Next consideration is the choice of surgical modality. Ventral hernia repairs have evolved considerably over the years. Traditional open primary suture repairs are falling out of favor especially in the obese population, as the reported recurrence rates have been over 50 % [15]. Open tension-free mesh repairs, including separation of components procedure, have considerably lower recurrence estimated at 20–30 %. Unfortunately, large abdominal incisions in the morbidly obese patients with wide tissue dissection and flap creation result in a fairly high incidence of postoperative morbidity and wound complications [15]. Nevertheless the latter still remains a good option in some patient groups and is still widely used.

Laparoscopic ventral hernia repair was first reported about 20 years ago. Application of this method in certain situations might be advantageous, as it is associated with fewer complications and faster recovery [15–17]. It appears that this advance in hernia repair might benefit the bariatric patient as well, just as recent studies have demonstrated an advantage of the laparoscopic approach over open bariatric surgery [18]. Similarly, shorter hospital stays, decreased pain, lower wound complications, lower recurrence rates, and quicker return to work are reported for laparoscopic ventral hernia repair patients [15–19].

The technique we have chosen to use in our patient population is based on the modified Rives-Stoppa technique. This involves reduction of the hernia and, under laparoscopic vision, outlining the hernia defect on anterior abdominal wall skin using a marker pen. A further outline adds an extra 4-cm overlay margin. An appropriate mesh, depending on the level of contamination during the case, is placed and then tailored to size using the outline on the abdominal wall. Nonabsorbable sutures are placed onto the corners of the mesh, which is then rolled up and introduced into the abdomen through a trocar. Using a Carter-Thomason device, the mesh is anchored into the desired position using the previously placed sutures. The mesh is further anchored with several rows of titanium helical tacks placed circumferentially at about 1-cm intervals. Through several small stab incisions, the mesh is secured in place using nonabsorbable sutures at 3-cm intervals along its circumference. This is also done with the Carter-Thomason device.

Weight loss surgery may be an important adjunct treatment in the management of ventral hernia. Unfortunately, laparoscopic gastric bypass as well as sleeve gastrectomy both require division of the gastrointestinal tract, which results in at least some contamination of the surgical field. In such cases, there is a general lack of acceptance within the surgical community of concomitant bariatric surgery and hernia repair with permanent mesh, due to risk of mesh infection. However, limited data has been reported demonstrating the feasibility of such an approach. A small trial in which ventral hernias were repaired with prosthetic dual meshes in conjunction with laparoscopic gastric bypass has been reported. No mesh infections and two recurrences were seen in this study [20]. While such data does exist, it is by no means considered a standard of care, as it only involves small series with lack of long-term follow-up. Mesh infection, necessitating subsequent mesh removal, is a very morbid and costly problem in an already high risk bariatric patient population, not to mention the high recurrence rates associated with mesh infections and the potential medical-legal implications. For those reasons, we do not favor this approach.

High recurrence rates have been encountered when bio-absorbable mesh is used as a bridge to close the hernia defect in a similar fashion to permanent mesh. Although initial data reported zero recurrence rates at short-term follow-up using this technique concomitantly with laparoscopic gastric bypass, unfortunately, majority of patients will present with a recurrence when followed for over 2 years. While some surgeons routinely use the above technique as a temporary fix with the main goal of avoiding bowel strangulation, clearly it cannot be considered a permanent repair. The reasoning behind this is that deferring repair of the defect carries a significant risk of bowel incarceration and possibly even strangulation, especially when the surgeon reduces an omental incarceration without addressing the underlying hernia [8]. Based on our experience, we believe that the use of bio-absorbable mesh with concomitant laparoscopic gastric bypass can only be effectively utilized as reinforcement for suture repair. On the other hand, concomitant bariatric surgery and hernia repair in patients with unfavorable hernia and body habitus characteristics as described above can be challenging and time consuming. Performing a bariatric procedure at the time of the hernia repair not only adds considerable operation time and risk, but also introduces contamination with subsequent risk for mesh infection as previously mentioned.