Ventral hernia and obesity

First submitted by:
Archana Ramaswamy
(see History tab for revisions)
Category

Introduction

Multiple consideration need to be dealt with when assessing a patient a ventral hernia, and when considering a bariatric patient with a ventral hernia.

Patient presenting for hernia evaluation who is obese

Preop considerations

Thought should be given to whether the repair can be delayed, what the best surgical approach would be, and whether or not the patient is interested in/qualifies for bariatric surgery.

Does Obesity Matter?

Commonly cited risk factors for recurrence in the obese population include technical difficulties, difficult initial access during laparoscopy, a large defect which would require a large piece of mesh, and higher peri-operative complications.

Approach for Ventral Hernia Repair in the Obese

Stoppa, components separation and laparoscopic approaches have all been described. At the time of introduction of laparoscopic ventral hernia repair technique, obesity was considered a contraindication, but its safety has been shown in numerous series.

Outcomes of various techniques

Laparoscopic

In a retrospective review of 168 patients, 42 patients had a BMI over 35. Standard laparoscopic ventral hernia repair technique was utilized with synthetic mesh. At 19 month follow-up there was a 12% recurrence rate which was influenced by the defect/mesh size. However, recurrence was not influenced by obesity.1 Another series presents  review of 27 pts with a mean BMI of 47 who underwent a standard laparoscopic ventral hernia repair. 48% underwent a concurrent laparoscopic gastric bypass, and 57% had biologic mesh placement. At 15 months follow-up, there was a 18.5% hernia recurrence rate.2 A large retrospective review of 901 patients found a 8.3% recurrence in those with BMI over 40 compared with those with a BMI <40 who had a recurrence rate of 2.9%. They noted a low morbidity but recognized the increased recurrence rate. 3 A slightly lower recurrence rate of 5.5% over 25 months was noted in a retrospective review of 163 patients with a mean BMI of 38 (range: 30-67) who underwent standard laparoscopic ventral hernia repair.4

Components Separation

A retrospective review of 30 patients with a mean BMI of 61 who underwent anterior components separation without placement of mesh notes a mean defect width of 12 cm (range: 3-55) and requirement for intestinal resections in 6 (20%) patients and panniculectomy in 16 (53%) . Of interest, Roux en Y gastric bypass was also performed concomitant with the hernia repair in 6 (20%) pts. At 44 month follow-up, 3% recurrence rate was reported.5

Rives- Stoppa repair

A retrospective review of 90 patients with a mean BMI of 40 reviews outcomes with a retromuscular repair with synthetic mesh as sublay. There was a morbidity rate of 8% and mortality rate of 1.1% with a recurrence rate of 5.5% at a follow up of 50 months.6

Staged Repair/Ventral Hernia in the Obese Patient

A retrospective review of 27 patients with a mean of BMI 51 (range: 39-69)  who underwent gastric bypass (open in 22, laparoscopic in 5) describes concurrent hernia repair being performed in 7 patients (primary in 4, biologic mesh in 3). All 7 of these hernias recurred. Following weight loss surgery, the mean BMI decreased to 33 (range 25-37), and all hernia were repaired at 1.3 years following bariatric surgery (laparoscopic ventral hernia repair in 8 (31%), Rives-Stoppa in 19 (69%)). There were no recurrences at 20 months.7 In a large review of 325 laparoscopic RYGB patients, 26 were noted to have a ventral hernias at the time of surgery. 8 patients had incarcerated omentum which was left in-situ and 8 patients underwent primary repair. Another 7 patients underwent repair with a synthetic mesh. Those who were “left alone” had no complications. Those who underwent primary repair had 25% incidence of small bowel obstruction and those with mesh repair did well without any infections. 8 In a slight variation to the above study, in a review of 85 patients undergoing gastric bypass, when adhesions were lysed within a ventral hernia and repair was deferred, small bowel obstruction occurred in 18%. 9

Conclusion

Obesity is a risk factor for hernia repair failure. Laparoscopic approach appears to be safe, though open repairs are an excellent alternative, and staged repair may improve outcomes. Ventral hernias in bariatric patient should be left alone if possible. Other options include synthetic or biologic mesh repair as primary repair seems to be associated with significant complications.

References

1. Ching SS. Sarela AI. Dexter SP. Hayden JD. McMahon MJ. Comparison of early outcomes for laparoscopic VHR between non-obese and morbidly obese patients. Surgical Endoscopy. 22(10):2244-50, 2008 Oct
2. Raftopoulos I. Courcoulas AP. Outcome of laparoscopic ventral hernia repair in morbidly obese patients with a body mass index exceeding 35 kg/m2. Surgical Endoscopy. 21(12):2293-7, 2007 Dec
3. Tsereteli Z. Pryor BA. Heniford BT. Park A. Voeller G. Ramshaw BJ. Laparoscopic ventral hernia repair (LVHR) in morbidly obese patients. Hernia. 12(3):233-8, 2008 Jun
4. Novitsky YW. Cobb WS. Kercher KW. Matthews BD. Sing RF. Heniford BT. Laparoscopic ventral hernia repair in obese patients: a new standard of care. Archives of Surgery. 141(1):57-61, 2006 Jan.
5. Chang EI. Foster RD. Hansen SL. Jazayeri L. Patti MG. Autologous tissue reconstruction of ventral hernias in morbidly obese patients. Archives of Surgery. 142(8):746-9; discussion 749-51, 2007 Aug.
6. Moore M. Bax T. MacFarlane M. McNevin MS. Outcomes of the fascial component separation technique with synthetic mesh reinforcement for repair of complex ventral incisional hernias in the morbidly obese. American Journal of Surgery. 195(5):575-9; discussion 579, 2008 May
7. Newcomb WL. Polhill JL. Chen AY. Kuwada TS. Gersin KS. Getz SB. Kercher KW. Heniford BT. Staged hernia repair preceded by gastric bypass for the treatment of morbidly obese patients with complex ventral hernias. Hernia. 12(5):465-9, 2008 Oct
8. Datta T. Eid G. Nahmias N. Dallal RM. Management of ventral hernias during laparoscopic gastric bypass. Surgery for Obesity & Related Diseases. 4(6):754-7, 2008 Nov-Dec
9. Eid GM. Mattar SG. Hamad G. Cottam DR. Lord JL. Watson A. Dallal RM. Schauer PR. Repair of ventral hernias in morbidly obese patients undergoing laparoscopic gastric bypass should not be deferred. Surg Endosc. 18(2):207-10, 2004 Feb
10.Yuri Novitsky, M.D.Ventral Hernia in the Morbidly Obese Patient –Timing of Repair / Role of Weight Loss Surgery /Hernia During Weight Loss Surgery. Challenging Hernias Post Graduate Course. 12th World Congress of Endoscopic Surgery. April 15th, 2010.