Background: Abdominal wall closure is often challenging in pediatric liver (LT) and multivisceral transplantation (MVT) due to size discrepancy of donor & recipient and abdominal wall defects from prior surgery / enteric fistulae. Use of En-bloc Vascularized Rectus sheath Allograft (EVRA) in continuity with the liver is a recent advance.

Methods: Retrospective review of the pediatric database for the use of EVRA at Duke university from 2010-15. Technique of EVRA has been previously described (Am J Transplant. 2012;12:2242-6).

Results: EVRA was used in 6 children (4 LT & 2 MVT). Median age was 11 months (range1-168). All LT recipients underwent transplant emergently and could not wait for size matched donors. Reduced grafts (n=2; 1 each of left-lateral segment & left lobe) and whole grafts (n=2) were used. The large graft size prevented primary closure of abdomen and the EVRA technique was used to bridge the defect. In the MVT group: EVRA was used to buttress lax abdominal wall in a 22 month-old with Megacystis microcolon and close the abdomen in a 10 month old with abdominal domain loss from gastroschisis. The EVRA fascia was insufficient and a temporary Goretex patch was additionally used to achieve closure in 3 of the 4 LT and 1 of 2 MVT (Fig.1)

Four LT & 1 MVT patient underwent planned re-operations (range:2-4) to plicate the donor fascia and narrow the gap between the wound margins, remove Goretex mesh and achieve skin closure. Median time for complete healing (Fig.2) was 26 days (9-33). One patient required skin graft over the donor fascia. Wound infection was not seen. Over a median follow up of 12 months (range:6-64), 5 patients have good graft function without wound complications / hernia. One MVT recipient expired at 15 months from unrelated cause.

Conclusion: EVRA facilitates abdomen closure & early wound healing in children undergoing LT /MVT and is not associated with long term complications. Routine procurement of the donor fascia is recommended in cases where abdominal closure is anticipated to be difficult due to large donor size / small abdominal domain in recipient (emergent cases).

CITATION INFORMATION: Reddy J, Rege A, Vikraman D, Collins B, Brennan T, Knechtle S, Sudan D, Ravindra K. Use of En-Bloc Vascularized Rectus Sheath Allograft to Achieve Abdominal Closure in Pediatric Liver and Multivisceral Transplantation. Am J Transplant. 2016;16 (suppl 3).

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