Laparoscopic ventral hernia repair (LVHR) in morbidly obese patients

Association of Metabolic Derangement and Postoperative Outcomes in Hernia Repair With Component Separation: A Propensity Score-matched Nationwide Analysis

INTRODUCTION

Metabolic syndrome (MetS) is characterized by cardiometabolic abnormalities such as hypertension, obesity, diabetes, or dyslipidemia. This study aims to evaluate the association of MetS on the postoperative outcomes of ventral, umbilical, and epigastric hernia repair using component separation.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent ventral, umbilical, and epigastric hernia repair with component separation between 2015 and 2021. MetS status was defined as patients receiving medical treatment for diabetes mellitus and hypertension, with a body mass index greater than 30 kg/m2. Propensity matching was performed to generate two balanced cohorts with and without MetS. T-tests and Fisher's Exact tests assessed group differences. Logistic regression models evaluated complications between the groups.

RESULTS

After propensity score matching, 3930 patients were included in the analysis, with 1965 in each group (MetS versus non-MetS). Significant differences were observed in the severity and clinical presentation of hernias between the groups. The MetS cohort had higher rates of incarcerated hernia (39.1% versus 33.2%; P < 0.001), and recurrent ventral hernia (42.7% versus 36.5%; P < 0.001) compared to the non-MetS cohort. The MetS group demonstrated significantly increased rates of renal insufficiency (P = 0.026), unplanned intubation (P = 0.003), cardiac arrest (P = 0.005), and reoperation rates (P = 0.002) than the non-MetS cohort. Logistic regression models demonstrated higher likelihood of postoperative complications in the MetS group, including mild systemic complications (OR 1.25; 95%CI 1.030-1.518; P = 0.024), severe systemic complications (OR 1.63; 95%CI 1.248-2.120; P < 0.001), and reoperation (OR 1.47; 95%CI 1.158-1.866; P = 0.002). There were no significant differences in the rates of 30-d wound complications between groups.

CONCLUSIONS

The presence of metabolic derangement appears to be associated with adverse postoperative medical outcomes and increased reoperation rates after hernia repair with component separation. These findings highlight the importance of optimizing preoperative comorbidities as surgeons counsel patients with MetS.

A Ventral Hernia Management Pathway; A "Getting It Right First Time" approach to Complex Abdominal Wall Reconstruction

INTRODUCTION

Abdominal wall reconstruction (AWR) is an emerging specialty, involving complex multi-stage operations in patients with high medical and surgical risk. At our hospital, we have developed a growing interest in AWR, with a commitment to improving outcomes through a regular complex hernia MDT. An MDT approach to these patients is increasingly recognized as the path forward in management to optimize patients and improve outcomes.

METHODS

We conducted a literature review and combined this with our experiential knowledge of managing these cases to create a pathway for the management of our abdominal wall patients. This was done under the auspices of GIRFT (Getting It Right First Time) as a quality improvement project at our hospital.

RESULTS

We describe, in detail, our current AWR pathway, including the checklists and information documents we use with a stepwise evidence and experience-based approach to identifying the multiple factors associated with good outcomes. We explore the current literature and discuss our best practice pathway.

CONCLUSION

In this emerging specialty, there is limited guidance on the management of these patients. Our pathway, the "Complex Hernia Bundle," currently provides guidance for our abdominal wall team and may well be one that could be adopted/adapted by other centers where challenging hernia cases are undertaken.

Preoperative optimization in hernia surgery: are we really helping or are we just stalling?

BACKGROUND

Managing patients with abdominal wall hernias and multiple comorbidities can be challenging because these patients are at increased risk for postoperative complications. Preoperative optimization has been used to identify and intervene upon modifiable risk factors to improve hernia repair outcomes, however, waiting to achieve optimization may cause unnecessary delays.

METHODS

We describe our approach to preoperative optimization in hernia and we review the current evidence for preoperative optimization.

CONCLUSION

Modifying risk factors before undergoing elective hernia repair can improve the overall health of patients with multiple comorbidities. However, when considering the hernia-specific data, prolonging waiting times for patients to achieve full optimization is not justified. Surgeons should take a nuanced approach to balance achieving patient optimization without unnecessarily delaying surgical care.

Descriptive Analysis of Outcomes After Onlay Ventral Hernia Repair in Obese Patients

OBJECTIVE

To determine outcomes after on lay large ventral hernia repair in obese patients.

INTRODUCTION

Large ventral hernia repairs (VHR) in obese patients remain a challenge. Obesity is a risk factor for intraoperative difficulties and postoperative complications. Recurrence rates after VHR in obese patients range between 12-50% versus 10% in nonobese patients. While results of laparoscopic techniques in VHR compare favorably to open, outcomes in correlation with obesity, technique, and defect size are less understood.

METHODS

A single surgeon's experience of 329 consecutive VHR between 2013-2022 was retrospectively reviewed. Inclusion criteria were obesity (BMI >30) and large hernia defects (>5 cm). A modified onlay technique was used which included component release and a lightweight monofilament polypropylene mesh. Primary outcome measures were hernia recurrence and wound complications.

RESULTS

A total of 56 patients met inclusion criteria. Patients were majority male (n=30, 54%), with a median age of 58.5 years (inter quartile range (IQR) 33-83), and median BMI of 36 kg/m2 (IQR: 30-72). Median hernia defect size was 8 cm (IQR: 5-15). Twenty patients had undergone prior mesh repairs. Median follow-up was 52 months (IQR: 6 months-9 years). Two patients experienced recurrence (3.6%) and four experienced wound complications (four seromas, one panniculitis, 8.9%). No patients suffered flap ischemia or necrosis.

CONCLUSION

Obesity is a risk factor for poor outcomes after VHR. We developed a protocol for obese patients with large defects involving a modified onlay technique which demonstrates comparable results to other VHR techniques in obese patients.

Body Mass Index Effect on Minimally Invasive Ventral Hernia Repair: A Systematic Review and Meta-analysis

PURPOSE

Obesity is one of the most important risk factors for complications after ventral hernia repair (VHR), and minimally invasive (MIS) techniques are preferred in obese patients as they minimize wound complications. It is common practice to attempt weight loss to achieve a specific body mass index (BMI) goal; however, patients are often unable to reach it and fail to become surgical candidates. Therefore, we aim to perform a meta-analysis of studies comparing outcomes of obese and nonobese patients undergoing laparoscopic or robotic VHR.

PATIENTS AND METHODS

A literature search of PubMed, Scopus, and Cochrane Library databases was performed to identify studies comparing obese and nonobese patients undergoing MIS VHR. Postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics.

