Obesity Surgery, 14, 655-658

Ventral Hernia Repair in Bariatric Surgery Hugo Bonatti; Elisabeth Hoeller; W. Kirchmayr; G. Muhlmann; M. Zitt; F. Aigner; H. Weiss; A. Klaus University Hospital Innsbruck, Department of General and Transplant Surgery, Innsbruck, Austria Background: Obesity is an important risk factor for perioperative complications including the development of ventral hernias. M e t h o d s : This retrospective study comprises patients who underwent abdominal hernia repair simultaneously with or following implantation of a Swedish Adjustable Gastric Band ® (SAGB). Results: 9 out of 415 patients (2.2%) who received a SAGB between January 1996 and June 2001 underwent ventral hernia repair. In 6 patients, hernias preexisted from previous abdominal surgery at the time of the bariatric procedure, and another 3 hernias occurred at the median and left upper abdominal trocar position following SAGB placement. Median BMI at time of SAGB implantation was 44 (range 35-52), and at time of hernia repair was 36 (range 25-46). 2 hernias were repaired during SAGB placement, 3 during redo surgery, and 2 during abdominoplasty. In 2 patients, significant weight loss with loss of soft tissue support of the hernia sac led to recurrent episodes of small bowel obstruction necessitating emergency repair. Repair included direct defect closure in 7 patients and sublay polypropylene net implantation in 2 patients. Recoveries have been uneventful without wound infections or recurrence in all patients after a median follow-up of 34 months (range 13-69). Conclusion: In morbidly obese patients, the optimal management and timing of incisional hernia repair should weigh the risk of recurrence and perioperative complications against the risk of hernia-associated complications. Key words: Ventral Hernia, gastric banding, laparoscopy, morbid obesity, bariatric surgery

Introduction There is a high incidence of incisional hernias and recurrence of hernias following surgical procedures in the obese populati o n .1-3 Therefo re, a d e q u ate Reprint requests to: Helmut Weiss, MD, Associate Professor of Surgery, University Hospital Innsbruck, Department of General and Transplant Surgery, Anichstrasse 35, 6020 Innsbruck, Austria. Fax: 43-512-504-4607;e-mail:[email protected] © FD-Communications Inc.

weight loss is generally recommended before elective surgery.4 For patients suffering from morbid obesity (i.e. body mass index (BMI) ³40 kg/m2) significant weight loss is not feasible by conventional therapy.5 Many procedures, such as cholecystectomy or bowel resection, have to be performed in obese patients despite risk for the occurrence of incisional hernias. In addi t i o n , mo rb i d ly obese patients are prone to other perioperative complications such as pneumonia, t h ro m b o s is , d elaye d wound healing and cardiovascular events.6-8 The laparoscopic approach reduces the incidence of incisional hernias. However, trocar-site hernias occur more frequently in the obese population compared to patients with normal weight.9-11 Bariatric surgery is successful in reducing weight and co-morbid conditions. The Swedish Adjustable G a s t ric Band® (S AGB, O b t ech associated with Ethicon EndoSurgery) is one of the most effective devices and is widely used in Europe. We evaluated our experience with incisional hernia repair in morbidly obese patients who underwent implantation of a SAGB.

Patients and Methods Patients with a BMI ³40 kg/m 2 or >35 kg/m 2 with co - existing diab e t es , hyp ertension or orth o p e d ic disorders were considered for the gastric banding operation. A psychological and metabolic evaluation to exclude any medical contraindication, was performed. In addition, patients underwent gast ro s co py and esophageal manometry to assess es o p h ageal function preoperat ively as descri b ed elsewhere.12 With respect to the trocar position, the initial 12mm trocar was placed using an open approach in the midline of the upper abdomen. The remaining trocars were placed subxyphoid (12-mm) and in the Obesity Surgery, 14, 2004

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left (5-mm and 15-mm) and right (5-mm) upper abdomen, respectively. After band placement, the connecting tube was pulled out at the subxyphoid trocar site, the pneumoperitoneum was released, and the tube was connected to the port anterior to the sternum through a separate incision. 13 A n alysis was performed re t ro s p ec t ive ly using charts of the routine outpatient follow-up at our department. Surgical repair was adjusted to the individual patient situation as described in this paper. Patient data were collected in a database and given as median (range).

Results From January 1996 to June 2001, nine patients (2.2%) out of 415 patients were identified who u n d e rwent abdominal incisional hernia rep ai r s imu lt an eo u s ly with or fo l lowing lap a ro sc o p i c implantation of a SAGB. These consisted of two men and seven women with median age 46.8 years (range 35-53). Age and course of body weight in patients undergoing SAGB and hernia repair are shown in Table 1. Six hernias pre-existed from previous abdominal surgery including open gastric banding in two patients, explorative laparotomy in one, cesarian section in one, hysterectomy in one and cholecystectomy in combination with a recurrent umbilical hernia in one. Of these six hernias, four were small in size and could be repaired simultaneously with SAGB implantation. The remaining two were giant hernias, and were therefore scheduled to be repaired after sufficient weight loss. Three hernias developed after SAGB placement, at the supraumbilical (two) and left upper abdominal (one) trocar-sites, respectively (Table 2). For these nine patients, median BMI at the time of SAGB implantation was 46.6 kg/m2 (range 35-52), and median BMI at hernia repair was 36.0 (range 2 5 -4 6 ), whi ch was performed at a median 16

