Abdominal Wall Reconstruction for Ventral Hernias in the Bariatric Patient: A Unique Challenge

The Hole in the Wall with Samuel Szomstein, MD, FACS
Dedicated to providing a venue for interactive exchange of ideas, interesting topics, and surgical pearls from experts in repair of abdominal wall defects as they relate to bariatric surgery.

A Message from Column Editor Samuel Szomstein, MD, FACS

Dear Readers of Bariatric Times:
I would like to welcome you to this installment of “The Hole in the Wall.” We are very pleased to have Dr. Michael G. Sarr from the Mayo Clinic in Rochester, Minnesota, as our guest expert. Dr. Sarr is a very close friend as well as a role model to me. In this issue we will cover the unique challenges of abdominal wall reconstruction (AWR) for ventral hernias in the bariatric patient. We welcome Dr. Sarr’s expertise and thank him for this contribution to the column.
Once again, welcome to The Hole in the Wall. We hope you will enjoy this column and we look forward to your questions, comments, and participation in future issues.

Sincerely,
Samuel Szomstein, MD, FACS
——-
This month’s installment by Michael G. Sarr, MD, James C. Masson Professor of Surgery, Mayo Clinic, Rochester, Minnesota

Funding: No funding was provided.
Financial disclosures: The author reports no conflicts of interest relevant to the content of this article.

Bariatric Times. 2013;10(9):12–13.

Obesity is a major associated comorbidity in the field of abdominal wall reconstruction (AWR) and vice versa. Obesity predisposes to incisional hernia and especially so in the patient with morbid obesity. This raises several questions, including the following: 1) Should the patient with a large incisional/ventral hernia who has morbid obesity be offered bariatric surgery? 2) Should an incisional hernia be repaired before, during, or after the bariatric procedure? Or not at all? 3) Is the AWR more durable when performed after the weight loss of bariatric surgery?

Should the patient with a large incisional/ventral hernia who has morbid obesity be offered bariatric surgery?
My response to this question is a resolute, “Yes, of course!” We are first physicians, and we all (should) appreciate the benefits to overall health of the weight loss that accompanies bariatric surgery. This concept should be self-evident to most of the readership of Bariatric Times. It always amazes me when I see a patient with a multiple recurrent incisional hernia and neither the internist nor surgeon has suggested bariatric surgery.

Should AWR be performed before, during, or after the bariatric operation?
Surprisingly, there is no consensus on this question. Yes, of course, it is easier to do AWR in the less heavy patient, but if the bariatric procedure is performed first (especially if it requires mobilization of the bowel out of the hernia sac), the possibility of small bowel obstruction in the postoperative period prior to subsequent AWR is increased. Also, closure of the abdominal wall during the bariatric procedure can be difficult and unstable unless the bariatric procedure can be done laparoscopically. A laparoscopic sleeve gastrectomy would probably be best in my opinion.

How about AWR at the time of bariatric surgery? AWR should (in this population) require a permanent prosthetic (component separation without a permanent prosthetic is a primary autogenous repair—very high recurrence rate); a basic surgical dictum is that when the gut is opened, a permanent prosthesis is (almost) contraindicated. While I am certain to get some criticism from a few surgeons on this topic, my response is—think of the wound complications, morbidity, and grief if the prosthesis gets infected.  Yes, unfortunately, I have personal experience with this problem. One exception may be a sleeve gastrectomy.  Use of the expensive bioprosthesis is as of yet unproven, and if used to bridge (patch) a defect, honest herniologists all know the eventual outcome of these expensive biologic dressings, (i.e. another hernia). In contrast, if forced into an open bariatric procedure in the patient with a large ventral hernia, bridging a defect with an expensive bioprosthetic prosthesis may give a more durable abdominal wall stability (8–12 months) to allow for postoperative weight loss than use of the absorbable polyglactin (Vicryl®, Ethicon, Inc., Cincinatti, Ohio) or polyglycolic acid (Dexon™, Covidien, Inc., Norwalk, Connecticut) prostheses, which provide only two to three months stability.

Bariatric surgery first (i.e., weight loss) with AWR later seems the most rational course of action provided it can be done safely and the patient has no obstructive symptoms. After weight loss, the AWR is easier to perform, there is more skin, postoperative morbidity should be less (e.g., wound infection, pneumonia, venous thromboembolism, mobility), and AWR recurrence is less in the less obese patient. Moreover, an abdominoplasty can be done concurrently.

What about not fixing either the hernia or the patient’s weight? The hernia will get bigger (and may be not fixable) and the morbidity of the obesity persists/worsens—not a rational approach. If the patient refuses bariatric surgery, the AWR can be done, but at a greater risk because of the comorbidities of their morbid obesity.

Summary
Is AWR more durable when performed after the weight loss of bariatric surgery?
No one knows.

In summary, bariatric surgery first makes the most sense to me, especially if it can be done laparoscopically without mobilization of the small bowel from the hernia sac. (e.g., laparoscopic sleeve gastrectomy). After weight loss, the AWR combined with abdominoplasty makes the most sense (at least to me).  See the selected resources for more information on this topic.

Resources
1.    Sarr M. Abdominal wall reconstruction in the morbidly obese patient. In: M Nahabedian, P Bhanot, eds. Abdominal Wall Reconstruction. Woodbury, CT: Cine-Med, Inc.; 2013.
2.    Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic repair of ventral hernias: nine years’ experience with 850 consecutive hernias. Ann Surg 2003;283:391–399.
3.    Datta T, Eid G, Nahmias N, Dallal RM. Management of ventral hernias during laparoscopic gastric bypass. Surg Obes Rel Dis. 2008;4:754–758.
4.    Eid GM, Mattar G, Hamad G, et al. Repair of ventral hernias in morbidly obese patients undergoing laparoscopic gastric bypass should not be deferred. Surg Endosc. 2004;18:207–210.
5.    Herbert GS, Tausch TJ, Carter PL.  Prophylactic mesh to prevent incisional hernia: a note of caution. Am J Surg. 2009;197:595–598
6.    Newcomb WL, Polhill JL, Chen AY, et al.  Staged hernia repair preceded by gastric bypass for the treatment of morbidly obese patients with complex ventral hernias. Hernia. 2008;12:465–469.
7.    Raghavendra SR, Gentileschi P, Kini SU.  Management of ventral hernias in bariatric surgery. Surg Obes Rel Dis. 2011;7:110–116.
8.    Schuster R, Curet MJ, Alami RS, et al. Concurrent gastric bypass and repair of anterior abdominal wall hernias. Obes Surg. 2006;16:1205–1208.
9.    Vilallonga R, Fort JM, Gonzalez O, et al. Management of patients with hernia or incisional hernia undergoing surgery for morbid obesity. J Obes. 2011;86092. Epub 2010 Dec 5.
10.    Downey SE, Morales C, Kelso RL, Anthone G. Review of technique for combined closed incisional hernia repair and panniculectomy status post open bariatric surgery. Surg Obes Rel Dis. 2005;1:458–14461.
11.    Foutopoulos K, Kehagias I, Kalfarenzos F. Dermolipectomies following weight loss after surgery for morbid obesity. Obes Surg. 200;10:451–459.

Category: Hole in the Wall, Past Articles