RESULTS

A total of 6483 studies were screened and 26 were thoroughly reviewed. Eleven studies and 3199 patients were included in the meta-analysis. BMI >40 kg/m 2 cutoff analysis included 5 studies and 1533 patients; no differences in hernia recurrence [odds ratios (OR): 1.64; 95% CI: 0.57-4.68; P = 0.36; I2 = 47%), seroma, hematoma, and surgical site infection (SSI) rates were noted. BMI >35 kg/m 2 cutoff analysis included 5 studies and 1403 patients; no differences in hernia recurrence (OR: 1.24; 95% CI: 0.71-2.16; P = 0.58; I2 = 0%), seroma, hematoma, and SSI rates were noted. BMI >30 kg/m 2 cutoff analysis included 4 studies and 385 patients; no differences in hernia recurrence (OR: 2.07; 95% CI: 0.5-8.54; P = 0.32; I2 = 0%), seroma, hematoma, and SSI rates were noted.

CONCLUSION

Patients with high BMI undergoing MIS VHR have similar hernia recurrence, seroma, hematoma, and SSI rates compared with patients with lower BMI. Further prospective studies with long-term follow-up and patient-reported outcomes are required to establish optimal management in obese patients undergoing VHR.

Obesity Stratification Predicts Short-Term Complications After Parastomal Hernia Repair

INTRODUCTION

While previous studies have documented adverse outcomes among obese patients undergoing ventral and inguinal hernia repairs, there is a lack of literature regarding the impact of obesity on parastomal hernia (PSH) repair. This retrospective study aims to determine the value of obesity stratification in predicting postoperative complications in patients undergoing PSH repair.

MATERIALS AND METHODS

Outcomes of elective PSH repairs from 2010 to 2020 in the American College of Surgeons National Surgical Quality Improvement Program database were analyzed. Patient demographics, preoperative characteristics, and postoperative outcomes were compared using bivariate analysis and multivariable regression models.

RESULTS

A total of 2972 patients were retrospectively analyzed. Multivariable regression found, compared to nonobese patients, patients of obesity class ≥ II were 1.37 times more likely to develop complications overall (P = 0.006) and 1.55 times more likely to develop wound complications (P < 0.001). This group also yielded a 1.60 times higher risk of developing superficial wound infection (P = 0.007) and a 1.63 times greater risk of developing postoperative sepsis (P = 0.044). Total length of stay was longer for patients of obesity class ≥ II but not for obesity class I when compared to patients with body mass index <30.0 kg/m².

CONCLUSIONS

Patients with a body mass index ≥35.0 kg/m² are more susceptible to an increased rate of complications after PSH repairs. The findings of this study will allow surgeons to stratify obese patients who would benefit from preoperative weight loss interventions prior to PSH repair and discuss associated risks with patients to facilitate informed consent.

Body Mass Index impact on Extended Total Extraperitoneal Ventral Hernia Repair: a comparative study

PURPOSE

Obesity is a risk factor for developing abdominal wall hernias and is associated with major postoperative complications, such as surgical site infection, delayed wound healing and recurrent hernia. Therefore, treating incisional hernia in this patient subgroup is a challenge.

METHODS

We conducted a comparative, prospective study on patients who underwent primary ventral hernia surgery or incisional hernia surgery through the extended totally extraperitoneal pathway, with body mass indices (BMIs) ≤ 30 (no obesity) and BMI > 30 (with obesity). We collected demographic data, preoperative and intraoperative variables, complication and recurrence rate, hospital stay and follow-up as postoperative data.

RESULTS

From May 2018 to December 2020, 74 patients underwent this surgery, 38 patients without obesity and 36 with obesity. The median area of the hernia defect measured by CT was 57 cm² and 93 cm² in patients without and with obesity, respectively (p = 0.012). The median follow-up was 16 months. One patient without obesity experienced some postoperative complication compared with four patients with obesity (p > 0.05). No patient without obesity had recurrent hernia compared with two patients with obesity (p > 0.05).

CONCLUSIONS

There were statistically significant differences between patients with and without obesity in the size of the hernia defect. However, there were no significant differences in terms of complications, hospital stay, postoperative pain or relapses. Therefore, the minimally invasive completely extraperitoneal approach for patients with obesity appears to be a safe procedure despite our study limitations. Studies with longer follow-ups and a greater number of patients are needed.

"Slim-Mesh" Technique for Giant Ventral Hernia

Background and Objective:

We devised a sutureless “Slim-Mesh” technique to treat ventral hernias, including large-giant/massive ones, reduce intra- and postoperative complications, and lower operation time.

Methods:

Between September 1, 2009 and October 31, 2020, 43 patients with large (10 – 14.9 cm)-giant (15 – 19.9 cm) and massive (≥ 20 cm) ventral hernia were operated at our Department with the above technique. This was a prospective (79%)-retrospective study.

Results:

This study comprised 22 males and 21 females. Mean age was 63 years. Large-giant and massive hernias were found intraoperatively in 37 and 6 cases respectively. Mean operation time for all hernias was 116 minutes, 104 for large-giant hernias, and 190 for massive. In 53.4% of cases, hernia-neck operative measurement was larger than preoperative size. In 25.5% of cases, laparoscopy found satellite hernias previously undetected by ultrasound- and/or computed tomography scan. A composite mesh and a noncomposite mesh were used in 95% and 5% of cases respectively. For mesh fixation, titanium tacks and absorbable straps were used in 14% and 86% of cases respectively. Mean length of hospital stay was 2.3 days. Mean follow-up time was 3 years and 4 months. In our study, there were 5 early postoperative complications: 3 seromas, 1 trocar-site hernia, and 1 case of cystitis. We found 2 late small symptomless recurrences (4.6%).

Conclusion:

The sutureless “Slim-Mesh” technique facilitates intra-abdominal introduction, as well as the handling and fixation of giant and monster (36 × 26 cm) meshes. In our experience, “Slim-Mesh” is safe, simple, and fast, and economical even for large-giant/massive ventral hernia repair.

Ventral Hernia Repair and Obesity: Results from a Nationwide Register Study in France According to the Timeframes of Hernia Repair and Bariatric Surgery

PURPOSE

Several strategies are suggested for ventral hernia repair (VHR) in bariatric candidates, in terms of timing and technique. The aim was to describe practices in VHR in bariatric patients on a nationwide scale in France.

MATERIALS AND METHODS

We used the prospective national hospital discharge summaries database system to conduct a retrospective cohort study. We included patients operated once for sleeve or bypass, between 2007 and 2018, and who had VHR concomitant with bariatric surgery (BS) or within 2 years before or after.

