Ventral Hernia Repair in the Morbidly Obese Patient: A Review of Medical and Surgical Approaches in the Literature

Abstract

Background:

Obesity is a risk factor for ventral hernias. As obesity becomes more prevalent, general surgeons will be faced with managing complex ventral hernias in the obese. Consensus is that weight loss improves outcomes in obese patients undergoing ventral hernia repair (VHR), but there is no agreement on the best approach.

Methods:

We conducted a literature search using EMBASE and Medline using the terms “hernia,” “morbid,” and “obesity.” We identified studies discussing the medical or surgical management of obesity with VHR. We assimilated the data into a literature review discussing management options for ventral hernia in the obese patient.

Results:

Fourteen articles were utilized in this review. Hernia repair preceded by physician monitored medical weight loss, concomitant hernia repair with weight loss surgery, or weight loss surgery staged prior to or after hernia repair were all viable options to approach this problem. However, there are limited level 1 data to address this problem.

Conclusions:

The data suggest that medical or surgical approaches to weight loss along with VHR are feasible options. The choice depends upon many factors involving the surgeon, patient, and institution. There is limited level 1 evidence as to the best approach or standard of care.

Introduction

Obesity, both in the United States and worldwide, is an epidemic. Over the past 30 years, the percentage of the U.S. population with a body mass index (BMI) >30 kg/m² has more than doubled.¹ Similar findings are being observed in worldwide populations, particularly in Europe, where the percentage of the population reaching BMIs >30 kg/m² is steadily increasing.² This trend has significant health-related implications, including hypertension, diabetes, heart disease, cholecystitis and cholelithiasis, menstrual and reproductive difficulties in women, and vascular disease. The increased intra-abdominal pressure of these patients also puts them at greater risk for developing abdominal wall defects.³

Repair of a ventral or incisional hernia is a common operation, performed with increasing frequency in general surgical practice.⁴ Studies evaluating the development of ventral or incisional hernias in patients undergoing primary elective midline laparotomy report incidence as high as 11–20% at 1 year.^5,6 Open repair for large midline hernias is often complicated by hernia recurrence as high as 52% with traditional suture repair, as well as surgical site infection.⁷ The Stoppa technique of placing prosthetic mesh anterior to the posterior rectus sheath has improved outcomes in open hernia repair. However, recurrence rates of 14.5% are still reported.⁸ As advancements in minimally invasive techniques become more refined, some authors have found laparoscopic hernia repair to be associated with fewer complications, lower recurrence rates, and faster recovery than open repair.^9,10

Indeed, obesity is a proven risk factor for the development of ventral hernias, as well as the risk factors of smoking, re-laparotomy or large midline wound, surgical site infection, and chronic steroid use.¹¹ Obesity increases the chances of emergent presentation and need for emergent surgery in patients with incisional hernia, negatively impacting morbidity and mortality.¹² In addition, ventral hernias in obese patients present a challenge for surgeons because of the greater risk of systemic and local wound complications, and the additional risks of small bowel obstruction, ischemia, and infection of mesh in prior repairs, which increase the morbidity of this patient population.¹³ In fact, repair of incisional and ventral hernias in morbidly obese patients with a BMI >35 kg/m² has an almost 20% morbidity rate, increased operative time, and increased length of stay (LOS).^14,15 Increasing numbers of complex abdominal wall repairs are being performed in the obese.¹⁶ Therefore, attention must be given to this vulnerable patient population with this complex disease process.

A number of options exist for the management of incisional or ventral hernias in the morbidly obese patient. These include (1) hernia repair without weight loss, (2) hernia repair with preoperative or postoperative medical weight loss, or (3) staged or concomitant surgical weight loss with hernia repair. The advent of bariatric surgery and its rapid advancement have been critical in reducing the impact of medical comorbidities in obese patients, including those related to diabetes mellitus, hypertension, and cardiovascular disease.¹⁷ As such, this idea has also been applied toward mitigating the effects of morbid obesity on incisional hernia, with increasing literature discussing the role of bariatric surgery in managing this morbidity. As a result, surgeons can consider these patients for combined or staged surgical procedures to help reduce morbidity and recurrence. In this review, we aim to outline the medical and surgical options for weight management in the context of determining the optimal time for ventral hernia repair (VHR) with or without bariatric surgery in this population.

Options for Treatment of Ventral Hernias in Obese Patients

Despite advancements in the fields of medical and surgical weight loss, and open and laparoscopic hernia surgery, there is no clear consensus on how best to manage ventral and incisional hernias in overweight and obese patients. Reasons include the difficulty in establishing clinical trials for this patient population, and the complicated and varied nature of the medical problem¹⁸ and surgical treatment. A review of the literature suggests the following approaches, for combined weight loss and hernia management (Table 1):

Table 1.

