Staged hernia repair preceded by gastric bypass for the treatment of morbidly obese patients with complex ventral hernias

Innovative Approaches to Address the Technical Challenge of Hernial Sac Distension Due to Pneumoperitoneum in the Synchronous Management of Complex Hernias in Individuals With Morbid Obesity

Although repairing ventral hernias in individuals who have undergone bariatric surgery is a common practice, persistent technical intricacies and controversies surround their management. Concurrently, addressing ventral hernias in morbidly obese patients undergoing bariatric surgery presents a significant surgical challenge, amplified by the larger intraperitoneal cavities and the presence of large hernial sacs. This technical report introduces two innovative techniques to alleviate the challenge of hernia sac distension due to pneumoperitoneum associated with simultaneous bariatric surgery and ventral hernia repair using laparoscopic technique. The methods are designed to address the complexities of the procedures, making their simultaneous execution feasible and safe. The goal is to eliminate the need for two separate interventions while ensuring the outcomes of each procedure remain uncompromised. The larger intraperitoneal cavities and the presence of large hernial sacs are managed successfully, demonstrating the feasibility and safety of the introduced methods. Importantly, the simultaneous execution of both procedures does not compromise the outcomes of either intervention. Concurrently managing ventral hernias in morbidly obese patients undergoing bariatric surgery requires innovative solutions to overcome technical challenges. The introduction of these two novel techniques proves to be a valuable approach, making simultaneous execution feasible and safe. Eliminating the need for two separate interventions streamlines the surgical process without compromising the outcomes of either bariatric surgery or ventral hernia repair.

Is simultaneous bariatric surgery and ventral hernia repair a safe and effective approach?

BACKGROUND

There is currently a lack of consensus regarding the timing of ventral hernia repair relative to bariatric surgery.

OBJECTIVES

To compare outcomes between patients undergoing simultaneous and selectively deferred ventral hernia repair and bariatric surgery.

SETTING

High volume UPPER gastrointestinal and Bariatric Unit. Sydney, Australia.

METHODS

A retrospective case series from a single institution's prospectively collected database (2003-21) was performed to determine the characteristics and outcomes in patients having simultaneous and deferred hernia repair relative to their bariatric surgery.

RESULTS

In our patient cohort (N = 134), 111 patients underwent simultaneous repair and 23 had a deferred procedure. Of the simultaneous patients, 95 (85.6%) underwent resection bariatric surgery. The median operative time in the simultaneous versus deferred groups was 155 versus 287 minutes and the length of stay was 3 versus 7 days. There has been one (.9%) mesh infection requiring explant, in an open, simultaneous repair undertaken in a gastric band patient, 3 (2.8%) infected seromas, 1 (.9%) surgical site infection, and 8 (7.5%) hernia recurrences in the simultaneous group. The deferred group has had no mesh infections, no hernia recurrence, and 2 (9.5%) infected seromas to date. There was 1 mortality in the simultaneous cohort (simultaneous gastric bypass group), from a massive Pulmonary Embolism (<30 days postoperatively) and one in the deferred group from an interval small bowel obstruction.

CONCLUSIONS

Simultaneous ventral hernia repair with bariatric surgery had a low rate of infection and a low mesh explant rate, even when coupled with resection bariatric surgery in this series. A combined approach may be safe, even in the clean-contaminated surgical context.

Hernia repair in the bariatric patient: a systematic review and meta-analysis

BACKGROUND

Repair options for ventral hernias in bariatric patients include performing a staged approach in which bariatric surgery is performed before definitive hernia repair (BS-first), a staged approach in which hernia repair is performed before bariatric surgery (HR-first), or a concomitant approach.

OBJECTIVES

This meta-analysis aims to determine which surgical approach is best for bariatric patients with hernias.

SETTING

PubMed, CENTRAL, and Embase databases.

METHODS

A comprehensive search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to screen for all studies that focused on outcomes of patients who underwent both hernia repair and bariatric surgery, either simultaneously or separately. Exclusion criteria included hiatal and inguinal hernia studies, case reports, and case series.

