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| ORIGINAL ARTICLE |
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| Year : 2020 | Volume
: 3
| Issue : 1 | Page : 1-3 |
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Obesity as a risk factor for complications and recurrences after ventral hernia repair
Elena Pareja Nieto, Carme Balague Ponz, Sonia Fernández Ananin, Eulalia Ballester Vazquez
General and Digestive Surgery Department, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| Date of Submission | 21-Aug-2019 |
| Date of Decision | 04-Sep-2019 |
| Date of Acceptance | 22-Sep-2019 |
| Date of Web Publication | 17-Feb-2020 |
Correspondence Address:
Elena Pareja Nieto
Avenida Industria 56, Bajos 1. 08960. Sant Just Desvern, Barcelona
Spain
 Source of Support: None, Conflict of Interest: None  | 8 |
DOI: 10.4103/ijawhs.ijawhs_35_19
OBJECTIVES AND BACKGROUND: Ventral hernias are a frequent reason for surgical consultation, and its incidence is higher in the obese population. In this article, we analyze the relationship between obesity and abdominal wall pathology and its influence in surgical results.
PROCEDURE: A literature search strategy was performed to analyze this relationship.
RESULTS: Obesity is not only a risk factor for the appearance of abdominal wall hernias and incisional hernias but also for complications after ventral hernia repair. Obesity also increases the risk of incarceration and recurrence after repair. In these patients, the laparoscopic approach minimizes the risk and comorbidity generated by obesity in abdominal wall surgery obtaining better results. Joint surgery with laparoscopic bariatric surgery seems to be a feasible technique with lower recurrence rates in different studies. Despite these results, conclusive studies are still insufficient to make recommendation concerning hernia repair in patients undergoing bariatric surgery.
CONCLUSIONS: There is a strong association between obesity and abdominal wall hernias, and the laparoscopic approach seems to offer better results regarding comorbidity of obesity.
Keywords: Bariatric surgery, incisional hernia, laparoscopy, obesity, ventral hernia
How to cite this article:
Nieto EP, Ponz CB, Ananin SF, Vazquez EB. Obesity as a risk factor for complications and recurrences after ventral hernia repair. Int J Abdom Wall Hernia Surg 2020;3:1-3 |
| Introduction | |  |
Ventral hernias are a frequent reason for surgical consultation,[1] but overweight or obese patients are often asked to lose weight before repair to reduce the risk of abdominal wall pathology. The incidence of ventral and incisional hernias is higher in the obese population than in normal-weight individuals.
The relationship between obesity and hernia repair offers different aspects from the appearance of hernias to the development of eventrations or the appearance of complications.
Objectives
The aim of this review is to analyze the relationship between obesity and abdominal wall pathology and its influence on surgical results and the management of hernias in bariatric surgery.
| Procedure | | |
We searched MEDLINE and ClinicalKey. Searches of reference lists of identified trials, journal supplements, relevant book chapters, and conference proceedings were also performed to identify further relevant trials. The World Wide Web was also searched.
| Results | | |
Obesity and ventral hernia – Risk of appearance and complications
Several studies relate obesity with the appearance of primary ventral hernias. In a sample of 26,268 patients from 14 hospitals, Lau et al.[2] stratified patients with obesity and ventral hernia according to the body mass index (BMI) and confirmed that the higher the BMI, the greater the risk of abdominal wall hernia. In addition, a BMI >40 was associated with an increased risk of incarceration, reaching a maximum in patients with a BMI >60 (odds ratio: 12.7, P < 0.0001).
Obesity is also a risk factor for the development of incisional hernias. In a prospective clinical trial, Veljkovic et al.[3] analyzed the possible predictors of early development of incisional hernias in middle laparotomy. In a series of 700 cases, a significant association was observed with the BMI. The incidence of incisional hernia below a BMI of 24.4 kg/m2 was 7.8%, but it reached 18.8% when BMI was >24.4 kg/m2 (P< 0.001). In addition, through the multivariate analysis, BMI >24.4 kg/m2 was identified as a predictive independent factor of the early appearance of incisional hernia (P = 0.03).
