Hernia repair in obese:
Most studies of hernia repair in patients with obesity are small-to-moderate size retrospective series. In addition, the methodology of these studies is heterogeneous, including different approaches (open versus laparoscopic), different hernia repair techniques (primary tissue repairs, onlay, underlay, and component separation mesh techniques), use of permanent versus biologic mesh, different types of hernias (primary, recurrent, simple, or complex), and ?nally different hernia sizes and locations. It is not possible to make de?nite recommendations on the ideal repair technique for patients with obesity or to determine the ideal BMI at which to perform such an operation.
a) Laparoscopic repair:
Laparoscopic surgical procedures have the advantages of decreased pain, quicker recovery, and lower wound complication rates compared with open surgical procedures. Several investigators have demonstrated the feasibility of laparoscopic ventral hernia repair (LVHR) in patients with obesity. In one of the largest series (19), LVHR in 163 patients with a mean BMI of 38 kg/m2 was associated with a very low, 1.2% rate of wound complications and a recurrence rate of only 5.5% at a mean 25-month follow- up. Contrarily, Raftopoulos et al. (20) reviewed the results of 27 LVHR in patients with a mean BMI of 46.9 kg/m2. The authors reported an 18.5% recurrence rate during mean follow-up of 15 months and a 25.9% incidence of 30-day major and minor complications, including small bowel obstruction, bladder injury, wound infection, pneumonia, and need for reoperation. Thus, hernia recurrence can be signi?cantly affected by the degree of obesity. A large retrospective multi-institutional review (21) of LVHR performed with a standardized synthetic mesh technique showed statistically signi?cant differences, including increased operative times in patients with a BMI >40 kg/m2 (mean 156 versus 114 min; P < .01), larger defects (mean size 167 versus 105 cm2 P 25 kg/m2 compared with 5% in patients with a normal BMI. Sauerland et al. (24) randomized 160 patients with IH to 3 different techniques of repair, including mesh repair, suture repair, or autologous dermal hernioplasty. Despite the different approaches, BMI was the only factor shown to play a role in hernia recurrence.
There is variability on the BMI cut-off at which increased recurrence rates have been reported. In a study by Anthony et al. (25), where patients with BMI >30 kg/m2 had a recurrence rate of 47.9%, compared with 37.5% in patients with a lower BMI at a median follow-up of 45 months.
c) Incisional hernia repair with panniculectomy:
Panniculectomy may be combined with open ventral hernia repair to excise redundant skin, reduce the pendulous effect of the pannus and to prevent a second surgery. Several authors have studied concomitant hernia repair with panniculectomy. Okusanya et al. (26) described the results of 10 patients with a BMI ?40 kg/m2 who underwent a partial underlay mesh repair at the time of panniculectomy. The wound complication rate was 40%, with a hernia recurrence rate of 10% at a mean follow- up of 1 year. On the other hand, Moreno-Egea et al. (27) performed a randomized prospective trial of 111 patients comparing isolated IH repair versus IH repair combined with abdominoplasty. While there was a signi?cant difference in operative time between the 2 groups, there was no signi?cant difference in early or late morbidity. In addition, there was signi?cant improvement in perceived quality of life in the combined surgery group. Thus, there is conflicting evidence for combining panniculectomy with IH repair.
d) Bariatric surgery with hernia repair:
A number of retrospective case reports, as well as one analysis of large-scale registry data, demonstrate the safety and good short-term results of simultaneous Laparoscopic VHR and and bariatric surgery. Spaniolas et al. (28) studied over 17,000 Roux en Y Gastric Bypass (RYGB) and Sleeve Gastrectomy (SG) patients reported in the National Surgical Quality Improvement Program, of whom 503 underwent synchronous VHR. Patients with concurrent VHR had slightly higher odds of SSI (OR 1.65, P < .05), but there was otherwise no increase in 30-day morbidity or mortality.
One concern of bariatric with hernia repair is the safety of implanting synthetic mesh at the time of stapled bariatric procedures, where the gastrointestinal tract is divided, potentially allowing for mesh contamination. A number of retrospective case series have shown implantation of synthetic mesh at the time of stapled MBS to be safe. In a study by Eid et al. (29), 59 patients underwent concomitant primary sutured UHR, 12 underwent UHR with biological mesh, and UHR was deferred for 14. Early morbidity was minimal in all groups and LOS was not affected by concomitant UHR. At a mean follow-up of 26 months, the authors reported a 22% recurrence rate in patients who underwent sutured UHR and no recurrences in those who underwent mesh UHR, suggesting mesh re- pair is preferable. Furthermore, 38% of patients with deferred hernia repair later developed intestinal obstruction due to incarceration. Raj et al. (30) reported on 36 patients who underwent RYGB or SG with VHR using polypropylene mesh. No mesh infections or hernia recurrences were observed. Raziel et al. (31) reported on 54 patients who underwent bariatric surgery combined with VHR repair with a dual polyvinylidene/polypropylene mesh. No mesh infections occurred, and there was only one recurrence.