RESULTS

27 studies fit our inclusion criteria after identifying 1584 studies initially. Seven comparative studies were included, enrolling 8548 staged patients (6458 BS-first) and 3528 concomitant patients. A total of 7 single-arm staged studies and 13 single-arm concomitant studies were also included. Data on hernia recurrence, mesh infection, reoperation, surgical site infections, seroma, bowel complications, and mortality were abstracted. The concomitant approach was associated with decreased odds of experiencing surgical site infections, reoperation, and seromas. The staged approach (BS-first) was associated with decreased odds of mesh infection. The single-arm studies suggest a lower incidence of hernia recurrence in a staged BS-first approach than in a concomitant approach.

CONCLUSIONS

The data suggest a concomitant approach is appropriate for hernias that the surgeon feels do not require mesh, while the staged (BS-first) approach is more appropriate if the hernia requires mesh placement.

Staged abdominal wall reconstruction in the setting of complex gastrointestinal reconstruction

PURPOSE

Literature on one- versus two-staged abdominal wall reconstruction (AWR) with complex gastrointestinal reconstruction (GIR) is limited to single-arm case series with a focus on patients who complete all planned stages. Herein, we describe our experience with both one- and two-staged approaches to AWR/GIR, with attention to those who did not complete both intended stages.

METHODS

A retrospective review of prospectively collected data was conducted to identify patients who underwent a one- or two-stage approach to GIR/AWR from 2013 to 2020. The one-stage approach included GIR and definitive sublay mesh herniorrhaphy. The two-stage approach included Stage 1 (S1)-GIR and non-definitive herniorrhaphy and Stage 2 (S2)-definitive sublay mesh herniorrhaphy.

RESULTS

Fifty-four patients underwent GIR/AWR: 20 (37.0%) underwent a planned 1-stage operation while 34 (63.0%) underwent S1 of a planned 2-stage approach. Patients assigned to the 2-stage approach were more likely to be smokers, have a history of mesh infection, have an enterocutaneous fistula, and a contaminated wound class (p<0.05). Of the 34 patients who underwent S1, 12 (35.3%) completed S2 during the mean follow-up period of 44 months while 22 (64.7%) did not complete S2. Of these, 10 (45.5%) developed hernia recurrence but did not undergo S2 secondary to elective nonoperative management (40%), pending preoperative optimization (30%), additional complex GIR (10%), hernia-related incarceration requiring emergent surgery (10%), or unrelated death (10%). No differences in outcome including SSI, SSO, readmission, and recurrence were noted between the 12 patients who completed the two-stage approach and the 20 patients who completed a one-stage approach, despite increased risk factors for complications in the 2-stage group (p>0.05).

CONCLUSION

Planned two-stage operations for GIR/AWR may distribute operative complexity and post-operative morbidity into separate surgical interventions. However, many patients may never undergo the intended definitive S2 herniorrhaphy. Future evaluation of 1- versus 2-stage GIR/AWR is needed to clarify indications for each approach. This work must also consider the frequent deviations from intended clinical course demonstrated in this study.

A history of bariatric surgery before surgery for colorectal cancer may improve short-term postoperative outcomes: Analysis of the national inpatient sample 2015-2019

BACKGROUND

Bariatric surgery is the most effective and sustainable form of weight loss. Bariatric surgery before elective operations for colorectal pathology may improve postoperative outcomes. To compare patients with and without prior bariatric surgery undergoing surgery for colorectal cancer in terms of postoperative morbidity and health care use.

METHODS

Adult patients undergoing resection for colorectal cancer from 2015 to 2019 were identified from the National Inpatient Sample. Patients were stratified according to their history of bariatric surgery. Propensity score matching with 4:1 nearest-neighbor matching was performed according to demographic, operative, and hospital characteristics. The primary outcome was postoperative morbidity. Secondary outcomes included system-specific postoperative complications, postoperative mortality, postoperative length of stay, total admission health care cost, and post-discharge disposition. McNemar's test and Wilcoxon matched-pairs signed-rank test were performed.

