Management of abdominal wall hernias in bariatric patients: a narrative review

Introduction

Abdominal wall hernias (AWH), characterized by defects or weaknesses in the abdominal wall, have emerged as a significant concern, particularly in obese patients. AWH is intertwined with multiple risk factors responsible for their development. Obesity, associated with numerous health complications, is also considered one of the most prevalent risk factors predisposing to hernias and their recurrence (1). Obese patients exhibit widening of the linea alba, visceral fat, and intraabdominal pressure, all of which have been associated with the development of AWH (2). Furthermore, studies have shown that the risk of developing AWH significantly increases with a body mass index (BMI) higher than 30 kg/m² (3-5). Therefore, obese patients require special consideration for the management of AWH.

Bariatric surgery (BS) has proven to be the best treatment for obesity and obesity-related complications (3,6). AWH presents specific challenges in the constantly evolving field of BS and extensive observational research in the past 5 years has focused on AWH management in this population (4), making this narrative review relevant to clinical practice.

A global assessment of patients with AWH is essential, which starts with the evaluation of the patient’s preoperative status, followed by the symptomatology of the hernia and the type of procedure required (7). This information is crucial for clinicians and surgeons making decisions about patient management, including the optimal timing for each procedure. In this context, we conducted a literature search focused on the management of AWH in the context of BS patients. We explored prevention strategies, as well as different management approaches for this unique population. We present this article in accordance with the Narrative Review reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-24-11/rc).

Methods

We conducted a literature search on three databases: PubMed, Scopus, and Embase to identify studies that focused on AWH management in the context of BS (Table 1). Given that one of the objectives was to find innovative and current techniques for the management of AWH, we decided to include articles published in the last 5 years, from January 2018 to August 2023. We used different search terms including “abdominal wall hernia”, “ventral hernia”, “incisional hernia”, “bariatric surgery”, “bariatric surgeries”, “gastric bypass”, “sleeve gastrectomy”, “severe obesity”, and “morbid obesity”. Only articles written in English were included. Two investigators performed the screening and evaluation of both abstracts and full texts. The inclusion criteria were studies with patients older than 18 years old who underwent BS or had obesity (BMI >30 kg/m²) at the time of diagnosis of an AWH. Observational, interventional, retrospective studies, as well as review articles such as guidelines, systematic reviews, and meta-analyses were also included. Pediatric patients, patients with internal or inguinal hernias, animal or in vitro studies, commentaries, case reports, and articles in other languages were excluded. The articles were categorized based on the type of AWH, preventative measures, pathogenesis in obesity, management strategies, and outcomes, all tailored to bariatric patients.

Definition

The term AWH will encompass both primary and incisional hernias that occur in the anterior region of the abdominal wall, following the classification proposed by the European Hernia Society (8). Nonetheless, it is crucial to acknowledge that while primary and incisional hernias are grouped together, each has its own relevant characteristics, and thus, requires a tailored therapeutic approach.

Pathogenesis of AWH in obesity

The pathogenesis of hernias is multifactorial, with several contributing factors that have been under investigation during the last decades. Obesity has been established as a risk factor for both primary and incisional hernias (4,5,9). A retrospective study conducted by Lau et al., reported that the odds of having a hernia diagnosis was directly correlated with an increase in BMI. The odds ratio peaked at 8.2 for individuals in the highest BMI group. The majority of the patients in the study were diagnosed with primary umbilical hernias (10). Similarly, Veljkovic et al. conducted a prospective clinical trial and found a significant association between BMI and the early development of incisional hernias (11). In patients with a BMI <24.4 kg/m² the incidence of incisional hernias was 7.8%, yet it increased to 18.8% in patients with a BMI >24.4 kg/m² (P<0.001). This tendency falls in line with Pascal’s principle which states that the pressure generated within a cavity will be transmitted equally to the walls of the cavity. When that pressure exceeds the wall’s capacity, the wall will rupture at the weakest point. The presence of excess fat in the visceral compartment in obese individuals leads to increased intraabdominal pressure, with each BMI point increase correlating with a 10% rise in intragastric pressure, therefore increasing the risk of herniation (12). The pathogenesis of hernias has also been related to the synthesis and breakdown of the extracellular matrix, a process in which matrix metalloproteinases (MMPs) play a main role. Patients with hernias have shown increased MMP levels and decreased MMP inhibitor levels compared to healthy controls (5,13,14). Szczęsny et al. found that morbidly obese patients have elevated serum concentration of MMP-2 and MMP-9 when compared with healthy controls (15).