months (range 0-52) following SAGB implantation. At the time of hernia repair, median weight loss was 14 kg (range 0-80). Procedures were carried out under general anesthesia in all but one patient. A pre-existing SAGB device was not released during hernia repair in any patient. Seven small size hernias (<3 cm) were closed directly using interrupted 1-0 Vicryl® or Mersilene ® sutures. Two preexisting giant hernias were repaired using a subl ay prepe ritoneal polyp ro pyl en e (Prolene®) mesh. In seven patients, surgery was planned to repair the hernia and simultaneously carry out other interventions: Two patients had hernia repair at time of SAGB implantation. In another two patients, hernia repair was perfo rmed sim u l t an eo u s ly durin g abdominoplasty after significant weight reduction. In another patient, an incisional hernia was repaired simultaneously with exchange of a leaking banding device which had been associated with significant weight gain. One patient presented with late pouch dilatation and was therefore reoperated. During that intervention, a small midline incisional hernia was repaired. In one patient, a hernia at the supra-umbilical port-site was repaired during band removal for psychological intolerance. Three patients were asymptomatic. Four patients presented with minor symptoms such as discomfort during physical activity. In two patients, significant weight loss req u i red emergen cy hernia rep ai r because of small bowel obstruction caused by kinking of the giant hernial sac at the hernial ring (Figures 1 and 2). After repair, no episodes of bowel obstruction have occurred in these patients. All patients had uneventful recoveries without wound infections and with no recurrence of hernia after a median follow-up of 34 months (range 1369). Median BMI of the patients at this time was 27 (range 20-46). The course of the BMI in the study patients is shown in Figure 3.

Table 1. Age and course of body weight in patients undergoing SAGB and hernia repair

Median Min Max

Age (years)

Weight (kg) at SAGB implantation

Weight (kg) at herniotomy

Intervall (mons) to herniotomy

Weight (kg) at nadir

Interval (mons) at nadir

48.2 30.1 58.7

134 95 173

105 69 137

16 0 52

79 56 136

34 14 70

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Incisional Hernia Repair during and after Swedish Banding Table 2. Type of incisional hernia Pre-existing hernia (6): Open gastric banding (2) Explorative laparotomy (1) Cesarian section (1) Hysterectomy (1) Recurrent umbilical hernia (1) Trocar-site hernia (3): Left upper abdominal port-site (1) Supraumbilical port-site (2)

Discussion D evelopment of an incisional hernia fo l l owin g laparotomy is a potential complication for obese patients. 11 Elevated intra-abdominal pressure combined with decreased abdominal wall resistance are mainly responsible for this. Reduced risk of general complications may be expected following adequate weight loss preceding major surgical interventions. Although intensive perioperative treatment will improve the outcome of s u rgical proc ed u res in morbidly obese pati en t s , weight loss is the optimal strategy; in particular, the risk for development of incisional hernias is minimized. In morbidly obese patients, the optimal timing of incisional hernia repair should weigh the risk of hernia recu rrence and perio perat ive complicat io n s against the risk of hernia-associated complications such as bowel obstruction. Incisional hernias have been diagnosed in 5-15% of patients following open band placement, in up to 25% of patients following other open bariatric oper-

Figure 2. Abdominal CT scan showing giant midline incisional hernia following past umbilical hernia repair.

ations and in up to 40% of patients following emergency abdominal surgery.14-16 In our series, four morbidly obese patients presented with small incisional hernias at the time of band implantation. Two of these hernias could be repaired sufficiently during the primary procedure, and the other two hernias were operated during elect ive ab d o mi n o pl as t y, all without rec u rren ce. Laparoscopic band placement may be more difficult due to hernial adhesions, and trocar placement must be adapted according to the site of the hernia. For this reason, hernia repair was only carried out primarily in two patients in whom the site of the hernia was eligible for trocar placement. 55 50 45 40

SAGB Removal SAGB Dysfunction

Simultaneous Hernia repair and SAGB implant

35 30 25 20 15

Figure 1. Abdominal CT scan of a giant: right subcostal hernia following cholecystectomy with kinking of the mesenteric vessels. Arrow indicates hernia ring.