RESULTS

After propensity score matching, 1,197 patients without prior bariatric surgery and 376 patients with prior bariatric surgery were included. Patients with prior bariatric surgery had an absolute reduction of 6.5% in overall in-hospital postoperative morbidity (19.1% vs 25.6%, P < .0001), a $5,256 decrease in hospitalization cost ($70,344 vs $75,600, P = .034), and were more likely to be discharged home after their index operation (72.9% vs 63.9%, P < .0001).

CONCLUSION

Bariatric surgery before surgery for colorectal cancer may be associated with decreased postoperative morbidity and health care use. Bariatric surgery and other forms of rapid and effective weight loss, such as very low-energy diets, should be evaluated further for the optimization of obese patients before nonbariatric abdominal surgery.

Management of abdominal wall hernias in patients with severe obesity

Obesity is a risk factor for abdominal wall hernia development and hernia recurrence. The management of these two pathologies is complex and often entwined. Bariatric and ventral hernia surgery require careful consideration of physiologic and technical components for optimal outcomes. In this review, a multidisciplinary group of Society of American Gastrointestinal and Endoscopic Surgeons' bariatric and hernia surgeons present the various weight loss modalities available for the pre-operative optimization of patients with severe obesity and concurrent hernias. The group also details the technical aspects of managing abdominal wall defects during weight loss procedures and suggests the optimal timing of definitive hernia repair after bariatric surgery. Since level one evidence is not available on some of the topics covered by this review, expert opinion was implemented in some instances. Additional high-quality research in this area will allow for better recommendations and therefore treatment strategies for these complex patients.

Association of body mass index with morbidity following elective ventral hernia repair

Background

Prior work has linked body mass index (BMI) with postoperative outcomes of ventral hernia repair (VHR), though recent data characterizing this association are limited. This study used a contemporary national cohort to investigate the association between BMI and VHR outcomes.

Methods

Adults ≥ 18 years undergoing isolated, elective, primary VHR were identified using the 2016-2020 American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by BMI. Restricted cubic splines were utilized to ascertain the BMI threshold for significantly increased morbidity. Multivariable models were developed to evaluate the association of BMI with outcomes of interest.

Results

Of ~89,924 patients, 0.5 % were considered Underweight, 12.9 % Normal Weight, 29.5 % Overweight, 29.1 % Class I, 16.6 % Class II, 9.7 % Class III, and 1.7 % Superobese. After risk adjustment, class I (Adjusted Odds Ratio [AOR] 1.22, 95 % Confidence Interval [95%CI]: 1.06-1.41), class II (AOR 1.42, 95%CI: 1.21-1.66), class III obesity (AOR 1.76, 95%CI: 1.49-2.09) and superobesity (AOR 2.25, 95 % CI: 1.71-2.95) remained associated with increased odds of overall morbidity relative to normal BMI following open, but not laparoscopic, VHR. A BMI of 32 was identified as the threshold for the most significant increase in predicted rate of morbidity. Increasing BMI was linked to a stepwise rise in operative time and postoperative length of stay.

Conclusion

BMI ≥ 32 is associated with greater morbidity following open, but not laparoscopic VHR. The relevance of BMI may be more pronounced in open VHR and must be considered for stratifying risk, improving outcomes, and optimizing care.

Key message

Body mass index (BMI) continues to be a relevant factor in morbidity and resource use for elective open ventral hernia repair (VHR). A BMI of 32 serves as the threshold for significant increase in overall complications following open VHR, though this association is not observed in operations performed laparoscopically.

Ventral hernia repair with enhanced-view totally extraperitoneal technique after a massive weight loss by laparoscopic sleeve gastrectomy

BACKGROUND

Ventral hernia repair (VHR) for obese patients is often associated with an increased risk of postoperative complications and hernia recurrences. Achieving preoperative weight loss is ideal before VHR; however, it is difficult to attain with medical treatment. Metabolic and bariatric surgery (MBS) offers the most effective and durable treatment for obesity. Therefore, massive weight loss occurring after MBS will improve the outcome of VHR.