Prevention

Preventing AWH in the bariatric population is a critical consideration for ensuring the long-term success and safety of these procedures (16,17). The decision regarding fascial closure after port placement remains a topic of debate among surgeons. Some advocate for fascial closure to prevent incisional hernia formation, especially in patients with risk factors like obesity. However, a prospective study conducted by Karampinis et al. found that suturing the fascia with absorbable sutures did not significantly reduce incisional hernias in bariatric patients, than leaving the fascia open (18). Another technique frequently employed for hernia prevention is prophylactic mesh placement which has gained attention as a means to reinforce the abdominal wall and provide an extra layer of protection. Nonetheless, prophylactic mesh placement has been associated with an increased risk of seroma and chronic wound pain in the general population (16). Further evidence is needed to evaluate the safety and feasibility of this practice among the bariatric population. Ultimately, the choice between fascial closure techniques and the use of prophylactic mesh should be individualized, taking into account patient factors, surgeon experience, and the specific risks associated with each approach. Especially when performing open procedures, as incisional hernias have an incidence rate as high as 20% following laparotomies (19).

Management of AWH in obesity

Initial evaluation

During the initial evaluation of obese patients with AWH, several critical factors must be carefully assessed. First, it is essential to determine the patient’s preoperative functional status, as it has been associated with postoperative complications and short-term morbidity in both hernia and bariatric patients (20,21). The preoperative assessment should extend to the examination of modifiable factors, including comorbidities, lifestyle adjustments and nutritional status, as these elements can significantly impact the patient’s overall outcome (22,23). It should also encompass the concept of prehabilitation, which allows improvement of physical training and aerobic endurance. Prehabilitation has been associated with fewer post-operative complications, reduced post-operative time and decreased length of hospital stay, after major abdominal surgery (24,25). The patient’s bariatric status is a critical consideration. It is essential to determine if the patient qualifies for BS, as per the new guidelines set forth by organizations such as the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO). These guidelines state that surgery may be considered for patients with a BMI over 30 kg/m² who have not achieved substantial or lasting weight loss or have not experienced improvements in comorbidities through nonsurgical methods (26). Consequently, BMI, comorbidities and history of previous BSs must be evaluated in AWH patients, as this can determine the need for additional imaging tests, as well as influence their candidacy for primary or revision bariatric procedures. Lastly, the characteristics of the hernia itself should be meticulously examined during this evaluation.

AWH repair (AWHR) in obesity—an algorithm

In this section, we propose a systematic approach for patients with AWH and obesity based on our institutional experience (Figure 1). The first step is to determine whether the hernia is symptomatic and in need of immediate attention due to skin changes, incarceration, or strangulation (7). Such cases require emergent surgical repair, which can be carried out through minimally invasive procedures such as intraperitoneal onlay mesh (IPOM) repair, laparoscopic extended totally extraperitoneal (TEP) repair, or laparoscopic transversus abdominis release, always following the “less is more” concept that will allow for flexibility in case future interventions become necessary (27,28). The choice of the most suitable procedure depends on the availability of robotic equipment and the surgeon’s expertise. If the symptomatic hernia doesn’t demand immediate attention, a bariatric consultation should be sought. Candidates for BS should undergo hernia repair approximately 6 months after their bariatric procedure (29). While patients who aren’t considered surgery candidates should pursue medical weight loss before hernia repair, with tailored diet and exercise plans, as well as with promising pharmacological options like semaglutide (Ozempic) (30).

Figure 1 Management of AWH in obesity. RYGB, Roux-en-Y gastric bypass; SG, sleeve gastrectomy; SADIS, single anastomosis duodenal ileal bypass; BPDDS, bilio-pancreatic diversion and duodenal switch; BMI, body mass index; AWH, abdominal wall hernias.