RESULTS

Among 11,680 eligible patients, 2039 underwent VHR in the 2 years before BS, 3388 had concomitant BS and VHR, and 6260 patients had VHR within 2 years after BS. Patients who underwent a concomitant surgery presented a higher suture repair rate (86.1% versus 37.1% and 44.0%, P < 0.001). Overall recurrence of VH at 10 years was 23.3% and was higher for patients who underwent VHR first (36.2%) than patients who underwent BS first (24.5%) and the concomitant group (18.6%), P < 0.001. Major complication rate was 11.1%, 7.8%, and 16.9% (P < 0.001) for VHR-first, concomitant, and BS-first groups, respectively. Mesh infection was found in 0.6% (13/2039) of patients in the VHR-first group, in 0.6% (20/3388) in the concomitant group, and in 1.1% (68/6260) in the BS-first group (P < 0.001).

CONCLUSION

About one-quarter of bariatric patients undergoing VHR will be reoperated for an anterior hernia. VHR before BS entailed a higher risk of reoperation for recurrence and should be avoided. A concomitant repair entailed the lowest rate of recurrence.

Abdominal Panniculectomy Can Simplify Kidney Transplantation in Obese Patients

BACKGROUND

Obesity is frequently present in patients suffering from end-stage renal disease (ESRD). However, overweight kidney transplant candidates are a challenge for the transplant surgeon. Obese patients tend to develop a large abdominal panniculus after weight loss creating an area predisposed to wound-healing disorders. Due to concerns about graft survival and postoperative complications after kidney transplantation, obese patients are often refused in this selective patient cohort. The study aimed to analyze the effect of panniculectomies on postoperative complications and transplant candidacy in an interdisciplinary setting.

METHODS

A retrospective database review of 10 cases of abdominal panniculectomies performed in patients with ESRD prior to kidney transplantation was conducted.

RESULTS

The median body mass index was 35.2 kg/m2 (range 28.5-53.0 kg/m2) at first transplant-assessment versus 31.0 kg/m2 (range 28.0-34.4 kg/m2) at panniculectomy, and 31.6 kg/m2 (range 30.3-32.4 kg/m2) at kidney transplantation. We observed no major postoperative complications following panniculectomy and minor wound-healing complications in 2 patients. All aside from 1 patient became active transplant candidates 6 weeks after panniculectomy. No posttransplant wound complications occurred in the transplanted patients.

CONCLUSION

Abdominal panniculectomy is feasible in patients suffering ESRD with no major postoperative complications, thus converting previously ineligible patients into kidney transplant candidates. An interdisciplinary approach is advisable in this selective patient cohort.

Laparoscopic ventral hernia repair in patients with obesity: should we be scared of body mass index?

BACKGROUND

Obesity is a risk factor for ventral hernia development and affects up to 60% of patients undergoing ventral hernia repair. It is also associated with a higher rate of surgical site occurrences and an increased risk of recurrence after ventral hernia repair, but data is lacking on the differences between obesity classes.

METHODS

Between 2008 and 2018, 322 patients with obesity underwent laparoscopic ventral hernia repair in our department: class I n = 231 (72%), II n = 55 (17%), III n = 36 (11%). We compared short and long-term outcomes between the three classes.

RESULTS

Patients with class III obesity had a longer median length of hospital stay compared to I and II (5 days versus 4 days in the other groups, p = 0.0006), but without differences in postoperative complications or surgical site occurrences. After a median follow up of 49 months, there were no significant differences in the incidence of seroma, recurrence, chronic pain, pseudorecurrence and port-site hernia. At multivariate analysis, risk factors for recurrence were presence of a lateral defect and previous hernia repair; risk factors for seroma were immunosuppression, defect > 15 cm and more than one previous hernia repair; the only risk factor for postoperative complications was chronic obstructive pulmonary disease.

CONCLUSION

Class III obesity is associated with longer length of hospital stay after laparoscopic ventral hernia repair, but without differences in postoperative complications and long-term outcomes compared with class I and class II obesity.

Ventral hernia repair in bariatric patients

Morbid Obesity is increasing worldwide at fast pace with associated co-morbidities also on the rise. Considering that Obesity is one of the main risk factors for developing a Ventral Hernia this will results that in the future we will experience a rise in those hernia in patients undergoing any abdominal surgery. There is no clarity on the best timing and choice for procedures. We are well aware also on the difficulties in hernia repair surgery and the relative outcome so adding obesity as co-factors amplify the challenges. In fact, today both general surgeons with expertise in abdominal wall repair and bariatric surgeons are faced with a new dilemma: the obese patient with an abdominal wall hernia. This article will briefly review the impact of obesity on the natural history of hernia, its associated complication, management strategies and outcome.

Management of ventral hernia in patients with BMI > 30 Kg/m2: outcomes based on an institutional algorithm

INTRODUCTION

Management of ventral hernia in obese is a complex problem. The methods of weight loss, alternatives if the patient cannot undergo bariatric surgery, timing, and type of hernia surgery lacks clarity and are dependent on resources and expertise. There is a need for algorithms based on local population and expertise. In this paper, we present the outcomes of our institutional algorithm.

METHODS

It was a retrospective analysis of prospectively collected data. Patients with body mass index (BMI) > 30Kg/m² were included to undergo surgery as per algorithm taking into account (a) presentation (symptomatic vs asymptomatic), (b) hernia characteristics (defect width, site, reducibility), and (c) obesity characteristics (BMI, subcutaneous fat, android vs gynecoid). Data on age, BMI, comorbidities, tobacco consumption, hernia width, location, contents, previous surgery, intraoperative parameters (the type of surgery, mesh, drain, fixation), and outcomes (seroma, hematoma, infection, recurrence) were collected.

RESULTS

A total of 50 patients underwent treatment as per the algorithm. Mean BMI was 36.6 ± 7.3 kg/m². The mean follow-up was 17.6 ± 7.2 months. The mean defect width was 4.8 ± 2.9 cm. There were two (4%) recurrences in patients who underwent an anatomical repair under emergency conditions. None of the patients who underwent an elective repair had a recurrence. Total surgical site occurrence was 12% and surgical site occurrence requiring procedural intervention was 8%. There was one (2%) mortality on postoperative day 7 due to myocardial infarction.

CONCLUSION

The algorithm has shown encouraging results in the short-to-medium term. Long-term evaluation with a higher number of patients is needed to confirm its usefulness.

Outcomes of Open Retro-Rectus Hernia Repair With Mesh in Obesity Class III

BACKGROUND

Abdominal wall hernias continue to be one of the most common general surgery pathologies. Patients with an elevated body mass index (BMI) are routinely counseled about weight loss before elective repair. However, a definitive BMI "cutoff" has not been established. Here, we report our experience with open retro-rectus hernia repair (ORRHR) with mesh in patients with a BMI over 40 kg/m², and we attempt to determine if a BMI "cutoff" can be established.

METHODS

Data from patients undergoing ORRHR with mesh at Geisinger Medical Center from January 1, 2014, to December 31, 2018, were collected and retrospectively analyzed.

