Management of Abdominal Wall Hernias in the Bariatric Patient

Pros

Cons

One anesthetic, one convalescence

Risk of infection of prosthetic-based herniorrhaphy

Less overall cost

Possible need for open hernia repair

Less absence from work

Need for concomitant full abdominal wall reconstruction^a

Possible dual-laparoscopic procedures

More difficult hernia repair

Prevents complications of hernia (obstruction, pain) while awaiting hernia repair

Greater risk of hernia recurrence

Fewer options for type of hernia repair

Need for future abdominoplasty

^aRequiring tissue transfers, rotational flaps, etc.

In contrast, there are several potentially compelling reasons to avoid a simultaneous procedure. First, all bariatric procedures except an LAGB open the gut with the potential risk of intraperitoneal/wound bacterial contamination, thereby risking infection of the prosthesis used to repair the hernia. This consideration may be especially pertinent if the herniorrhaphy requires an open approach and/or a true abdominal wall reconstruction necessitating tissue transfer (component separation , skin/subcutaneous advancement flaps, wide sublay on onlay repairs with the prosthetic “patching” of the defect in the subcutaneous space, as opposed to being covered by musculofascial autogenous tissues, etc.). In addition, many surgeons maintain that repair of the abdominal wall hernia, especially if large, is much easier in patients after substantial weight loss and that the risk of recurrence is less. Also, the type of hernia repair possible may be limited in the morbidly obese for both technical reasons or because of concerns about wound complications or prosthetic-based infections. If a future abdominoplasty is probable, a second operation under general anesthesia will be necessary, and the hernia repair may very well have been easier at the time of abdominoplasty. Finally, in some cases, with the gain of intra-abdominal domain after substantial weight loss, the use of mesh may potentially be avoided altogether for smaller hernias due to the development of extreme laxity of the abdominal wall.

15.3.1.2 Staged Repair—Bariatric Surgery First, Hernia Repair Later

Many surgeons argue that a staged approach is best for multiple reasons (Table 15.2). First, the morbidity and possibly mortality of any abdominal operation are increased, especially for formal abdominal wall reconstructions that require more than just a laparoscopic sublay herniorrhaphy in patients with medically complicated obesity. Second, the hernia operation after weight loss is technically easier, more options are available (more skin to advance, less poorly vascularized subcutaneous fat, possibility of avoiding the use of mesh), and often the herniorrhaphy and an abdominoplasty (for redundant lower abdominal skin and subcutaneous tissue after the bariatric-induced weight loss) can be performed simultaneously. Finally, the risk of hernia recurrence is less after substantial weight loss.

Table 15.2

Bariatric surgery FIRST, abdominal wall herniorrhaphy SECOND

Pros	Cons
Healthier patient at the time of herniorrhaphy^a	Hernia-related pain/symptoms persist
Easier herniorrhaphy^a	Hernia can enlarge, incarcerate, strangulate, or cause small bowel obstruction^b
More options for herniorrhaphy	Hernia may interfere with a bariatric procedure
More skin to use for herniorrhaphy^a	More adhesions at the time of herniorrhaphy
Can do simultaneous abdominoplasty
Less chance for hernia recurrence^a

^aWeight much less

^bWhile awaiting weight loss, especially if bariatric procedure required mobilization of bowel from within the hernia

But others will acknowledge arguments against bariatric surgery prior to hernia repair (Table 15.2). Most importantly, the strongest arguments include the following question—How should we manage the patient who is very symptomatic from their hernia? We know that a certain percentage of patients with an abdominal wall hernia, especially incisional hernias , develop complications such as incarceration, strangulation, or enlargement of the hernia; moreover, these hernias themselves can cause a small bowel obstruction independent of incarceration/strangulation. There is also concern that the reduction of hernia contents (omentum/bowel) that is often necessary when performing RYGB or BPD/DS without definitive repair may predispose to future hernia complications such as incarceration with possible obstruction or strangulation. Other considerations include the possibility of the bariatric operation increasing the difficulty of the hernia operation or that a very large hernia may necessitate an open bariatric operation or may prevent the possibility of a laparoscopic approach. Finally, repairing the hernia first may allow a later laparoscopic, minimally invasive bariatric operation.

15.3.1.3 What Are the Data?

Does Obesity Predispose to Recurrence of Abdominal Wall Herniorrhaphy?

The answer is “yes.” Although we all as surgeons “know” this by experience, there are studies which document this increase in recurrence. Possibly the most visible study is that of the large prospective study of laparoscopic incisional herniorrhaphy by Heniford and colleagues [2]. Unfortunately, there are no other good studies addressing the incidence of recurrent hernia after a primary incisional hernia repair in patients with BMI ≥ 35. The remainder of this chapter addresses the bariatric patient with an abdominal wall hernia.

Incisional hernias develop in ~20–25 % of patients undergoing open bariatric surgery. Thus, obesity predisposes to hernia formation after any celiotomy, and many patients we see (or should see) with medically complicated obesity have an abdominal wall hernia and/or have a recurrent abdominal wall hernia. Therefore, the association of medically complicated obesity and abdominal wall hernia is not at all uncommon, and especially so for umbilical hernias.