BMI SAGB Median BMI 46.6 at SAGB implant

BMIhernia Hernia repair BMI at repair median 19 months post SAGB

BMInadir NADIR at BMI 40 months post SAGB

Figure 3. Course of BMI in 9 patients with SAGB and hernia repair. Obesity Surgery, 14, 2004

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In contrast, two patients suffered from giant hernias that were initially planned to be repaired following marked weight reduction. As noted, the complication rate of incisional hernia repair in morbidly obese patients is high.1 Although pre-existing large epigastric incisional hernias may hinder a laparoscopic approach for band placement, both these laparoscopic SAGB placements were carried out uneventfully. However, in these two patients we were forced to repair the giant hernia before ideal weight was achieved, because they suffered from recurrent episodes of small bowel obstruction due to tissue kinking. In this situation, the optimal time to operate depends on the clinical symptoms of the hernia rather than on further weight loss. Therefore, for patients with giant hernias and ongoing weight loss, close follow-up is recommended. For large hernias in obese individuals, placement of an intragastric balloon anticipating repair after weight loss has been described.17 This method is not applicable to patients with gastric bands. Trocar-site hernias have been reported to occur in 1% following laparoscopic SAGB implantation.9 Overall, the incidence of port-site hernias in our series of 415 patients was low (0.7%), comparable to other studies.9,18 Two trocar-site hernias developed at midline incisions. In contrast to midline incisions, we no longer routinely suture the fascia at the left upper abdominal incisions, because oblique trocar penetration of the lateral abdominal wall should provide overl apping safe cl o s u re of the defect. New-fashioned dilation trocars may further reduce the risk for trocar-site hernia. Considering technical properties, we close small hernias directly using absorbable sutures as long as these are not recurrent hernias. For repair of large incisional herni a s , the use of mesh is re co mmended.19,20 . In conclusion, little evidence is given in the literature to define the optimal time for hernia repair in morbidly obese patients. Closure of small hernias in this cohort is obviously associated with a low recurrence risk and can therefore be performed at any time. Attention should be directed to giant hernias that may become complicated during rapid weight reduction. In these patients, hernia repair should weigh the risk of recurrence and perioperative complications against the risk of hernia-associated complications. 658 Obesity Surgery, 14, 2004

References 1. Flancbaum L,Choban PS. Surgical implications of obesity. Annu Rev Med 1998; 49: 215-34. 2. AnthonyT, Bergen PC,Kim LT et al. Factors affecting recurrence following incisional herniorrhaphy. World J Surg 2000; 24: 95100; discussion. 3. Gecim IE, Kocak S, Ersoz S et al. Recurrence after incisional hernia repair: results and risk factors. Surg Today 1996; 26: 6079. 4. Sugerman H, Windsor A, Bessos M et al. Intra-abdominal pressure, sagittal abdominal diameter and obesity comorbidity. J Intern Med 1997; 241: 71-9. 5. Buchwald H. A bariatric surgery algorithm. Obes Surg 2002; 12: 733-46. 6. Choban PS, Heckler R, Burge JC et al. Increased incidence of nosocomial infections in obese surgical patients. Am Surg 1995; 61: 1001-5. 7. Blaszyk H, Wollan PC, Witkiewicz AK et al. Death from pulmonary thromboembolism in severe obesity: lack of association with established genetic and clinical risk factors. Virchows Arch 1999; 434: 529-32. 8. Wu EC,Barba CA. Cur rent practices in the prophylaxis of venous thromboembolism in bariatric surgery. Obes Surg 2000; 10:7-13; discussion 14. 9. Azurin DJ , Go LS , Arroyo LR et al. Trocar site herniation following laparoscopic cholecystectomy and the significance of an incidental preexisting umbilical hernia. Am Surg 1995; 61: 71820. 10. Nehoda H, Hourmont K, Sauper T et al. Laparoscopic gastric banding in older patients. Arch Surg 2001; 136: 1171-6. 11. Sugerman HJ, Kellum JM Jr, Reines HD et al. Greater risk of incisional hernia with morbidly obese than steroid-dependent patients and low recurrence with prefascial polypropylene mesh. Am J Surg 1996; 171: 80-4. 12. Weiss HG, Nehoda H, Labeck B et al. Treatment of morbid obe sity with laparoscopic adjustable ga s t ric banding affects esophageal motility. Am J Surg 2000; 180: 479-82. 13. Weiss H,Nehoda H,Labeck B, et al. Injection port complications after gastric banding: incidence, management and prevention. Obes Surg 2000; 10: 259-62. 14. Brolin RE. Prospective, randomized evaluation of midline fascial closure in gastric bariatric operations. Am J Surg 1996; 172: 32831. 15. Higa KD , Boone KB , Ho T. Complications of the laparoscopic Roux-en-Y gas tric by pas s: 1,040 patients – wh at have we learned? Obes Surg 2000; 10: 509-13. 16. Mingoli A, Puggioni A, Sgarzini G et al. Incidence of incisional hernia fo l lowing emerge ncy abdominal surgery. Ital J Gastroenterol Hepatol 1999; 31: 449-53. 17. De Waele B, Reynaert H,Urbain D et al. Intragastric balloons for preoperative weight reduction. Obes Surg 2000; 10: 58-60. 18. Plaus WJ. Laparoscopic trocar site hernias. J Laparoendosc Surg 1993; 3: 567-70. 19. Welty G, Klinge U, Klosterhalfen B et al. Functional impairment and complaints following incisional hernia repair with different polypropylene meshes. Hernia 2001; 5: 142-7. 20. Paul A, Korenkov M, Peters S et al. Unacceptable results of the Mayo procedure for repair of abdominal incisional hernias. Eur J Surg 1998; 164: 361-7.

(Received November 28, 2003; accepted February 26, 2004)