As for asymptomatic hernias, the approach centers on the patient’s history of prior weight loss surgery. If there is no history of weight loss surgery, a bariatric consultation provides an individual weight loss plan, with the choice of the bariatric procedure based on the patient’s characteristics. The timing of hernia repair can be determined according to the patient’s BMI. Patients with a BMI ranging from 30 to 35 kg/m² may be candidates for a concomitant procedure, while those with a BMI exceeding 35 kg/m² may undergo a staged procedure (31).

In cases of prior weight loss surgery, evaluating eligibility for revision procedures is essential. Revisions may involve altering the bariatric anatomy to achieve further weight loss, and not all patients will qualify, because these procedures are associated with increased risk of complications and longer hospital stays (32). When revision is not an option, medical weight loss, including pharmacotherapy, is pursued. For patients with loss of domain hernias and morbid obesity, especially those with a history of BS, neither a surgical repair nor a revision procedure may be feasible, requiring alternative supportive measures. This algorithm provides a comprehensive and tailored approach to AWH management in obese patients, while considering their individual needs and circumstances. Nonetheless, it is essential to note that further high-quality research needs to be conducted to validate and refine the efficacy of our proposed algorithm to optimize patient outcomes.

Timing of the AWHR

After determining confirming the hernia’s characteristics and determining if the patient is a candidate for a bariatric procedure, the timing of the surgery must be defined. The optimal approach to managing AWHs in obese patients raises a crucial question: should the hernia be addressed first, should obesity take precedence, or should both be tackled simultaneously? Despite the abundance of retrospective studies published in this regard, there is still not enough high-quality evidence, such as randomized controlled trials, to support the conclusions. Therefore, the decision regarding the timing of BS in obese patients with AWHs demands meticulous consideration. After conducting a thorough initial evaluation, the patient’s primary concern regarding symptomatology and complaints related to either the hernia or the obesity should be considered. Primarily because the approach may change depending on whether the BS will be performed to facilitate hernia repair or to lower the burden of obesity (1). In this section, we discuss the experience and intricacies of repairing AWH before, during, and after BS.

AWHR before BS

The decision to proceed with AWHR before BS is often reserved for patients facing complex challenges. Such individuals may present with sizable abdominal wall defects, loss of domain, extensive adhesions, compromised skin quality, or incarcerated hernias. In these cases, a careful consideration of the sequence is imperative. The ASMBS emphasizes the importance of recommending various methods of weight loss before both AWHR and BS, to mitigate the risk of recurrence (4). However, multiple patients will remain with severe obesity and increased intra-abdominal pressure despite these methods, which may complicate tension-free closures. For such cases, a good option is component separation alone or combined with mesh reinforcement. Oleck and Chang have concluded that this is an effective and viable technique for complex ventral hernias in patients with morbid obesity (33,34). One of the largest retrospective studies on this subject was published by Moszkowicz et al., by using a nationwide register study. Their investigation compared the outcomes of the three possible timings; they included 2,039 patients who underwent ventral hernia repair (VHR) up to 2 years before BS, 3,388 who underwent concomitant BS and VHR, and 6,260 patients who underwent VHR within 2 years after BS. They found that the overall recurrence of VHR at 10 years was higher for patients who underwent VHR before BS (36.2%; P<0.001). This suggests that performing AWHR before BS carries a higher risk of reoperation due to recurrence. However, it’s important to note that the authors acknowledged that potential confounding factors (such as the size of the defect, specific location, or type of hernia), were not considered in the analysis and may have exerted influence on the reported rate (35).

Simultaneous AWHR + BS

Simultaneous AWHR alongside BS has undergone extensive documentation, with numerous retrospective studies published in the last 5 years. A few of the advantages this approach has are reducing the number of surgical interventions and avoiding the possibility of needing an emergency hernia repair. Notably, concomitant AWHR with BS has been proven a safe and feasible procedure, particularly in high-volume centers with expertise (36,37).