Relevant Studies Reviewed

Title	Authorship	Journal	Year of Publication	Type of study
Staged Hernia Repair Preceded by Gastric Bypass for the Treatment of Morbidly Obese Patients with Complex Ventral Hernias	Newcomb	Hernia	2008	RS
Outcome Laparoscopic Ventral Hernia Repair in Morbidly Obese Patients with a Body Mass Index Exceeding 35 kg/m²	Raftopoulos	Surgical Endoscopy	2007	PS
Ventral Hernias in Morbidly Obese Patients: A Suggested Algorithm for Operative Repair	Eid	Obesity Surgery	2013	PS
A Review of Incisional Hernia Repairs: Preoperative Weight Loss and Selective Use of the Mesh Repair	Chan	Hernia	2005	RS
Concurrent Gastric Bypass and Repair of Anterior Abdominal Wall Hernias	Schuster	Obesity Surgery	2006	RS
Concomitant Laparoscopic Ventral Hernia Mesh Repair and Bariatric Surgery: A Retrospective Study from a Tertiary Care Center	Raj	Obesity Surgery	2012	RS
Concomitant Bariatric and Ventral/Incisional Hernia Surgery	Raziel	Surgical Endoscopy	2013	RS
Laparoscopic Ventral Hernia Repair (LVHR) in Morbidly Obese Patients	Tsereteli	Hernia	2008	RS
Laparoscopic Ventral Hernia Repair in Obese Patients: A New Standard of Care	Novitsky	Archives of Surgery	2006	RS
Surgeon's Requirement for Obesity Reduction: Its Influence on Weight Loss	Goldberg	American Surgeon	2012	RS
Feasibility of a Supervised Inpatient Low-Calorie Diet Program for Massive Weight Loss Prior To RYGB in Superobese Patients	Huerta	Obesity Surgery	2010	PS
Laparoscopic Repair of Ventral Hernias: Nine Years' Experience with 850 Consecutive Hernias	Heniford	Annals of Surgery	2003	RS
Laparoscopic vs Open Ventral Hernia Repair in the Era of Obesity	Lee	JAMA Surgery	2013	RS
Long-Term Outcomes in Laparoscopic vs Open Ventral Hernia Repair	Bingener	Archives of Surgery	2007	PS

RS, retrospective study; PS, prospective study.

1. Medically supervised or medically recommended weight loss followed by VHR.

2. Surgical weight loss combined with VHR:

a. Concomitant approach

b. Bariatric surgery with VHR staged approaches:

i. Bariatric surgery followed by VHR

ii. VHR followed by bariatric surgery.

Nonsurgical weight loss and hernia repair

One option to reduce perioperative morbidity and mortality of VHR in obese patients is to promote weight loss prior to surgery, primarily through diet and exercise. Eid et al.¹⁹ in their study of 28 patients, identified two patients who qualified for medical weight loss prior to surgery according to their algorithm, which grouped obese patients based on their anatomy (favorable vs. unfavorable) and presence of obstructive symptoms due to their ventral hernia. Patients underwent a low calorie diet for up to 12 weeks with an average of 4–5 lb weight loss per week. They subsequently received concomitant bariatric surgery and hernia repair, of which there was one recurrence, no mortality, and no wound infections.

Chan et al.²⁰ retrospectively reviewed 236 patients undergoing ventral incisional hernia repair for rate of recurrence and risk factors. In obese patients with a BMI >30 kg/m² (35.6% of patients), the desired weight loss goal was a BMI <28 kg/m², with a desired loss of 11±13 kg. After a period of 2–6 months, the number of patients with a BMI >30 kg/m² was reduced to 13.3%, resulting in an immediate preoperative average BMI of 26.4 kg/m² compared to an initial BMI of 28.9 kg/m². There were 15 recurrences (8%) with risk analysis indicating large hernia (>6 cm), postoperative surgical site infection (SSI), and GI complications to be significantly related to the recurrence. No larger studies have been done to highlight the benefit of medical weight loss in the obese population prior to hernia repair.

Preoperative weight loss prior to general surgical procedures to decrease overall morbidity is a worthy goal, albeit a difficult one. Interestingly, Goldberg et al. showed that patients directed by a surgeon to lose weight to prepare for an elective general surgical procedure were more likely to reach their target weight, and overall had better weight loss than patients without surgery as an endpoint.²¹ The weight loss was modest, and there was no follow-up on the overall outcomes of patients that lost weight prior to surgery versus those that did not, although that was not the focus of the study. Preoperative weight loss prior to bariatric surgery is routine at most centers, and it is even feasible to achieve massive weight loss in the superobese prior to bariatric surgery.²² Preoperative medical weight loss prior to ventral hernia surgery is an excellent option, and for many complex patients, it is possibly the only option toward a safer hernia repair with the potential for low recurrence and morbidity.

