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Hernia Repairs in the Obese Timing and technique

Hernia Repairs in the Obese Timing and technique. Gina L. Adrales MD, MPH, FACS Associate Professor Dartmouth Medical School Dartmouth-Hitchcock Medical Center. Hernia repairs in the obese. Overview Timing and technique of hernia repair when…

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Hernia Repairs in the Obese Timing and technique

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  1. Hernia Repairs in the ObeseTiming and technique Gina L. Adrales MD, MPH, FACS Associate Professor Dartmouth Medical School Dartmouth-Hitchcock Medical Center

  2. Hernia repairs in the obese Overview Timing and technique of hernia repair when… …the hernia is the primary problem in the obese patient …the bariatric surgery patient has an incidental ventral hernia

  3. Inguinal hernia in the obese patient • Lower incidence of groin hernia among the obese • Swedish Hernia Registry1 • Only 5.2% of 49,094 patients were obese • BMI <20 or >25 had higher risk of complications • 34 year follow-up study2 • With each BMI increase, RR decreased by 4% • Obese men had 43% lower risk • US epidemiologic study 20073 • Overweight (HR 0.79, 95% CI 00.66,.95) or obese men (HR 0.51, 95% CI 0.36, 0.71) had a lower incidence of groin hernia Obesity: protective factor or just lower rate of diagnosis? 1. Rosemar A, et al. Ann of Surg 2010.252(2):397-401 2. Rosemar A, et al. Ann Surg 2008.247(6):1064-7 3. Ruhl CE, Everhart JE. Am J of Epid Vol 2007. 165(10)1154-61

  4. Inguinal hernia in the obese:Technique Laparoscopic versus open repair • Lower rate of chronic pain with laparoscopic1 • Lower risk of seroma/hematoma with laparoscopic2 • No difference in wound infection or recurrence in metaanalysis (5 RCT, 7 comparative trials) 2 • Technically challenging with either approach 1. Ecklund A, et al. Br J Surg. 2010;97:600-8 2. Dedmadi G, et al. Am J Surg. 2010;200: 291-7

  5. Inguinal hernia in the obese:Technique TAPP versus TEP • Both pose challenges • TAPP • Intraabdominal fat • Torque on abdominal wall • Limited visualization due to angle of camera • Challenging peritoneal closure • Mechanical device closure rather than sutured • TEP • Limited exposure of rectus sheath through thick subcutaneous layer • May require larger initial incision with subsequent air leak

  6. Ventral hernia in the obese patient • Preoperative evaluation and patient preparation • Imaging • Preoperative counseling for weight loss • Consideration of concomitant bariatric surgery • Skin optimization • Treatment of intertrigo • May require tissue expanders or preoperative pneumoperitoneum if large hernia and/or concern for loss of domain

  7. Ventral hernia in the obese patient Laparoscopic versus open repair, all BMI • VA Hospital RCT-Stratified for BMI • SSI significantly decreased in lap (5.6%) versus open (23.3%) • No significant difference in risk of recurrence (12.5% lap v 8.2% open, p=.44) • Cochrane Systematic Review 2011 • 10 RCTs, heterogeneous studies • No difference in recurrence risk (RR 1.22) • Lower wound complication risk for lap (RR 0.26, 95% CI 0.15-0.46) Itani, et al. Arch Surg 2010 Sauerland, et al. Cochrane Database Syst Rev 2011

  8. Laparoscopic ventral hernia repair (LVHR) in the morbidly obese Special considerations in technique • Meticulous skin prep and occlusive barrier • 3 way foley for suprapubic hernias • Venous thromboembolism prophylaxis • Veress needle abdominal access when possible • Lateral port placement but may also be limited by extremities

  9. Laparoscopic ventral hernia repair (LVHR) in the morbidly obese Special considerations in technique • Frequent patient position changes may facilitate exposure • May lose considerable working space as large hernia contents are reduced • Meticulous hemostasis • Precise intraabdominal defect measurement • May require approaching mesh fixation from above the mesh • Bony fixation when appropriate (lateral, low hernias)

  10. LVHR in the obese patient Morbidly obese versus non-obese • Ching et al Surg Endosc 2008 BMI >35 v <35k/m2 • No difference in hernia recurrence rate at median follow-up of 19 m • Hernia recurrence significantly related to fascial defect size and not to BMI

  11. 163 obese patients • 67% BMI >35 • 54% recurrent hernias (Mean 1.9 repairs) • 97% completed laparoscopically • 12% complication rate • Two mesh infections requiring removal • 5.5% recurrence (9 pts) in ~2 year follow up Arch Surg. 2006 Jan;141(1):57-61

  12. Laparoscopic VHR in the obese *Includes only patients with BMI >30 kg/m2 ** Patients with BMI >35 kg/m2 *** Patients with BMI >40 kg/m2

  13. Ventral hernia repair and Bariatric Surgery: Timing Should bariatric surgery be performed first or concomitantly with hernia repair? Considerations: • Acuity of symptoms from ventral hernia • Type of bariatric surgery- can the level of contamination be controlled? • Hernia recurrence risk • Postoperative bowel obstruction • Future surgery (Panniculectomy)

  14. Staged VHR after gastric bypass • 27 patients- 22 open and 5 lap RYGB • 7 patients with small defects repaired primarily or with biologic bridging repair at time of RYGB- all recurred • BMI 51 kg/m2 decreased to 33 kg/m2 at time of delayed hernia repair • 1 pt required urgent repair for incarceration with bowel obstruction during interval between surgeries • Follow up 20 m, no recurrences of staged repairs Newcomb WL, et al. Hernia 2008; 12:465-469

  15. Simultaneous hernia repair and obesity surgery • Open gastric bypass combined with open ventral hernia repair • Components separation and biologic mesh reinforcement • May require bridging biologic mesh repair • Laparoscopic gastric band and laparoscopic ventral hernia prosthetic repair • Laparoscopic gastric bypass or sleeve with endoscopic CST and biologic mesh reinforcement or bridging underlay repair

  16. Incidental hernia in the bariatric patient: timing • Deferred repair only if the hernia is incarcerated with omentum and can be left undisturbed • If the hernia is reduced during course of surgery and/or the hernia is symptomatic prior to surgery, it should be repaired • Primary repair of small defects is feasible but higher risk of recurrence • Bridging repair with biologic mesh during laparoscopic bariatric surgery • Likely that definitive repair will be needed later

  17. Management of Ventral Hernia during Bariatric Surgery • 85 gastric bypass patients • mean BMI 50.p kg/m2 • 61 pts with primary or umbilical hernia • Mean follow up 26 months • 59 Primary repair (22% recurrence) • 12 Biologic mesh repair (0 recurrence) • 14 repairs deferred • 37.5% small bowel obstruction with incarceration “Repair …should not be deferred.” Eid GM. Surg Endosc. 2004 Feb;18(2):207-1

  18. Conclusion • The approach to inguinal hernia repair in the obese patient should be tailored to the patient and surgical expertise • The symptomatic ventral hernia can be repaired • At time of open gastric bypass • At time of endoscopic CST and laparoscopic closure/reinforcement with biologic mesh • Ventral hernia repair in bariatric surgery patient should be deferred only if the defect is incarcerated fully with omentum and can be left undisturbed

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