RESULTS

Cohorts were composed of 2 groups, BMI ≥ 40 kg/m² (n = 117) and BMI < 40 kg/m² (n = 90). All patients underwent an elective ORRHR with mesh. Operative time increased significantly as the patient's BMI increased (P ≤ .01). Patients in the higher BMI group had a significantly higher rate of surgical site infections (SSIs) (8.55% vs. 1.1%, P = .018). Higher BMI did not translate to a higher recurrence rate.

CONCLUSIONS

Patients undergoing ORRHR with mesh who had a BMI over 40 kg/m² had an increased risk of SSI and longer operative time, possibly suggesting a potential association other than SSI and BMI. More studies are needed to determine if BMI is indeed correlated with hernia recurrence and if BMI should influence the decision to undergo repair.

Obesity and Ventral Hernia Repair: Is There Success in Staging?

Introduction: Obesity predisposes patients to the development of abdominal wall hernias. Ventral hernia incidence, size, and recurrence rate are all increased in this population. As such, the surgeon is likely to encounter patients presenting for metabolic and bariatric surgery with existing ventral hernias. Controversy persists regarding the algorithm for treatment in this situation. Do we wait to repair, or is the weight inconsequential? Materials and Methods: We critically reviewed the available literature accessed through PubMed on the repair of ventral hernias in the obese population. Specifically, we focused on the outcomes after staged repair versus concurrent repair at the time of bariatric surgery. We aim at providing an overview of the conclusions from past and present publications with commentary by the authors. Results: A review of the literature finds conflicting opinions regarding the safety and success of concurrent ventral hernia repair at the time of bariatric surgery. Obese patients frequently have complex hernias and are predisposed to poor wound healing and increased recurrence. Although some small studies find success with concurrent repair, large registry analyses as well as expert consensus statements advocate for staged repair. Conclusion: For the obese patient with large ventral hernia, the authors recommend a staged approach, beginning with bariatric surgery and deferring the hernia repair until significant weight loss is obtained. The exception exists, and each patient must be evaluated critically regarding hernia size, contents, and risk of obstruction if left untreated.

Operating on the Edge? Body Contouring Procedures in Patients with Body Mass Index Greater 35

BACKGROUND

Body contouring surgery after massive weight loss was shown to ameliorate the patient's quality of life and to enhance physical and psychological well-being. However, numerous patients are still obese when presenting for body contouring surgery, not able to lose additional weight for various reasons. Data regarding general feasibility, outcome, and postoperative complications in obese patients is rare. The aim of this study was to investigate the outcome in body contouring procedures in obese patients.

METHODS

A retrospective chart review of 65 cases in 42 patients was performed. Patients with a body mass index (BMI) > 35 kg/m² at the time of operation were enrolled and all different types of body contouring surgery were included. Complications were classified as major (need for surgical intervention) and minor complications.

RESULTS

The median BMI of all patients was 38 kg/m² (range 35.1-65.1 kg/m²). The majority of performed types of body contouring was abdominal body contouring (panniculectomy n = 27 (42%), abdominoplasty n = 12 (18%)). Complications occurred in 27 cases (41.5%). Twenty-one cases (32.3%) were classified as minor complications, six (9.2%) as major complications. The most common major complications were hematoma and wound dehiscence; the most common minor complication was seroma.

CONCLUSION

A reasonable risk for complications is well known in body contouring surgery especially in obese patients. It is imperative to discuss related risks and expected results. Taking several points into account concerning the perioperative management, reduction of major complications is possible even in still obese patients, making body contouring surgery a discussible option.

Expectant Management of Patients with Ventral Hernias: 3 Years of Follow-up

BACKGROUND

The safety and effectiveness of expectant management (e.g., watchful waiting or initially managing non-operatively) for patients with a ventral hernia is unknown. We report our 3-year results of a prospective cohort of patients with ventral hernias who underwent expectant management.

METHODS

A hernia clinic at an academic safety-net hospital was used to recruit patients. Any patient undergoing expectant management with symptoms and high-risk comorbidities, as determined by a surgeon based on institutional criteria, would be included in the study. Patients unlikely to complete follow-up assessments were excluded from the study. Patient-reported outcomes were collected by phone and mailed surveys. A modified activities assessment scale normalized to a 1-100 scale was used to measure results. The rate of operative repair was the primary outcome, while secondary outcomes include rate of emergency room (ER) visits and both emergent and elective hernia repairs.

RESULTS

Among 128 patients initially enrolled, 84 (65.6%) completed the follow-up at a median (interquartile range) of 34.1 (31, 36.2) months. Overall, 28 (33.3%) patients visited the ER at least once because of their hernia and 31 (36.9%) patients underwent operative management. Seven patients (8.3%) required emergent operative repair. There was no significant change in quality of life for those managed non-operatively; however, substantial improvements in quality of life were observed for patients who underwent operative management.

CONCLUSIONS

Expectant management is an effective strategy for patients with ventral hernias and significant comorbid medical conditions. Since the short-term risk of needing emergency hernia repair is moderate, there could be a safe period of time for preoperative optimization and risk-reduction for patients deemed high risk.

Enterocutaneous fistula occurring 10 years after an open umbilical hernia repair with placement of an onlay polypropylene mesh: A case report

•

An enterocutaneous fistula is a rare complication that can arise many years after an umbilical hernia repair.

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Recurrence of the hernia may be a predisposing factor leading to mesh erosion into the underlying structures.

•

Modification of repair technique and mesh type and location may aid in reducing the incidence of an enterocutaneous fistula.

Introduction

Ventral hernia repair is a common surgical procedure performed within the specialty of general surgery. Short and long term complications can arise after this procedure. Although rare, an enterocutaneous fistula may occur, leading to a significant morbidity and the possible need for surgical intervention.

Presentation of case

We present a rare case of a 76 years old female, who presented with the sudden occurrence of an enterocutaneous fistula arising ten years after a primary umbilical hernia repair with placement of a polypropylene onlay mesh. She was also found to have a large recurrent umbilical hernia. She underwent a laparotomy with the identification of a mesh eroding into the small bowel lumen, causing an enterocutaneous fistula. An enterectomy was performed to remove the fistula with the mesh, and a small bowel anastomosis was created.

Discussion

Ventral hernia recurrence is associated with risk factors including old age, obesity, wound infection as well as the type and location of the mesh used. As in this case, enterocutaneous fistula after hernia repair can occur due to multiple factors including mesh migration and erosion into near-by structures including bowel. These risk factors can perhaps be modified to possibly reduce the incidence of complications like an enterocutaneous fistula.

Conclusion

The case highlights a rare but serious complication associated with a ventral hernia repair. It also addresses key aspects with regards to the possible mechanisms involved in the occurrence of an enterocutaneous fistula following a hernia repair with the use of a synthetic mesh.