CASE PRESENTATION

A 49-year-old man (122.9 kg, BMI 39.1 kg/m²) presented to our hospital wishing to undergo laparoscopic sleeve gastrectomy and VHR. Physical examination revealed a tennis ball-sized lower midline defect. Computed tomography (CT) scans revealed a hernia orifice 5 cm in width and 10 cm in height. As the hernia orifice was large, mesh reinforcement was essential. We planned for him to undergo VHR after massive weight loss was achieved by MBS. VHR was performed using the enhanced-view totally extraperitoneal (eTEP) technique after weight loss of 38 kg was achieved 9 months following laparoscopic sleeve gastrectomy. His postoperative course was uneventful, and neither recurrence nor seroma was observed at 1 year follow-up.

CONCLUSIONS

eTEP repair of a ventral hernia after massive weight loss following MBS would appear to be the best combination treatment for obese patients with ventral hernias. However, long-term follow-up is necessary to establish its safety and efficacy.

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.

The European Hernia Society Prehabilitation Project: a systematic review of patient prehabilitation prior to ventral hernia surgery

BACKGROUND

Ventral hernia repair is one of the most commonly performed surgical procedures worldwide. To reduce the risk of complications, patient prehabilitation has received increasing focus in recent years. To assess prehabilitation measures, this European Hernia Society endorsed project was launched. The aim of this systematic review was to evaluate the current literature on patient prehabilitation prior to ventral hernia repair.

METHODS

The strategies examined were optimization of renal disease, obesity, nutrition, physical exercise, COPD, diabetes and smoking cessation. For each topic, a separate literature search was conducted, allowing for seven different sub-reviews.

RESULTS

A limited amount of well-conducted research studies evaluating prehabilitation prior to ventral hernia surgery was found. The primary findings showed that smoking cessation and weight loss for obese patients led to reduced risks of complications after abdominal wall reconstruction.

CONCLUSION

Prehabilitation prior to ventral hernia repair may be widely used; however, the literature supporting its use is limited. Future studies evaluating the impact of prehabilitation before ventral hernia surgery are warranted.

Smoking, Obesity, and the Elective Operation

Smoking and obesity are commonly encountered problems in the elective, perioperative setting. This article reviews the risks posed by smoking and diabetes and explores way to mitigate such risks. Other means of perioperative optimization are also discussed in an effort to describe perioperative strategies that can improve patient outcomes.

Excess Body Weight and Abdominal Hernia

Background

Obese patients have an increased incidence of ventral hernias; in over 50% of these cases, patients are symptomatic. At the same time, morbid obesity is a disease of epidemic proportions. The combination of symptomatic hernia and obesity is a challenge for the treating surgeon, because the risk of perioperative complications and recurrence increases with increasing BMI.

Summary

This review outlines this problem and discusses interdisciplinary approaches to the management of affected patients. In emergency cases, the hernia is treated according to the surgeon's expertise. In elective cases, an individual decision must be made whether bariatric surgery is indicated before hernia repair or whether both should be performed simultaneously. After bariatric surgery a weight reduction of 25-30% of total body weight in the first year can be achieved and it is often advantageous to perform a bariatric operation prior to hernia repair. Technically, the risk of complications is lower with minimally invasive procedures than with open ones, but laparoscopy is challenging in obese patients, and meshes can only be implanted in intraperitoneal position. This mesh position has to be questioned because of adhesions, recurrence rate, and risk of contamination during re-interventions in patients who are often still relatively young.

Key Messages

Obese patients with hernia need to be approached in an interdisciplinary manner, in some patients a weight loss procedure may be advantageous before hernia repair. Recent data show the benefits of robotic hernia surgery in obese patients, as not only haptic advantages result, but especially the mesh can be implanted in a variety of extraperitoneal positions in the abdominal wall with low morbidity.

