Ventral Hernia at the Time of Laparoscopic Gastric Bypass Surgery: Should It Be Repaired?

Isabelle Raiche, MD FRCSC, Fatima Haggar, MPH, Joseph Mamazza, MD FRCSC, Husein Moloo, MD MSc FRCSC, Eric C Poulin, MD MSc FRCS C, Guillaume Martel, MD FRCSC, Jean-denis Yelle, BA MD FRCSC FACS. The Minimally Invasive Surgery Research Group, The Ottawa Hospital, University of Ottawa

Objective: Despite the relatively high prevalence of ventral hernias in the morbidly obese population, there is no clear consensus regarding the optimal treatment for patients with ventral hernias who present for gastric bypass. The objective of this study was to conduct a systematic review of the current evidence to determine the most appropriate surgical management of patients found to have a ventral hernia at the time of a laparoscopic gastric bypass (LGB).

Method: Medline, Embase and Cochrane databases were searched from January 1995 to September 2010. The search strategy, prepared with experienced systematic reviewers and a librarian, included the following MESH terms: ventral hernia, abdominal hernia, laparoscopy, minimally invasive surgery, bariatric surgery, Roux en Y, and gastric bypass. The reference lists of pertinent articles were manually reviewed to ensure that no published data was missed. Outcomes of interest included post-operative bowel obstructions secondary to ventral hernia, recurrence of ventral hernia and mesh infection. Data pertaining to relevant articles were abstracted and synthesized according to accepted methods.

Results: The search identified 534 articles. After duplicate records and irrelevant studies were removed, 83 potentially relevant articles were reviewed (4 systematic reviews, 3 randomized controlled trials, 59 observational studies, 17 narrative reviews). After exclusion of reviews, case reports and any study in which fewer than 50% of patients underwent laparoscopic gastric bypass, 3 retrospective articles, with a total of 123 patients reporting on the management of ventral hernias at the time of LGB were included. Eight percent of patients undergoing LGB presented with a ventral hernia. Three management strategies were reported: deferred treatment of the hernia, primary repair or repair with biological or synthetic mesh. Up to 35.7% of patients in whom the treatment was deferred presented with SBO within 150 days. Recurrence after primary repair of the hernia varied from 22-100%. No recurrence was found in the group using biologic mesh after a follow-up of 13 months. In the group using synthetic mesh, the recurrence varied from 0-9% with a mean follow-up of 14 months. No mesh infection was reported.

Conclusion: Ventral hernia in patients considered for LGB is a complex problem. There is a paucity of high level evidence to guide clinical decisions. The available information suggests that mesh repair of the hernia at the time of bypass may be a safe and appropriate treatment option for preventing an obstruction in the perioperative period.
 

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