The short-term outcomes of concomitant repair remain controversial. On the one hand, Moolla et al. revealed that concurrent AWH with BS was associated with a higher major complication rate (5.8% vs. 3.8%; P<0.001), after conducting a propensity-matched study utilizing the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database (38). On the other hand, Moszkowicz et al. concluded that concomitant surgery had the de lowest rate of complication rate when compared to AWHR before or after BS (18.6%; P<0.001) (35). Similarly, patients with small hernias undergoing laparoscopic sleeve gastrectomy (LSG) with simultaneous hernia repair had no difference in the rate of single complications and had a lower overall morbidity, when compared to a two-step approach (39). For long term outcomes, concomitant surgery has been linked to low recurrence and reoperation rates (37), as well as an improvement in patient satisfaction and quality of life (40).

Finally, one of the main concerns that arises when performing a concomitant procedure relates to the introduction of a foreign body (the mesh) into a clean-contaminated field such as the one created after performing gastrointestinal anastomosis. One might argue that in order to avoid this risk a repair without mesh could be better, however Eid et al., report a recurrence rate as high as 22% for bariatric patients who underwent concomitant laparoscopic Roux-en-Y gastric bypass (LRYGB) and primary suture repair, in contrast with the mesh group which didn’t have any recurrences (41). However, a study by Cozacov et al., showed that intraperitoneal bacterial cultures in patients undergoing LSG are negative, which would decrease the risk of contamination and resultant infection. This supports the notion that the concomitant use of prosthetic material to repair ventral hernias during an LSG procedure should be considered safe and feasible (42). Overall, the evidence suggests that concomitant AWHR and BS, when performed with careful consideration and expertise, can offer favorable outcomes and address concerns associated with deferred hernia repair, which is why we recommend performing this procedure in patients with a BMI of 30–34.9 kg/m² with comorbidities.

AWHR after BS/weight loss interventions

The last option consists of performing AWHR after weight loss due to BS. The analysis behind the decision to defer the repair includes that weight loss will contribute to a less technically challenging procedure, shorter operative times, and decreased risk of contamination (43). Chandeze et al. conducted a case-matched study in which they compared a group of morbidly obese patients who underwent immediate hernia repair with a group of patients who underwent hernia repair after BS-induced weight loss. After a median follow-up of 4.6±4.1 years, they concluded that the recurrence rate was significantly lower in the group that underwent the repair after BS (P=0.048), similar to the conclusion reported by Moszkowicz et al. (35,44). An interesting approach to achieve weight loss before hernia repair is the use of an intragrastric balloon as a bridging therapy to decrease surgical risk and improve general health status (45). Abbitt et al. concluded that intragastric balloon placement 6 months before hernia repair, results in sufficient weight loss allowing repair at an optimal weight (29).

It is also relevant to mention the availability of pharmacological therapies for weight loss before hernia repair. The number of drugs for weight loss approved by the Food and Drug Administration (FDA) keeps growing, with tirzepatide (Zepbound) being the last one approved in November 2023. Other alternatives such as orlistat, bupropion, topiramate, and semaglutide have proven effective for weight loss in various clinical trials (30). However, further studies are needed to compare these pharmacological drugs against other alternatives for weight loss in the context of hernia surgery.

After massive weight loss, some hernia patients will also complain of excess loose skin and subcutaneous tissue. Diverse management strategies are available for such cases. One safe and feasible option is to perform a concomitant abdominoplasty and hernia repair. A retrospective analysis conducted by Akiska et al., encompassing 481 individuals who underwent a simultaneous repair, established that this approach does not increase the risk of postoperative morbidity (46). Another option is to use the excess skin as a natural source of a coverage and reinforcement by creating an autologous dermal flap. Both Bitterman et al. and Bogetti et al. report that the use of dermal flaps both with and without mesh repair, are useful alternatives in bariatric patients with large abdominal defects (47,48).

Nevertheless, acknowledging the risks of deferring hernia repair is essential, such as the inherent risk that the presence carries of incarceration and bowel obstruction. Morrell et al. report that 10% of patients who underwent repair of complex AWH after LSG had a complication during the deferral period (49). While Eid et al. reported a complication rate as high as 36% for patients who deferred VHR until after laparoscopic Roux-en-Y gastric bypass (RYGB) (41). Additionally, the risk of bowel obstruction can also jeopardize the indemnity of the bariatric procedure by causing anastomotic or staple-line disruption, as reported by Sarwal et al. (43).