Effects of Botulinum Toxin A on an Incisional Hernia Reconstruction in a Rat Model

BACKGROUND

Although the effects of botulinum toxin A on hernia reconstruction have been consistently reported, few studies provide objective evidence. The authors aimed to compare the effects of chemical component separation with those of mechanical component separation, and with a combination of chemical and mechanical component separation, in a rat hernia model.

METHODS

Rats were divided into four groups: 1, control; 2, chemical component separation; 3, mechanical component separation; and 4, chemical and mechanical component separation. Four weeks after hernia induction, botulinum toxin A was injected into groups 2 and 4. Hernia repair was performed 2 weeks after chemical component separation when mechanical component separation was performed in groups 3 and 4. Pretreatment and posttreatment defect sizes, traction forces, intraabdominal pressure, and hernia recurrences were analyzed.

RESULTS

The defect size was significantly decreased in groups 2 and 4 after chemical component separation. The traction force was significantly smaller in groups 2 and 3 compared with the control group, and the effects of chemical and mechanical component separation were additive. The mean intraabdominal pressure was 16.83 mmHg in group 1, 10.67 mmHg in group 2, 10.17 mmHg in group 3, and 9.67 mmHg in group 4, thus showing significant reductions following chemical and mechanical component separation. Recurrence was observed in all six animals (100 percent) in groups 1 and 3, but in only one of six (17 percent) in groups 2 and 4.

CONCLUSIONS

Preoperative botulinum toxin A significantly reduces hernia size (by 30 percent) and the traction force required to medialize the rectus abdominis. After hernia repair, chemical component separation decreases the intraabdominal pressure to a similar degree as mechanical component separation, but only chemical component separation appears to reduce hernia recurrence.

Ventral Hernia Management in Obese Patients

Ventral and incisional hernias in obese patients are particularly challenging. Suboptimal outcomes are reported for elective repair in this population. Preoperative weight loss is ideal but is not achievable in all patients for a variety of reasons, including access to bariatric surgery, poor quality of life, and risk of incarceration. Surgeons must carefully weigh the risk of complications from ventral hernia repair with patient symptoms, the ability to achieve adequate weight loss, and the risks of emergency hernia repair in obese patients.

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.

Laparoscopic sleeve gastrectomy in patients with complex abdominal wall hernias

BACKGROUND

Patients with severe obesity and complex abdominal wall hernias (CAWH) present a challenging clinical dilemma. Their body mass index (BMI) is often prohibitive of successful ventral hernia repair (VHR) and the CAWH presents technical challenges when pursuing bariatric surgery. Our hernia center policy is to refer patients with severe obesity for evaluation with the surgical weight loss program. This study describes outcomes of laparoscopic sleeve gastrectomy (LSG) in patients with both severe obesity and CAWH.

METHODS

A retrospective analysis was performed on data prospectively collected between 2014 and 2020. CAWH patients referred for and undergoing LSG were included. Revisional bariatric surgery patients were excluded. The dataset was augmented with operative time, BMI changes, length of stay (LOS), hernia characteristics, postoperative complications, time from referral to weight loss surgery, and time from LSG to VHR.

RESULTS

Twenty patients (10 males, mean age 54.3 years) met inclusion criteria. Mean BMI at LSG was 45.6 ± 6.1 kg/m². Mean hernia area was 494.9 ± 221.2 cm² and 90% had hernia extension into the subxiphoid and/or epigastric regions. Mean time from bariatric referral to LSG was 10.5 ± 5.4 months. Mean LSG operative time was 121.2 ± 50.3 min, and mean LOS was 1.6 ± 0.8 days. One patient had postoperative bleeding necessitating laparoscopic re-exploration. There were no readmissions. Sixteen patients subsequently underwent VHR on average13.5 ± 11.7 months later and on average 22.6 ± 12.5 months after initial hernia consultation. Two patients had a hernia-related complication between the period of initial hernia consultation and ultimate repair. Mean BMI was 37.5 ± 7.5 kg/m² (mean 20.7 ± 12.3% decrease, p < 0.0001) at mean follow-up of 27.2 ± 17.2 months.