Similarly, other studies relate obesity to the recurrence of incisional hernias after repair. In the Sauerland et al.[4] study, for example, in which 160 patients were prospectively surveyed to identify predictive factors of recurrence a statistically significant relationship with obesity was identified (P = 0.03). Other studies also reached these conclusions.[5],[6]
Numerous studies suggest that obesity is not only a risk factor for the appearance of abdominal wall hernias but also for complications of ventral hernia repair. In a cohort of 102,191 patients, Owei et al.[7] retrospectively analyzed the relationship between BMI and postoperative complications of this surgery. They observed that the risk of complications for patients with BMI >40 kg/m2 was higher and that complications ranged from surgical wound infection to evisceration. The most common complication was infection of the superficial surgical wound.
In a series of 992 patients undergoing open ventral hernia repair, Pernar et al.[8] reached similar conclusions. Patients were stratified into five groups according to the BMI, and the authors observed a progressively greater risk of complications, both medical and surgical, as the BMI increased. The incidence of complications for patients with a BMI over 40 was 16.5%, while for patients with BMI <30, this percentage decreased to 5.7% (P = 0.002). They concluded that complications were most likely to occur in patients with BMI over 40, the same group of patients who have a significantly higher risk of undergoing surgery for a recurrent hernia.
Benefits of laparoscopy for obese patients undergoing hernia repair
Obesity is clearly a risk factor for postoperative complications. One of these complications is surgical site infection (SSI).
The risk of SSI can be related to the surface area of fat exposed to the environment and potential contaminants during open surgery. As the laparoscopic approach reduces exposed fat, it can reduce the incidence of SSI.
This was the hypothesis of Fekkes and Velanovich[9] who compared laparoscopic versus open ventral hernia repair in a series of 12,000 patients. They observed that SSI was significantly lower with laparoscopy than with the open approach in patients with a BMI over 30. The laparoscopic group also had better results in terms of the need for blood transfusions and the length of hospital stay.
In 2017, Owei[7] related BMI to postoperative complications in open hernia surgery. In 2019, these same authors[10] carried out a similar study, but this time, they analyzed the relationship with laparoscopic surgery. Significant differences were found in open approach with BMI >35, while in laparoscopic approach, differences appear from BMI >50.
These findings support the notion that the laparoscopic approach minimizes the risk and comorbidity generated by obesity in abdominal wall surgery.
Bariatric surgery and abdominal wall surgery
Weight loss is commonly recommended in obese patients prior to ventral hernia surgery. However, according to some studies, those with the highest BMI are not those who lose weight.[7]
Can a candidate for bariatric surgery with abdominal hernia benefit from a concomitant intervention? Does this improve the results of hernia surgery? Krivan et al.[11] analyzed this hypothesis and concluded that joint surgery is a feasible technique with a low recurrence rate. In addition, they found that the laparoscopic approach was superior to the open approach; they observed a recurrence rate of 8.5% versus 14.9% and an infection rate of 1.7% and 10.6%, respectively.
In another recent study, Palanivelu et al.[12] analyzed their experience of concomitant bariatric surgery with laparoscopic ventral hernia mesh repair with intraperitoneal onlay mesh repair (IPOM). They concluded that this approach is effective and safe and reduces the risk of recurrence.
Despite these results, conclusive studies are still insufficient to make recommendation concerning hernia repair in patients undergoing bariatric surgery.