Propensity score matching analysis of short-term outcomes in robotic ventral hernia repair for patients with a body mass index above and below 35 kg/m2

OBJECTIVE

The purpose of this study was to compare perioperative complications after robotic ventral hernia repair between patients with non-obese, class-I obesity with those with class-II or class-III obesity.

BACKGROUND

Obesity is a growing epidemic and is considered as an independent risk factor for a multitude of perioperative complications. Laparoscopic ventral hernia repair has been shown as a safe and feasible approach in population with elevated body mass index (BMI). This study compared overall perioperative complications and surgical site events (SSEs) after robotic ventral hernia repair (RVHR) between patients with a BMI 35 kg/m² or more and patients with a BMI lower than 35 kg/m².

METHODS

A retrospective cohort analysis was conducted with one-to-one propensity score matching (PSM) method to obtain balanced groups evaluating patients who underwent RVHR between February 2012 and June 2019 in a single institution. Preoperative, intraoperative, and postoperative variables were reviewed. Postoperative complications and morbidity were assessed using the Clavien-Dindo classification and comprehensive complication index (CCI^®) score system. SSEs were compared.

RESULTS

Our unmatched sample included 526 patients with an average BMI of 31.2 kg/m². Of these, 29.8% (n = 160) patients were in high-BMI group (range 35-59.2). After PSM, 142 patients were assigned to each group. Both groups experienced similar complication rates during 90 days. Clavien-Dindo grades, CCI^® scores, and SSEs did not differ between the two groups.

CONCLUSION

RVHR in class-II and class-III obese patients is safe, feasible, and effective. In addition to this, it has comparable short-term outcomes with those non-obese and class-I obese patients.

Robotic ventral hernia repair: a safe and durable approach

BACKGROUND

Short-term success following robotic-assisted ventral hernia repair (RVHR) is well established; however, data describing outcomes after the first year are limited. In this study, we followed a cohort of patients with an average of 1.8 years of follow-up to demonstrate the durability of this technique and examine risk factors for recurrence.

METHODS

A retrospective analysis of RVHR performed by a single surgeon from 2012 to 2016 was done. The technical approach for hernia repair consisted of tension-free primary fascial closure with placement of preperitoneal mesh when possible. The primary end point of hernia recurrence was determined based on physical examination or imaging documented in the medical record. A logistic regression model was used to identify patient risk factors for recurrence.

RESULTS

One hundred and eight RVHRs were performed over 4 years. Mean age was 52.72 ± 13.61 years, BMI was 33.07 ± 7.82 kg/m², and hernia defect size was 70.1 ± 86.3 cm². In terms of patient characteristics, 17.6% of patients were diabetic, 13.9% were smokers preoperatively, 72.2% were ASA class 3 or higher, and 29.6% had prior VHR. Primary fascial closure was achieved in all RVHRs, with 23.1% requiring component separation. Mesh was used in 97.2% of patients: 79.5% had preperitoneal mesh and 17.6% had intraperitoneal onlay mesh. Ninety-eight percent of patients had long-term follow-up at a mean of 625.6 days. Recurrence rate was 12%, with one recurrence attributed to an inguinal hernia fixed concurrently with a midline defect. There were no statistically significant differences in gender, age, BMI, ASA class, incidence of diabetes, smoking status, or number of previous hernia repairs. Hernia defect size and perioperative complications including SSO, ileus, obstruction, or any other medical complication were not predictive of recurrence. Technical approach did not affect outcomes.

CONCLUSION

RVHR is safe and durable with a low recurrence rate at a mean of 21 months postoperatively. Patient characteristics or type of repair were not predictive of recurrence.

[Analysis of the causes of recurrent postoperative ventral hernias]

OBJECTIVE

To study the causes of recurrent postoperative ventral hernias and methods for their prevention.

MATERIAL AND METHODS

There were 58 patients with recurrent postoperative ventral hernias after various methods of abdominal wall repair for the period 2005-2017.

RESULTS

The main causes of recurrent postoperative ventral hernias were identified. Local tissue rearrangement resulted recurrent hernia in 21 (36.2%) patients, that was observed even in patients with small hernia. Size discrepancy between endoprosthesis and hernial orifice caused a recurrence in 20 (34.5%) patients. In 11 (19%) patients, implant detachment followed by recurrent hernia occurred. Postoperative wound complications followed by recurrent hernia were diagnosed in 6 (10.3%) patients. Non-compliance with recommendations for wearing a bandage and restricting physical exertion also contributed to the development of recurrent hernia. Moreover, recurrent hernia occurred mainly in obese patients. Mean body mass index was 34.27±2.2 kg/m². Recurrent hernia was again detected in 12 out of 35 patients in long-term period after surgical treatment.

CONCLUSION

It is necessary to abandon local tissue rearrangement and to select a correct size of synthetic material for prevention of recurrent postoperative hernia. Preoperative body weight control is essential in patients with obesity. Wearing a bandage and restricting physical exertion are obligatory in postoperative period. Annual examination during 3-5 years after surgery is essential for timely diagnosis of recurrent hernia.

Robotic ventral hernia repair in morbidly obese patients: perioperative and mid-term outcomes

BACKGROUND

Obesity is a growing epidemic and it has been found to be an independent risk factor for a multitude of perioperative complications. We describe our experience with morbidly obese patients who underwent robotic ventral hernia repair (RVHR), examining factors affecting perioperative and mid-term outcomes.

METHODS

From a prospectively maintained database, all morbid obese (BMI ≥ 40 kg/m²) patients who underwent robotic procedures between 2013 and 2018 were analyzed retrospectively including perioperative outcomes and the mid-term follow-up. Complications were assessed with validated grading systems and index. Univariate analyses and multivariate logistic regression analysis were performed to determine the factors associated with the development of any complication. Kaplan-Meier's time-to-event analysis was performed to calculate freedom-of-recurrence.

RESULTS

Fifty patients with median BMI 42.9 kg/m² were included. The median last pain score before leaving PACU was 4. The mean LOS of all cohorts was 0.32 day. The postoperative complication rate was 46%. The most frequent complication was persistent pain/discomfort (32%) in early postoperative period. Minor complications (Clavien-Dindo grade-I and II) were seen in 40% of patients while major complications (Clavien-Dindo grade-III and IV) were seen in 6%. The maximum comprehensive complication index® score was 42.9. In regression analysis, BMI, adhesiolysis, intraperitoneal mesh placement, and off-console time were found to be significantly associated with postoperative complications. Mean follow-up was 22.7 months. Hernia recurrence was seen in 2% and the mean freedom-of-recurrence was 57.4 months (95% CI 54.6-60.2).

CONCLUSIONS

To our best knowledge, this study is the first to present outcomes of morbidly obese patients who underwent RVHR. The results indicate the safety and efficacy of RVHR in morbid obesity with a low recurrence rate as well as a long freedom-of-recurrence time. Further studies are needed to better elucidate the role of robotic surgery in morbidly obese patients.