CONCLUSIONS

LSG can be performed successfully even in patients with CAWH. Outcomes do not appear to differ significantly from typical patients undergoing LSG. Further study with larger cohorts is warranted to better delineate complication rates in this population as well as to determine long-term outcomes.

Abdominal Wall Hernia and Metabolic Bariatric Surgery

The management of morbidly obese patients with a concomitant ventral hernia (VH) is a great challenge for surgeons. There is controversy over the optimal strategy to tackle both health problems, requiring an individualized approach. Obese patients have a higher recurrence rate after hernia repair, and bariatric surgery in the presence of a VH can be difficult. As morbid obesity is related with severe comorbidities, including increased cardiovascular and anesthetic risks, some advocate for a single-stage strategy. A primary hernia repair carried out during the bariatric surgery, however, may increase morbidity without definitively solving the problem. Biological meshes are expensive and also have a high recurrence rate. The laparoscopic placement of a synthetic mesh offers good results, but it is worrisome because bariatric surgery is a clean-contaminated procedure. Moreover, there is a great chance that a plastic surgery would be necessary after completing the weight-loss process, and the abdominal wall surgery could be performed at that point. There are many arguments, but the evidence is weak. We present an extensive review of the currently available literature on the management of VH in morbidly obese patients. We aim to provide objective information regarding the pros and cons of the different strategies that have been proposed, to facilitate the selection of the best approach to individual morbidly obese patients with abdominal wall hernias precising both of surgical repair.

Staged complex abdominal wall hernia repair in morbidly obese patients

PURPOSE

The repair of complex abdominal wall hernias in morbidly obese patients is often associated with a higher risk of complications and hernia recurrences. Improvement in obesity and its associated metabolic complications are hypothesized to improve hernia repair outcomes. This study analyzes outcomes from morbidly obese patients who underwent bariatric surgery with staged complex abdominal wall reconstruction at Creighton University Medical Center (CUMC).

METHODS

This retrospective study included morbidly obese patients with complex abdominal wall hernia, who underwent bariatric surgery with staged abdominal wall reconstruction. Data points collected included patient demographics, obesity-related co-morbidities, pre-operative BMI, EBMIL at 12 months, hernia characteristics, postoperative complications, BMI at time of hernia repair, and hernia recurrence.

RESULTS

Twelve patients with an average BMI of 48 and complex abdominal wall hernias (mean width 14.0 cm) met inclusion criteria. Seven patients (58%) had significant loss of domain. Bariatric procedures included six laparoscopic sleeve gastrectomies (LSG), three laparoscopic Roux-en-Y gastric bypasses (LRNYGB), and three revisional procedures (2 vertical band gastroplasties to LRNYGB and 1 LRNYGB revision). At 12-month follow-up, the mean excess BMI loss (EBMIL) was 64.6%. The average time to staged complex abdominal wall reconstruction was 22.3 months. Two non-elective hernia repairs were performed due to one incarceration and one strangulation. There were no recurrences after an average follow-up of 21.9 months.

CONCLUSIONS

In this study, staged mesh repair of complex abdominal wall hernias after bariatric surgery in morbidly obese patients was associated with acceptable morbidity and no hernia recurrences at approximately 1.5 year follow-up.

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

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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.

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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.

Primary non-complicated midline ventral hernia: is laparoscopic IPOM still a reasonable approach?

PURPOSE

Ventral hernia repair has become a common procedure, but the way in which it is performed still depends on surgeon's skill, experience, and habit. The initial open approach is faced with extensive dissection and a high risk of infection and prolonged hospital stay. To tackle these problems, minimally invasive procedures are gaining interest. Several new techniques are emerging, but laparoscopic intra-peritoneal onlay mesh (IPOM) is still the mainstay for many surgeons. We will discuss why laparoscopic IPOM is still a valuable approach in the treatment of primary non-complicated midline hernias and review the current literature.

