Laparoscopic treatment of incisional and primary ventral hernia in morbidly obese patients with a BMI over 35

Ludovic Marx, MD, Mahery Raharimanantsoa, MD, Stefano Mandala, MD, Antonio D’Urso, MD, Michel Vix, MD, Didier Mutter, MD, PhD, FACS. University Hospital of Strasbourg, Department of Digestive and Endocrine Surgery; IRCAD; IHU Strasbourg.

Introduction
Incisional and ventral hernias are commonly encountered surgical indications in regular surgical practice and emergency situations. Their management is associated with significant surgical site infections (SSI) (20 to 40%) and recurrence rates in open surgery (15 to 25%). Since laparoscopic surgery has been established as a standard for bariatric surgery, there was a natural trend for treating obese patients with parietal wall defects laparoscopically. The aim of our study was to evaluate the feasibility and safety and the results of the laparoscopic approach for the management of parietal wall defects in morbidly obese patients with a BMI over 35.

Method
Between March 2003 and August 2013, 334 patients were operated on laparoscopically for ventral and/or umbilical hernia, with application of a partially absorbable composite mesh. When 166 patients were obese (BMI>30kg/m2), 71 presented with severe obesity (BMI≥35kg/m2) and 8 were super-obese (BMI>50kg/m2). Patient data were prospectively acquired and retrospectively analyzed. Early and late complications were evaluated. All surgical procedures were performed in a standard fashion including composite mesh fixation (Parietex™ Composite mesh, Covidien, France), using non-absorbable transfascial suture and a single crown of tackers (AbsorbaTackTM fixation device, Covidien, France).

Results
Out of 79 patients (29 men, 50 women) treated laparoscopically, 43 presented with umbilical hernias and 36 ventral hernias. Mean patient age was 51.8 years for men and 52.7 for women. Mean BMI was 40.83kg/m2 (41.02kg/m2 for men, 40.71kg/m2 for women). Five patients were operated on in emergency. Mean postoperative hospital stay was 2 days. Postoperative pain evaluated by VAS (Visual Analog Scale) was 2.86. No intraoperative complications or death were observed. The postoperative complication rate was 7.11% (9 patients). We observed two parietal wall hematomas treated by radiological embolization, two cases of postoperative pain managed by painkillers, one postoperative obstruction for one day, one respiratory failure spontaneously resolving after two days in the ICU, one acute parietal wall defect with early reoperation at postoperative day one on the optical trocar incision site, two umbilical abscesses treated locally. Postoperative seroma rate was 16.59% (21 patients), all treated conservatively. Postoperative follow-up was 18.10 months (1-84 months) and recurrence rate was 1.58% (2 patients).

Discussion
This study confirms the feasibility and safety of the laparoscopic approach to ventral hernia in severely obese patients. SSI and recurrence rates (1.5% for each) appeared significantly lower than those currently observed in the literature (respectively 20 to 40% and 15 to 25%). The recurrence rate appeared particularly low as compared to other studies with a rate lower than 2%. Postoperative hemorrhage and trocar site hernia are specific complications of this approach. Postoperative hospital stay is significantly reduced (2 days) as compared to open surgery. The minimally invasive treatment of parietal wall defects should be considered a standard option in morbidly obese patients with specific benefits in terms of low SSI, recurrence rates, and hospital stay.