Massive abdominal herniation after dual kidney transplantation

A 68-year-old man with end-stage renal disease of unknown cause received a dual non heart-beating renal allograft in October 2009. He had previously received peritoneal dialysis for 14 months. His postoperative course was complicated by cytomegalovirus disease, which resulted in a prolonged period of immobility and undernutrition. On recovery, massive abdominal herniation related to his dual transplant became apparent (Figure 1 and 2). On examination, this was due to general laxity of the abdominal musculature rather than a specific defect. Unfortunately, we are not in possession of imaging (computed tomography or magnetic resonance imaging) to show the position of the kidneys. Reported risk factors for transplantation-associated incisional herniation relevant to his case include the following: an ‘open’ technique of implantation; increasing recipient age; the use of mycophenolate mofetil; continued exposure to maintenance glucocorticoids and previous peritoneal dialysis. Perhaps surprisingly, dual kidney organ implantation has not previously been reported as a risk factor. Other reported predisposing factors for an incisional hernia include the use of sirolimus; wound haematoma, urinoma and lymphocele. There have been no apparent effects of his herniation on transplant function. However, it was associated with significant discomfort on standing and walking. His symptoms have been alleviated by the use of a tailored elasticated corset.