METHODS

We performed a literature search across PubMed and MEDLINE using the following search terms: "Laparoscopic hernia repair", "Ventral hernia repair" and "Primary ventral hernia". Articles corresponding to these search terms were individually reviewed by the primary author and selected on relevance.

CONCLUSION

Laparoscopic IPOM still is a good approach for the efficient treatment of primary non-complicated midline hernias. Several techniques are emerging, but are faced with increased costs, technical difficulties, and low study patient volume. Further research is warranted to show superiority and applicability of these new techniques over laparoscopic IPOM, but until then laparoscopic IPOM should remain the go-to technique.

Case report of ventral hernia complicating bariatric surgery

Ventral hernias (VHs) are common in the bariatric population with incidence of around 8% of patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB). The factors contributing to the incidence of VH includes high intra-abdominal pressures, previous histories of abdominal surgeries, defects in fascial structure and reduced healing tendency. There is a high index of suspicion in BS patients with VH for hernia complications which can be lethal after LRYGB. Here, we present a case where VH complicated the LRYGB surgery.

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.

Best evidence topic: Should ventral hernia repair be performed at the same time as bariatric surgery?

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In morbidly obese patients undergoing bariatric surgery, when a ventral hernia is picked up in clinic or intraoperatively is concurrent repair of the hernia better than delayed repair after weight loss with regards to complication rates? Using the reported search, 179 papers were found. 5 studies were deemed to be suitable to answer the question.

All 5 studies assessed were non randomised studies either retrospective or prospective and the overall quality of these studies was poor. The outcomes assessed were incidence of complications associated with hernia repair (recurrence, infection) and deferral of repair (small bowel obstruction). The patient's symptoms and anatomy is important in determining the timing of repair.

The evidence does not provide a consensus for the optimal timing of ventral hernia repair for patients undergoing bariatric surgery, with some of the selected studies contradicting each other. However, the studies do affirm the risk of small bowel obstruction if hernias are left alone. The reported rate of surgical site infection is low when mesh repair is performed at the same time as weight loss surgery.

Until large volume, high quality randomized control trials can be performed, a case by case approach is best, where the patients' symptoms, anatomy, type of bariatric surgery and their personal preferences are considered, and an open discussion on the risks and benefits of each approach is undertaken.

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There is a paucity of evidence on this topic & overall, the quality is poor.

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Some of the selected studies contradict each other.

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The studies affirm the risk of small bowel obstruction if hernias are left alone.

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SSI rates are low during concomitant bariatric surgery & mesh repair of hernia.

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A case by case approach is best, with an open discussion of the risks & benefits.

Current Trends in Laparoscopic Ventral Hernia Repair

Background and Objectives:

The purpose of this study was to analyze the surgical technique, postoperative complications, and possible recurrence after laparoscopic ventral hernia repair (LVHR) in comparison with open ventral hernia repair (OVHR), based on the international literature.

Database:

A Medline search of the current English literature was performed using the terms laparoscopic ventral hernia repair and incisional hernia repair.

Conclusions:

LVHR is a safe alternative to the open method, with the main advantages being minimal postoperative pain, shorter recovery, and decreased wound and mesh infections. Incidental enterotomy can be avoided by using a meticulous technique and sharp dissection to avoid thermal injury.

Computed tomographic measurements predict component separation in ventral hernia repair

BACKGROUND

Preoperative imaging with computed tomography (CT) scans can be useful in preoperative planning. We hypothesized that CT measurements of ventral hernia defect size and abdominal wall thickness (AWT) would correlate with postoperative complications and need for complex abdominal wall reconstruction (AWR).

MATERIALS AND METHODS

Patients who underwent open ventral hernia repair and had preoperative abdominal CT imagining were identified from an institutional hernia-specific surgery outcomes database at our tertiary referral hernia center. Grade III and IV hernias and biologic mesh cases were excluded. CT measures of defect size and AWT were analyzed and correlated to complications and the need for AWR techniques using univariate, multivariate, and principal component (PC) analyses. PC1 and PC2 used five AWT measures, hernia defect width, and body mass index to create a new component variable.

