Complications and recurrence
There is no one recommended repair technique or ideal BMI for hernia repair in obese patients, the authors wrote. One study found laparoscopic VHRs had a complication rate of 1.2% and reoccurrence rate of 5.5% at mean 25-month follow-up in patients with BMIs of 38 kg/m2 or greater, while a different study with a similar design found a 3.8% reoccurrence rate at 18-month follow-up. Degree of obesity can affect complication rate: One study showed that 73% of all complications after laparoscopic VHR occurred in the group of patients with BMIs of 30 kg/m2 or greater; a different study of laparoscopic VHR had an 8.3% hernia reoccurrence rate in patients with BMIs of 40 kg/m2 or greater, compared with patients at a normal weight (2.9%), with time to hernia reoccurrence being shorter in the higher-BMI group. A study of obese patients undergoing retromuscular open repair had a wound complication rate of 16% and a reoccurrence rate of 6%, with another study of patients undergoing umbilical hernia repair showing similar rates of complication and reoccurrence.
Panniculectomy
Among patients who underwent IH repair with panniculectomy, the authors found a 40% complication rate and a 10% reoccurrence rate in patients with BMIs of 40 kg/m2 or greater who received a partial underlay mesh placement hernia repair, while a different study found an increased risk of surgical site occurrences but not SSI in patients with BMIs of 34.3 kg/m2 or greater who underwent open ventral incisional hernia repair with panniculectomy. A third study found BMIs were not linked to a 55% complication rate in patients who underwent open ventral IH repair with and without mesh.
Simultaneous surgery
The authors noted that studies have shown that performing laparoscopic hernia repair and metabolic and bariatric surgery simultaneously is safe and has good short-term results. Specifically, patients who underwent the surgery with synthetic mesh had a low rate of infection or reoccurrence. Patients who underwent simultaneous weight-loss surgery and VHR had an elevated risk of SSI but no increased rate of 30-day mortality or morbidity, according to results from a large-scale registry. However, the authors noted patients with severe obesity may not be good candidates for simultaneous metabolic and bariatric surgery [MBS] and VHR, such as in patients with “large abdominal wall defects, loss of abdominal domain, extensive intestinal adhesive disease, poor quality skin (i.e., attenuated skin, prior skin graft, or ulcerated skin), incarcerated hernias containing bowel, hernias with previous synthetic mesh, hernias with chronic infection, or patients who have already undergone MBS with altered anatomy that is still intact.”
Preop weight loss
There is mixed data on the effect of weight loss prior to VHR through interventions such as very-low-calorie diets, pharmacotherapy, intragastric balloon therapy, and MBS as a first-stage procedure prior to VHR. Many patients treating their obesity with very-low-calorie diets lose approximately 10%-20% of their initial body weight and keep the weight off for at least 18 months, while one study showed patients who underwent intragastric balloon therapy lost approximately 10% of their body weight over 6 months; however, other studies have questioned the efficacy of this therapy, compared with a structured weight loss program or bariatric surgery. The authors also noted the difficulty of coordinating VHR after weight-loss surgery, lack of support from insurers, and they cited reports that cautioned bariatric surgeons to not leave hernias untreated during MBS. There is no current evidence pharmacotherapy through Food and Drug Administration–approved weight-loss drugs prior to hernia repair yield the weight-loss results needed for these patients to improve hernia outcomes, they added.
“Ultimately, there are various appropriate treatment modalities for each patient, and surgeons must use their judgment in selecting from among the different feasible options,” Dr. Lo Menzo and his colleagues wrote in the guidelines.
The authors report no relevant conflicts of interest.
SOURCE: Lo Menzo E et al. Surg Obes Relat Dis. 2018 Jul 19. doi: 10.1016/j.soard.2018.07.005.