Surgical weight loss and hernia repair

Laparoscopic versus open repair

Although a discussion of the merits and disadvantages of laparoscopic ventral and incisional hernia repair (LVHR) is beyond the scope of this review, the central relevance of this issue toward the management of obese patients with abdominal wall hernias is worthy of consideration. LVHR, overall, has been shown in multiple studies to result in decreased LOS, fewer postoperative complications, and reduced recovery time^23,24 compared to open repair. The largest cohort to date consists of 47,661 obese patients who underwent VHR from 2008 to 2009.¹⁵ A fourfold increase in the use of LVHR versus open repair was noted during the study period. Outcome analysis showed a significantly shorter LOS (3 vs. 4 days; p<0.001), reduced postoperative wound (0.1% vs. 1.5%; p<0.001) and pulmonary complications (2.4% vs. 4.8%; p<0.001), and reduced overall complication rate (6.3% vs. 13.7%; p<0.001). A smaller study evaluated patients undergoing either laparoscopic or open VHR over 10 years at a single institution.²⁵ Patients were similar in their demographics. However, the number of patients undergoing repair as a result of an incarcerated hernia was significantly higher in the open group. The authors found a significantly lower hernia recurrence rate in the open (9%) versus laparoscopic (13%) group, and a decreased overall complication rate (15% vs. 9%; p<0.01) and LOS (0.9 vs. 1.4; p=0.01) in the laparoscopic versuss open group respectively.

Although the benefits of laparoscopic hernia repair have been extensively studied, similar studies in the obese population are not as prevalent. In a retrospective review, Novitsky et al. evaluated 163 patients with a BMI >30 kg/m² undergoing LVHR and found a low rate of conversion to laparotomy, minimal perioperative morbidity, and a low recurrence rate of 5.5% overall. Similarly, Tsereteli et al. evaluated the feasibility of LVHR in two groups: morbidly obese (BMI >40 kg/m²) and obese (BMI <40 kg/m²) patients. The groups differed in that the morbidly obese group had longer operative times (154 vs. 119 minutes; p<0.01) and required larger mesh (449 vs. 349 cm²; p=0.002). They found a significantly higher rate of recurrence in the morbidly obese group, but no significant difference in the rate of complications, suggesting that LVHR in the morbidly obese is safe and feasible.

Concomitant bariatric surgery with VHR

Frequently, patients with ventral hernias undergoing elective abdominal operations will have their VHR performed at the same time, depending on the characteristics of the hernia and the patient. This has also applied to morbidly obese patients with ventral hernias undergoing a laparoscopic bariatric procedure. Schuster et al.²⁶ reviewed 12 patients who underwent concurrent laparoscopic Roux-en-Y gastric bypass (LRYGB) and anterior wall hernia repair. The average BMI was 50.4±10.3 kg/m² with an average age of 54.9±8.5 years. All patients had prosthetic mesh repair of their hernias using either polypropylene/cellulose or polyester/collagen, except one who underwent primary repair. At 14-month follow-up, there were two recurrences: one in the patient with primary repair, and a second in a patient who had two previous failed repairs. In the previously mentioned study by Eid et al., the largest subgroup comprised 20 patients who qualified for concomitant LRYGB and VHR performed with biologic mesh of porcine intestinal submucosa. Only two recurrences were noted in the 2-year follow-up period. Raj et al.²⁷ reviewed their database to identify patients who underwent concomitant LRYGB or laparoscopic sleeve gastrectomy (LSG) with VHR. Of the 36 patients who had combined surgery, 25 underwent LSG and 11 LRYGB with primary suture repair of the hernia defect followed by composite mesh placement and 5 cm overlap at the fascial level. They reported no incidence of mesh infection and one occurrence of subacute intestinal obstruction, which was relieved by laparoscopic intervention.

Recently, Raziel et al.²⁸ published a retrospective review of 54 patients who underwent concomitant bariatric surgery and VHR, with 89% (N=48) undergoing LSG and the remainder LRYGB, open RYGB, and laparoscopic gastric banding (N=2 each). The hernia repair was done using a dual mesh. One patient with a hernia recurrence declined reoperation, and six patients (11%) had complications including anastomotic leak, abdominal wall hematoma, and PE. However, they had no infectious complications. Chan et al. studied 45 patients over 6 years from a prospective database, which revealed a low rate of mesh infection and zero mortality with a respectable operative, in morbidly obese patients with ventral hernias who underwent simultaneous surgery.