RESULTS

There were 151 open ventral hernia repairs included in the study. Preoperative findings included 37.7% male; age 55.3 ± 12.5 years; body mass index (BMI) 33.3 ± 7.8 kg/m(2); 60.3% were recurrent hernias with average defect width 8.5 ± 5.0 cm and area 178.3 ± 214 cm(2); AWT at umbilicus 3.5 ± 1.8 cm; and AWT at pubis 7.0 ± 3.2. Component separation was performed in 24.0% of patients and panniculectomy in 34.4%. Wound complications occurred in 13.3% patients, and 2.7% had hernia recurrence. Increasing defect width, length, and area as well as select AWT measurements were associated with increased need for component separation, concomitant panniculectomy, and higher rates of wound and total complications (all P < 0.05). Using multivariate regression, PC1 was associated with wound complications (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.01-1.16); PC2 (hernia defect width) was associated with the need for component separation (OR, 1.16; 95% CI, 1.03-1.30). Hernia recurrence was not predicted by AWT or defect size (OR, 1.00; 95%CI, 0.87-1.15).

CONCLUSIONS

Preoperative CT measurements of hernia defects and AWT predict wound complications and the need for complex AWR techniques. Obtaining preoperative CT imaging should be a consideration in preoperative planning and may help with patient counseling.

Concomitant bariatric and ventral/incisional hernia surgery in morbidly obese patients

INTRODUCTION

Ventral hernias are not uncommon in the bariatric population. Their management is technically demanding and remains controversial. Hernia complications can be lethal after bariatric surgery (BS). We herein report our experience with concomitant BS and ventral hernia repair (VHR).

METHODS

We performed a retrospective analysis of a prospectively maintained database queried for combined procedures. Hernias were repaired after complete reduction (when the defect was not empty) using a dual mesh fixed to the abdominal wall with absorbable tackers. Data collected included demographics, anthropometrics, co-morbidities, peri-operative course, and intermediate weight loss and co-morbidity status.

RESULTS

Between 2007 and 2012, a total of 54 patients (34 females, mean body mass index 44.2 kg/m(2)) underwent concomitant BS and VHR. The vast majority of procedures were laparoscopic sleeve gastrectomies (N = 48; 89 %). Others included laparoscopic Roux-en-y gastric bypass (RYGB), open RYGB, and laparoscopic gastric banding (two each). Six patients had complications (11 %): three leaks, two abdominal wall hematomas, and one pulmonary embolism. Hernia recurrence was noted in one patient (1.8 %). Average excess weight loss post-surgery was 49.9 ± 10.3 and 57.7 ± 9.2 % at 6 and 12 months, respectively. The total number of pre-operative co-morbidities was 110. At 12-month follow-up, 50 % (N = 56) were completely resolved and 38 % (N = 42) were improved.

CONCLUSION

Concomitant BS and VHR is feasible and safe, obviating the need for two separate procedures while not hampering the outcome of either. Complication rates for the combined surgery do not seem to be adversely affected.

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.

Deepithelialized flap closure: an adjunct to complex ventral hernia repairs

Ventral hernias are a major surgical challenge with complications such as wound separations, infections, and recurrences contributing to patient morbidity. We describe a new adjunctive technique that may be helpful in repairing difficult ventral hernias: it involves using an appropriately chosen, redundant abdominal skin edge that is deepithelialized and used to reinforce the hernia repair. A series of 7 patients aged 23 to 84 years in whom the technique was used is presented. All patients had complete repair of their incisional ventral hernia defects without complications of infection, wound dehiscence, seroma formation, reoperation, or hernia recurrence. Furthermore, patients reported a subjective improvement in performing daily activities. Mean follow-up in this series was 19.2 months, with a range from 15.0 to 26.8 months. Advantages include the redistribution of mechanical tension, reinforcement of the midline site of greatest pressure, elimination of dead space, and staggering of suture lines to prevent direct external contamination of prosthetic material should wound dehiscence occur.