In a recent systematic review, Palanivelu et al.[12] concisely summarized part of the recommendations published by Menzo et al.[13] (American Society for Metabolic and Bariatric Surgery and American Hernia Society Consensus Guideline on Bariatric Surgery and Hernia Surgery). Palanivelu stated:
“Treatment options include:
- Bariatric procedure first leaving the omental plug intact followed by IPOM after substantial weight loss. It is not recommended in case of spontaneously or surgically reducing the hernia with posterior pneumoperitoneum due to risk of incarceration
- IPOM first followed by bariatric surgery after a few months. In this case, here is the problem of not addressing obesity, which is a risk factor for hernia and also the appearance of adhesions that make the second surgery difficult
- Bariatric procedure with anatomic repair of the hernia defect. This approach is only limited to small (<2 cm) primary ventral hernias, because de high incidence of recurrence and obstruction of large hernias
- Concomitant IPOM with bariatric surgery. Here are 2 issues with this approach: Risk of mesh infection and the management approach of the patient if there is a staple line or anastomotic leak.”
| Conclusions | | |
In summary, there is a strong association between obesity and abdominal wall hernias. The laparoscopic approach seems to offer better results regarding the comorbidity of obesity. The recommendation to repair hernias in patients undergoing bariatric surgery continues to be limited to specific cases, and evidence does not yet allow a clear recommendation.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Poulose BK, Shelton J, Phillips S, Moore D, Nealon W, Penson D, et al. Epidemiology and cost of ventral hernia repair: Making the case for hernia research. Hernia 2012;16:179-83.  |
| 2. | Lau B, Kim H, Haigh PI, Tejirian T. Obesity increases the odds of acquiring and incarcerating noninguinal abdominal wall hernias. Am Surg 2012;78:1118-21. |
| 3. | Veljkovic R, Protic M, Gluhovic A, Potic Z, Milosevic Z, Stojadinovic A, et al. Prospective clinical trial of factors predicting the early development of incisional hernia after midline laparotomy. J Am Coll Surg 2010;210:210-9. |
| 4. | Sauerland S, Korenkov M, Kleinen T, Arndt M, Paul A. Obesity is a risk factor for recurrence after incisional hernia repair. Hernia 2004;8:42-6. |
| 5. | Itatsu K, Yokoyama Y, Sugawara G, Kubota H, Tojima Y, Kurumiya Y, et al. Incidence of and risk factors for incisional hernia after abdominal surgery. Br J Surg 2014;101:1439-47. |
| 6. | Mureşan M, Mureşan S, Bara T, Neagoe R, Sala D, Suciu B. Hernia recurrence long term follow-up after open procedures of abdominal wall plasty-prospective study including 142 patients. Cir Cir 2016;84:376-83. |
| 7. | Owei L, Swendiman RA, Kelz RR, Dempsey DT, Dumon KR. Impact of body mass index on open ventral hernia repair: A retrospective review. Surgery 2017;162:1320-9. |
| 8. | Pernar LI, Pernar CH, Dieffenbach BV, Brooks DC, Smink DS, Tavakkoli A, et al. What is the BMI threshold for open ventral hernia repair? Surg Endosc 2017;31:1311-7. |
| 9. | Fekkes JF, Velanovich V. Amelioration of the effects of obesity on short-term postoperative complications of laparoscopic and open ventral hernia repair. Surg Laparosc Endosc Percutan Tech 2015;25:151-7. |
| 10. | Owei L, Swendiman RA, Torres-Landa S, Dempsey DT, Dumon KR. Impact of body mass index on minimally invasive ventral hernia repair: An ACS-NSQIP analysis. Hernia 2019;23:899-907. |
| 11. | Krivan MS, Giorga A, Barreca M, Jain VK, Al-Taan OS. Concomitant ventral hernia repair and bariatric surgery: A retrospective analysis from a UK-based bariatric center. Surg Endosc 2019;33:705-10. |
| 12. | Praveen Raj P, Bhattacharya S, Saravana Kumar S, Parthasarathi R, Cumar B, Palanivelu C, et al. Morbid obesity with ventral hernia: Is concomitant bariatric surgery with laparoscopic ventral hernia mesh repair the best approach? An experience of over 150 cases. Surg Obes Relat Dis 2019;15:1098-103. |
| 13. | Menzo EL, Hinojosa M, Carbonell A, Krpata D, Carter J, Rogers AM, et al. American society for metabolic and bariatric surgery and American hernia society consensus guideline on bariatric surgery and hernia surgery. Surg Obes Relat Dis 2018;14:1221-32. |
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