Expanding the Abdominal Domain: Long‐Term Success of the Vascularized Posterior Rectus Sheath–Liver Composite Allograft

BACKGROUND: Achieving a tension-free abdominal wall closure in liver transplantation (LT) is challenging, particularly in the presence of donor-recipient size mismatch, prior surgeries, or loss of abdominal domain. These difficulties are amplified when expanded-criteria donor (ECD) grafts are used, as graft reduction is unsafe and prolonging cold ischemia time (CIT) is not feasible. A vascularized posterior rectus sheath (PRS) allograft, supplied via the hepatic falciform artery (HFA), offers physiological abdominal domain expansion without the infection risks associated with prosthetic meshes or non-vascularized fascia. METHODS: A retrospective review was conducted of all patients undergoing LT with a vascularized PRS allograft at our center. PRS retrieval and implantation were performed using a standardized technique. All patients received conventional immunosuppression. Recipient and donor characteristics, postoperative outcomes, and long-term follow-up were analyzed. RESULTS: Five patients (four adults, one child) received a composite liver-PRS allograft. Median donor-recipient weight ratio was 1.7 (range: 1.46-2.18). All grafts met ECD criteria. Mean CIT and warm ischemia time were 4 ± 1.01 h and 43.6 ± 9.54 min, respectively. Primary fascial closure was achieved in all patients without graft infection, abdominal wall infection, or PRS necrosis. One patient developed a rectus sheath hematoma requiring drainage, and another developed a postoperative bulge requiring plication. Median long-term follow-up of 9.1 (range: 8.38-10.63) years demonstrated durable fascial integrity. CONCLUSION: The vascularized PRS allograft is a simple, reproducible, single-stage solution for abdominal closure in LT, particularly valuable when using ECD grafts, minimizing infection risk, reexplorations, and prolonged CIT.