yr for the silastic group and no statistically significant difference in the hernia incidence compared with the primary closures in the remaining 149 patients. Nearly 50% of recurrences following hernioplasty do not appear until 5 yr after surgery; statistical significance is best determined with a 10-yr follow-up. 2 The very short follow-up in the Jafri et al. 1 study does not permit sound conclusion as to the superiority of one approach over another. The authors also do not provide details about the closing method (continuous vs. single sutures) or suturing material (absorbable vs. nonabsorbable) used to oppose the fascia. The published randomized clinical trials and meta-analyses suggest that there is very little evidence for superiority of certain types of incisions, suture materials, or closure methods in decreasing the hernia incidence in the general population. 3 Recent trials suggest that a fundamental defect in the collagen metabolism plays a most important role in the formation of ventral hernias 4,5 ; unfortunately, this was not addressed in the work of Jafri et al. 1 It will be extremely interesting to know how all these considerations are reflected in the liver transplantation population.