Mesh or no mesh: a hamletic dilemma to prevent Renal Allograft Compartment Syndrome (RACS)

Tension-free muscle closure is essential in kidney transplantation, both in adult and pediatric patients. Tight muscle closure may lead to renal allograft compartment syndrome either due to compression of the renal parenchyma or due to kinking of the renal vessels. It may also cause kinking of the transplant kidney ureter, wound dehiscence and incisional hernia. Many techniques have been proposed in an attempt to achieve tension-free closure. There is a wrong belief among surgeons that using prosthetic mesh may increase the incidence of infective complications in these immunosuppressed patients. Also, there is fear that one is not able to monitor the renal graft by ultrasound and perform biopsy in the presence of a mesh. Other alternative techniques to mesh closure include subcutaneous placement and intraperitonealization of the kidney transplant. These techniques however, are valuable when mesh closure is unfavorable or contraindicated as in case of a potential source of infection, like a stoma. Abdominal wall fasciotomy can be adjunctive to the various techniques of muscle closure.