Impact of body mass index on minimally invasive ventral hernia repair: an ACS-NSQIP analysis

PURPOSE

Body mass index (BMI) ≥ 35 kg/m² is a known independent risk factor for complications following open ventral hernia repair (VHR). We sought to examine the relationship between BMI and minimally invasive VHR.

METHODS

The ACS-NSQIP database was queried for all patients age ≥ 18 years undergoing minimally invasive VHR (2005-2015). Patients were stratified into seven BMI classes: underweight (BMI < 18.5 kg/m²), normal weight (BMI 18.5-24.9), overweight (25-29.9), obese (30-34.5), severely obese (35-39.9), morbidly obese (40-49.9), and super obese (BMI ≥ 50), as well as by hernia type (reducible vs. strangulated) and time of repair (initial vs. recurrent). Multivariate logistic regression was employed to assess the risk of complication by BMI class.

RESULTS

A total of 55,180 patients met inclusion criteria, and 61.4% had a BMI > 30 kg/m². When stratified by BMI class, we found significant differences in age, gender, race, comorbidities, and pre-operative characteristics across groups. The overall complication rate was 4.0%, ranging from 3.0% for normal BMI patients, to 6.9% for patients with a BMI ≥ 50 kg/m². Recurrent repairs and strangulated hernias both demonstrated higher complication rates. All complications (surgical and medical) were significantly associated with BMI class after adjustment (p < 0.0001). Patients with a BMI ≥ 50 kg/m² had a 1.4 times greater risk for complications than patients with normal BMIs (18-24.9 kg/m², p = 0.01).

CONCLUSION

BMI ≥ 50 kg/m² was determined to be an independent risk factor for surgical and medical complications after minimally invasive VHR.

Long-term clinical experience with laparoscopic ventral hernia repair using a ParietexTM composite mesh in severely obese and non-severe obese patients: a single center cohort study

Background: The treatment of incisional and ventral hernias is associated with significant complications and recurrences, especially in severely obese patients. Recent studies have shown a reduced rate of surgical site infections and length of hospital stay in severely obese patients undergoing a laparoscopic ventral hernia repair.Aim: This study aims to describe the clinical experience in terms of efficacy and safety with laparoscopic ventral hernia repair using the ParietexTM Composite mesh (Covidien Sofradim Production, Trevoux, France) in severely obese patients (body mass index ≥35) compared with non-severe obese patients in a seven-year single-center cohort.Material and methods: All patients with a primary ventral or incisional hernia admitted to our hospital from 2006 until December 2012 who underwent a laparoscopic repair with the Parietex Composite mesh were included in this study. Pain scores using a numeric rating were collected prospectively 24-48 hours postoperatively. Patient data were retrospectively collected.Results: A total number of 210 patients were included; 173 with a BMI <35 and 37 with a BMI ≥35. Mean follow-up was 31 months. No statistically significant differences were found with regard to operation time, hospital stay, use of analgesics and postoperative complications. The long-term follow up recurrence rate in non-severely obese patients was 13% compared to 16% in severely obese patients (p = .60).Conclusion: Laparoscopic ventral and incisional hernia repair using the Parietex Composite mesh is feasible and safe in severely obese patients compared to non-severely obese patients.

The Impact of Body Mass Index on Abdominal Wall Reconstruction Outcomes: A Comparative Study

BACKGROUND

Obesity and higher body mass index may be associated with higher rates of wound healing complications and hernia recurrence rates following complex abdominal wall reconstruction. The authors hypothesized that higher body mass indexes result in higher rates of postoperative wound healing complications but similar rates of hernia recurrence in abdominal wall reconstruction patients.

METHODS

The authors included 511 consecutive patients who underwent abdominal wall reconstruction with underlay mesh. Patients were divided into three groups on the basis of preoperative body mass index: less than 30 kg/m (nonobese), 30 to 34.9 kg/m (class I obesity), and 35 kg/m or greater (class II/III obesity). The authors compared postoperative outcomes among these groups.

RESULTS

Class I and class II/III obesity patients had higher surgical-site occurrence rates than nonobese patients (26.4 percent versus 14.9 percent, p = 0.006; and 36.8 percent versus 14.9 percent, p < 0.001, respectively) and higher overall complication rates (37.9 percent versus 24.7 percent, p = 0.007; and 43.4 percent versus 24.7 percent, p < 0.001, respectively). Similarly, obese patients had significantly higher skin dehiscence (19.3 percent versus 7.2 percent, p < 0.001; and 26.5 percent versus 7.2 percent, p < 0.001, respectively) and fat necrosis rates (10.0 percent versus 2.1 percent, p = 0.001; and 11.8 percent versus 2.1 percent, p < 0.001, respectively) than nonobese patients. Obesity class II/III patients had higher infection and seroma rates than nonobese patients (9.6 percent versus 4.3 percent, p = 0.041; and 8.1 percent versus 2.1 percent, p = 0.006, respectively). However, class I and class II/III obesity patients experienced hernia recurrence rates (11.4 percent versus 7.7 percent, p = 0.204; and 10.3 percent versus 7.7 percent, p = 0.381, respectively) and freedom from hernia recurrence (overall log-rank, p = 0.41) similar to those of nonobese patients.

CONCLUSION

Hernia recurrence rates do not appear to be affected by obesity on long-term follow-up in abdominal wall reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Ventral Hernia Management: Expert Consensus Guided by Systematic Review

OBJECTIVE

To achieve consensus on the best practices in the management of ventral hernias (VH).

BACKGROUND

Management patterns for VH are heterogeneous, often with little supporting evidence or correlation with existing evidence.

METHODS

A systematic review identified the highest level of evidence available for each topic. A panel of expert hernia-surgeons was assembled. Email questionnaires, evidence review, panel discussion, and iterative voting was performed. Consensus was when all experts agreed on a management strategy.

RESULTS

Experts agreed that complications with VH repair (VHR) increase in obese patients (grade A), current smokers (grade A), and patients with glycosylated hemoglobin (HbA1C) ≥ 6.5% (grade B). Elective VHR was not recommended for patients with BMI ≥ 50 kg/m (grade C), current smokers (grade A), or patients with HbA1C ≥ 8.0% (grade B). Patients with BMI= 30-50 kg/m or HbA1C = 6.5-8.0% require individualized interventions to reduce surgical risk (grade C, grade B). Nonoperative management was considered to have a low-risk of short-term morbidity (grade C). Mesh reinforcement was recommended for repair of hernias ≥ 2 cm (grade A). There were several areas where high-quality data were limited, and no consensus could be reached, including mesh type, component separation technique, and management of complex patients.

CONCLUSIONS

Although there was consensus, supported by grade A-C evidence, on patient selection, the safety of short-term nonoperative management, and mesh reinforcement, among experts; there was limited evidence and broad variability in practice patterns in all other areas of practice. The lack of strong evidence and expert consensus on these topics has identified gaps in knowledge where there is need of further evidence.