Bariatric surgery followed by VHR

A common belief is that patients should have a lower BMI at the time of the VHR to reduce the risk of recurrence and complication. Several authors have investigated the role of surgical weight loss prior to hernia repair. In a retrospective review of patients with ventral hernias, 27 morbidly obese patients were identified and underwent either laparoscopic or open RYGB prior to VHR. Mean BMI dropped from 55 kg/m² to 33 kg/m², and VHR was staged at a mean of 1.3 years after the weight loss operation (range 0.9–1.3 years). No patients developed recurrence of their hernia at 20-month follow-up. However, one patient developed small bowel obstruction from incarceration and required emergent surgery.² Eid et al. identified three patients using the algorithm previously described that qualified for bypass surgery followed by LVHR. They reported one occurrence of hernia incarceration that required emergent repair with placement of permanent ePTFE based mesh.

VHR followed by bariatric surgery

One of the complications of ventral hernias in obese patients is that of small bowel obstruction, which Eid et al.¹² used as criteria to perform a laparoscopic VHR followed by a bariatric procedure at a later date. Per their algorithm, these patients had partial or complete bowel obstruction and at least two hospitalizations for abdominal pain. They identified three patients meeting these criteria who underwent hernia repair using a modified Rives-Stoppa technique with intra-abdominal placement of permanent mesh followed by LRYGB. No hernia recurrences occurred in this subgroup.

Discussion

The advancement of laparoscopy and improvement in surgeon training continue to impact the management of ventral hernias in the obese population.¹⁵ For those patients not eligible for weight loss surgery or those that do not desire it, laparoscopic hernia repair appears to have an advantage. The decreased LOS, reduction in wound complications and overall complications with LVHR versus open repair are consistently demonstrated.^9,10,14,15 In the retrospective review by Lee et al.,¹⁸ the authors report that data are lacking with regard to development of postoperative wound complications in the outpatient setting, which may underestimate the true incidence of such complications. When taken in the context of a reduced postoperative inpatient observation, the incidence of surgical site infections may be quite significant and should be further evaluated with long-term follow-up.

Although no large studies exist to evaluate the superiority of combined bariatric surgery and VHR, either concomitantly or staged, multiple small studies demonstrate success of concomitant bariatric surgery with hernia repair. Schuster et al.¹⁷ showed a low infection rate and low hernia recurrence in their prosthetic mesh repairs. They report a change from polypropylene/cellulose to polyester/collagen mesh without a higher rate of infection or recurrence. Additionally, their results with mesh repair allow surgeons to conclude that the long-standing fear of placing mesh in a clean-contaminated or contaminated field is not fraught with high infection rates.

Most recently, a study by Carbonell et al. corroborated findings of favorable infection, recurrence, and mesh removal rates when synthetic mesh is used in clean-contaminated or contaminated fields (such as those of RYGB and LSG).²⁹ Their findings suggest there is a role for synthetic mesh placement in complex fields that is comparable to that of biologic mesh. However, because this is a retrospective review, the potential for selection bias exists and may underestimate the true incidence of mesh-related complications in these patients. Therefore, a large-scale, prospective randomized trial is needed to define practice guidelines further, despite overall positive results from this series.

The outcomes of the studies reported earlier suggest that concomitant bariatric surgery and ventral hernia repair may be superior to performing a staged procedure in those patients that are candidates for weight loss surgery. They report overall hernia recurrence rates of 9–10%, which are comparable to those reported with staged procedures and avoid the potential complication of bowel obstruction that occurs in the waiting period. Concomitant procedures also have the advantage of subjecting the patient to a single surgical intervention and no significantly increased risk of adverse outcomes. Despite the positive outcomes, the main limitation is the small sample size in each treatment group and the variability in patient demographics among the studies.^13,17,19

Conclusion

The studies discussed above address the concerns among general and bariatric surgeons when faced with incisional or ventral hernias in the obese and morbidly obese populations. With regard to laparoscopic versus open hernia repair, the data suggest that the laparoscopic approach is superior and should be the primary procedure of choice in patients without contraindications to laparoscopic surgery. For patients with a ventral hernia requiring or desiring a bariatric procedure, the majority of the data suggests that a concomitant approach is safe and should be considered. It is important to note that the more commonly performed procedures are LRYGB and LAGB, with fewer studies providing data from LSG. Finally, although the data regarding the use of prosthetic mesh in clean or clean-contaminated cases are not substantiated by multiple studies, the initial data appear to favor the use of prosthetic mesh without a significant increase in mesh infection. With this in mind, the option of concomitant bariatric surgery and ventral hernia repair appears to be a more feasible and preferred surgical intervention.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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