Technical considerations

Once the optimal timing for hernia repair and BS has been established, the next step is to examine some technical considerations.

In the management of AWHs in bariatric patients, the choice between open surgery and minimally invasive techniques is crucial. While open surgery was traditionally used, it is essential to acknowledge that it comes with higher operative times and higher complication rates when compared to laparoscopy. In fact, multiple randomized control trials and meta-analyses have proven that laparoscopic surgery has reduced surgical site infections, complications, and operative times when compared to open surgery (27,28). Various studies have explored different techniques from IPOM repair to TEP repair, for hernia repair in bariatric patients, with good long-term results and reduced risk of recurrence (50,51). Robotic surgery has also gained popularity as a novel approach associated with decreased length of hospital stay, low recurrence rates, and longer time without recurrence (52,53). However, there are scenarios, not uncommon in bariatric patients, where the laparoscopic approach may be problematic, and an open surgery is needed. According to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), patients with loss of domain, abdominal skin grafts overlying the hernia, or small defects with large hernia sacs may need to undergo open surgery, because of a high risk of conversion and complications (54). Another important consideration involves the prevention of recurrence by using a mesh for hernia repair (44). Eid et al. report no recurrences in patients who underwent mesh repair when compared with a primary suture repair (41). Recent developments in mesh design that increase even tension distribution also show promise to reduce hernia recurrence (17), however the mesh selection process is beyond the scope of this review.

Outcomes

Several factors can influence the outcomes of AWHR in bariatric patients. Madsen et al. highlighted that patients with a BMI over 30 are associated with an increased risk of complications after VHR (55). Similarly, high visceral fat volume and elevated BMI have been associated with a higher risk of surgical site infection (4,56). For patients with complex AHWs or catastrophic abdomen, which are not unusual in morbid obesity, closed incision negative pressure, can be beneficial in reducing wound complications (57). Additionally, while the frequency of abdominal compartment syndrome doesn’t significantly differ between obese and non-obese patients, research by Piatnochka suggests that reducing the use of stretching methods during hernioplasty can decrease early postoperative complications and recurrences in this population (58). Encouragingly, advancements in technology have made techniques like robotic VHR safer for bariatric patients, as shown in a study by Kudsi et al., which reported comparable outcomes for patients with BMIs over 40 kg/m² and those with BMIs of 35–39.9 kg/m² (59). Ultimately, to achieve the best possible outcomes in AWHRs for bariatric patients, careful patient selection, thorough preoperative assessment, and vigilant postoperative monitoring are crucial.

Strengths and limitations

In this narrative review, our primary objective was to consolidate and synthesize the most recent data regarding AWH in the context of bariatric and obese patients. Our approach was comprehensive, encompassing a diverse range of sources, including existing reviews, to offer a well-rounded perspective on the subject. It’s important to acknowledge the inherent limitations of this review, including the absence of a systematic methodology for quality assessment of the included articles and potential constraints on generalizability. However, we have strived to mitigate these limitations by maintaining complete transparency throughout the description of our search and screening processes.

Conclusions

In conclusion, the management of AWH in patients with obesity demands a comprehensive approach. It is crucial to acknowledge obesity as a modifiable risk factor for both morbidity and recurrence, underscoring the importance of integrating weight management into hernia care. All patients presenting with obesity and AWH should undergo referral to a bariatric multidisciplinary team to establish an individualized operative plan. The central goal is to create a systematic approach that considers the optimal surgical technique and timing of the procedure, tailored not only to the patient’s unique characteristics but also following the principle of minimizing the intervention, as encapsulated in the “less is more” concept. This approach not only improves patient outcomes but also allows flexibility to address potential future complications.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-24-11/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-24-11/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-24-11/coif). A.D.G. serves as an unpaid editorial board member of Annals of Laparoscopic and Endoscopic Surgery from August 2022 to July 2024. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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