Long-Term Outcomes after Abdominal Wall Reconstruction with Acellular Dermal Matrix

BACKGROUND

Long-term outcomes data for hernia recurrence rates after abdominal wall reconstruction (AWR) with acellular dermal matrix (ADM) are lacking. The aim of this study was to assess the long-term durability of AWR using ADM.

STUDY DESIGN

We studied patients who underwent AWR with ADM at a single center in 2005 to 2015 with a minimum follow-up of 36 months. Hernia recurrence was the primary end point and surgical site occurrence (SSO) was a secondary end point. The recurrence-free survival curves were estimated by Kaplan-Meier product limit method. Univariate and multivariable Cox proportional hazards regression models and logistic regression models were used to evaluate the associations of risk factors at surgery with subsequent risks for hernia recurrence and SSO, respectively.

RESULTS

A total of 512 patients underwent AWR with ADM. After excluding those with follow-up less than 36 months, 191 patients were included, with a median follow-up of 52.9 months (range 36 to 104 months). Twenty-six of 191 patients had a hernia recurrence documented in the study. The cumulative recurrence rates were 11.5% at 3 years and 14.6% by 5 years. Factors significantly predictive of hernia recurrence developing included bridged repair, wound skin dehiscence, use of human cadaveric ADM, and coronary disease; component separation was protective. In a subset analysis excluding bridged repairs and human cadaveric ADM patients, cumulative hernia recurrence rates were 6.4% by 3 years and 8.3% by 5 years. The crude rate of SSO was 25.1% (48 of 191). Factors significantly predictive of the incidence of SSO included at least 1 comorbidity, BMI ≥30 kg/m², and defect width >15 cm.

CONCLUSIONS

Use of ADM for AWR was associated with 11.5% and 14.6% hernia recurrence rates at 3- and 5-years follow-up, respectively. Avoiding bridged repairs and human cadaveric ADM can improve long-term AWR outcomes using ADM.

Laparoscopic ventral/incisional hernia repair: updated Consensus Development Conference based guidelines [corrected]

BACKGROUND

The Executive board of the Italian Society for Endoscopic Surgery (SICE) promoted an update of the first evidence-based Italian Consensus Conference Guidelines 2010 because a large amount of literature has been published in the last 4 years about the topics examined and new relevant issues.

METHODS

The scientific committee selected the topics to be addressed: indications to surgical treatment including special conditions (obesity, cirrhosis, diastasis recti abdominis, acute presentation); safety and outcome of intraperitoneal meshes (synthetic and biologic); fixing devices (absorbable/non-absorbable); abdominal border and parastomal hernia; intraoperative and perioperative complications; and recurrent ventral/incisional hernia. All the recommendations are the result of a careful and complete literature review examined with autonomous judgment by the entire panel. The process was supervised by experts in methodology and epidemiology from the most qualified Italian institution. Two external reviewers were designed by the EAES and EHS to guarantee the most objective, transparent, and reliable work. The Oxford hierarchy (OCEBM Levels of Evidence Working Group*. "The Oxford 2011 Levels of Evidence") was used by the panel to grade clinical outcomes according to levels of evidence. The recommendations were based on the grading system suggested by the GRADE working group.

RESULTS AND CONCLUSIONS

The availability of recent level 1 evidence (a meta-analysis of 10 RCTs) allowed to recommend that not only laparoscopic repair is an acceptable alternative to the open repair, but also it is advantageous in terms of shorter hospital stay and wound infection rate. This conclusion appears to be extremely relevant in a clinical setting. Indications about specific conditions could also be issued: laparoscopy is recommended for the treatment of recurrent ventral hernias and obese patients, while it is a potential option for compensated cirrhotic and childbearing-age female patients. Many relevant and controversial topics were thoroughly examined by this consensus conference for the first time. Among them are the issue of safety of the intraperitoneal mesh placement, traditionally considered a major drawback of the laparoscopic technique, the role for the biologic meshes, and various aspects of the laparoscopic approach for particular locations of the defect such as the abdominal border or parastomal hernias.

Meta-analysis and systematic review of laparoscopic versus open mesh repair for elective incisional hernia

CONTEXT

The utility of laparoscopic repair in the treatment of incisional hernia repair is still contentious.

OBJECTIVES

The aim was to conduct a meta-analysis of RCTs investigating the surgical and postsurgical outcomes of elective incisional hernia by open versus laparoscopic method.

DATA SOURCES

A search of PubMed, Medline, Embase, Science Citation Index, Current Contents, and the Cochrane Central Register of Controlled Trials published between January 1993 and September 2013 was performed using medical subject headings (MESH) "hernia," "incisional," "abdominal," "randomized/randomised controlled trial," "abdominal wall hernia," "laparoscopic repair," "open repair", "human" and "English".

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Prospective RCTs comparing surgical treatment of only incisional hernia (and not primary ventral hernias) using open and laparoscopic methods were selected.

STUDY APPRAISAL AND SYNTHESIS METHODS

Data extraction and critical appraisal were carried out independently by two authors (AA and MAM) using predefined data fields. The outcome variables analyzed included (a) hernia diameter; (b) operative time; (c) length of hospital stay; (d) overall complication rate; (e) bowel complications; (f) reoperation; (g) wound infection; (h) wound hematoma or seroma; (i) time to oral intake; (j) back to work; (k) recurrence rate; and (l) postoperative neuralgia. These outcomes were unanimously decided to be important since they influence the practical and surgical approach towards hernia management within hospitals and institutions. The quality of RCTs was assessed using Jadad's scoring system. Random effects model was used to calculate the effect size of both binary and continuous data. Heterogeneity amongst the outcome variables of these trials was determined by the Cochran Q statistic and I (2) index. The meta-analysis was prepared in accordance with PRISMA guidelines.

RESULTS

Sufficient data were available for the analysis of twelve clinically relevant outcomes. Statistically significant reduction in bowel complications was noted with open surgery compared to the laparoscopic repair in five studies (OR 2.56, 95 % CI 1.15, 5.72, p = 0.02). Comparable effects were noted for other variables which include hernia diameter (SMD -0.27, 95 % CI -0.77, 0.23, p = 0.29), operative time (SMD -0.08, 95 % CI -4.46, 4.30, p = 0.97), overall complications (OR -1.07, 95 % CI -0.33, 3.42, p = 0.91), wound infection (OR 0.49, 95 % CI 0.09, 2.67, p = 0.41), wound hematoma or seroma (OR 1.54, 95 % CI 0.58, 4.09, p = 0.38), reoperation rate (OR -0.32, 95 % CI 0.07, 1.43, p = 0.14), time to oral intake (SMD -0.16, 95 % CI -1.97, 2.28, p = 0.89), length of hospital stay (SMD -0.83, 95 % CI -2.22, 0.56, p = 0.24), back to work (SMD -3.14, 95 % CI -8.92, 2.64, p = 0.29), recurrence rate (OR 1.41, 95 % CI 0.81, 2.46, p = 0.23), and postoperative neuralgia (OR 0.48, 95 % CI 0.16, 1.46, p = 0.20).

CONCLUSIONS

On the basis of our meta-analysis, we conclude that laparoscopic and open repair of incisional hernia is comparable. A larger randomized controlled multicenter trial with strict inclusion and exclusion criteria and standardized techniques for both repairs is required to demonstrate the superiority of one technique over the other.

Laparoscopic tension-free abdominal wall repair: impact of mesh size and of different fixation devices in a consecutive series of 120 patients

PURPOSE

To assess the impact of mesh size and fixation devices on short-term outcomes in a consecutive series of tension-free laparoscopic abdominal wall repairs.

METHODS

Data for 120 consecutive, unselected patients undergoing tension-free laparoscopic incisional (n=63) or umbilical (n=57) hernia repair were prospectively collected. A multivariate analysis was performed to evaluate variables influencing outcomes.

RESULTS

Persistent seromas were observed in 13 patients (10.83%) and 2 recurrences (1.98%) occurred. Mesh size >300 cm was associated with increased hospital stay [odds ratio (OR) 4.83; 95% confidence interval (CI), 1.5-15.53; P=0.008], increased postoperative day 1 (POD1) pain assessed with visual analog scale (OR 5.51; 95% CI, 1.76-17.2; P=0.003), and the presence of complications (OR 10.4; 95% CI, 1.85-58.96; P=0.007). Body mass index >30 resulted in increased hospital stay (OR 3.05; 95% CI, 1.23-7.57; P=0.01) and increased POD1 visual analog scale (OR 2.28; 95% CI, 1-5.18; P=0.04).

CONCLUSIONS

Mesh size and obesity were the main factors influencing postoperative outcomes.

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

INTRODUCTION

Incisional and ventral hernias are common surgical indications. Their management is associated with significant complications and recurrences in open surgery (15-25%). Since laparoscopy has become a standard in bariatric surgery, there has been a natural trend to treat obese patients with parietal wall defects laparoscopically. The aim of our study was to evaluate the feasibility and the results of the laparoscopic management of parietal wall defects in patients with a BMI >35.

MATERIALS AND METHODS

A series of 79 patients were included. Data were acquired prospectively and analyzed retrospectively. The surgical procedure was standardized: 3 ports, mesh type (Parietex™ Composite mesh, Covidien, France), fixation with non-absorbable transfascial sutures, and tackers. Complications were evaluated.

RESULTS

Out of 79 patients (29 men, 50 women), 43 had umbilical and 36 had ventral hernias. Mean age was 52.4 years, and mean BMI was 40.83 kg/m(2). Mean postoperative hospital stay was 2 days. Postoperative pain evaluated by visual analog scale was 2.86. No intraoperative complications or deaths occurred. Seven postoperative complications occurred (8.86%): two parietal wall hematomas treated by radiological embolization, two significant cases of postoperative pain, one postoperative obstruction, one spontaneously resolved respiratory failure, and one early (day 1) parietal wall defect with immediate reoperation. Postoperative seroma rate was 26.58% (21 patients, all of whom were treated conservatively). Postoperative follow-up was 18.10 months (1-84 months), and recurrence rate was 3.8% (3 patients).

DISCUSSION

This study confirms the feasibility and safety of the laparoscopic approach for ventral hernias in morbidly obese patients. Recurrence rates (3.8%) appeared lower than the ones observed in the literature (15-25%). Postoperative hemorrhage and port-site hernia are specific complications of this approach. Postoperative hospital stay is low (2 days) as compared to open surgery. Laparoscopic management of parietal wall defects should be considered a standard option in morbidly obese patients.

Ventral hernias in morbidly obese patients: a suggested algorithm for operative repair

With the rise in prevalence of obesity, most general surgeons will have to face the problem of the obese patient with an abdominal wall defect. Treatment of these bariatric patients raises unique challenges, and at this time there is still no consensus on the best treatment option. This study was performed in a high-volume bariatric and minimally invasive surgery center at a tertiary care facility in the USA. Twenty-eight morbidly obese patients treated at our facility between 2003 and 2008 were separated into four groups according to anatomic features and symptoms. Patients with the following characteristics were classified as having a favorable anatomy: body mass index not exceeding 50 kg/m(2), gynecoid body habitus, reducible hernias found in a central location, abdominal wall thickness less than 4 cm, and the defect's largest diameter not exceeding 8 cm. All other patients were classified as having an unfavorable anatomy. In this study, we report a systematic treatment approach for the morbidly obese patient presenting with a ventral hernia based on whether the hernia is symptomatic or asymptomatic, as well as the distinct characteristics of the hernia and body habitus features. We followed up on these patients postoperatively for at least 2 years, with a mean follow-up period of 30 months. Only a total of three hernia recurrences were observed. Successful treatment of ventral hernias in morbidly obese patients should be individualized based on the patient's symptoms and defined hernia characteristics.

Laparoscopic ventral hernia repair

Laparoscopic ventral hernia repair (LVHR) has established itself as a well-accepted option in the treatment of hernias. Clear benefits have been established regarding the superiority of LVHR in terms of fewer wound infections compared with open repairs. Meticulous technique and appropriate patient selection are critical to obtain the reported results.

Laparoscopic ventral hernia repair in obese patients under spinal anesthesia

PURPOSE

The aim of the present study was to evaluate the feasibility and efficacy of laparoscopic ventral hernia repair under spinal anesthesia in obese patients (BMI > 30 kg/m(2)).

METHODS

From January 2007 to February 2010, 23 obese patients had their elective laparoscopic ventral hernia repair under spinal anesthesia. We looked primarily for intra-operative incidences as well as immediate postoperative complications. Long term results and especially recurrences were also to be evaluated.

RESULTS

Median operative time was 55 min (range 20-100). Intraoperatively, six patients (26%) complained of shoulder pain, three patients (13%) developed bradycardia and two (8.7%) hypotension. Postoperatively, nausea and/or vomiting were recorded in four patients (17.4%), four patients (17.4%) experienced urinary retention and one patient developed wound infection. Median pain score at 4th, 8th and 24th postoperative hour was 0.5 (0-5), 1.5 (0-6), and 1.5 (0-5) respectively. The median length of hospital stay was one day (1-2). At a median follow up of 39 months, one patient was diagnosed with a recurrence.

CONCLUSION

Spinal anesthesia for LVHR in obese patients (BMI > 30 kg/m(2)) proved an efficient and safe alternative to general anesthesia in the given patient sample.