What Do You Do For This Patient? Male or female Age: 30-70 Large midline abdominal wall hernia (>12x20 cm)* S/P multiple repairs

or S/P colectomy, sigmoid diverticulitis/Hartmann’s

procedures, THA/BSO, AAA repair, open Nissen, etc! AND (of course)

Ht: 5’ 8” Wt: >300 lb

*Big hernia; note > 12x20 cm!i.e. BMI > 35

Role of Bariatric Surgery in the Patient with Large Abdominal Wall

Hernia*

Michael G. Sarr, MDProfessor of Surgery

Mayo Clinic

*Ventral hernias

Role of Bariatric Surgery in AWR:Importance

TimingResults

Bariatric Surgery in AWR3 Questions

Does recurrence of AWR with morbid

obesity (BMI>35)?

Bariatric Surgery in AWR3 Questions

Does recurrence of AWR with morbid obesity

(BMI>35)?

Should bariatric surgery be done BEFORE,

DURING, or AFTER the AWR?

Bariatric Surgery in AWR3 Questions

Does recurrence of AWR with morbid obesity

(BMI>35)?

Should bariatric surgery be done BEFORE,

DURING, or AFTER the AWR?

or

NOT AT ALL?

Bariatric Surgery in AWR3 Questions

Does recurrence of AWR with morbid obesity

(BMI>35)?

Should bariatric surgery be done BEFORE,

DURING, or AFTER the AWR?

Does the weight loss of bariatric surgery

allow a better, more durable AWR?

Bariatric Surgery in AWRStaged AWR-Bariatric Surgery First

In theory, MAKES THE MOST SENSE! Healthier patient (benefits of weight loss-comorbidities) Less risk occurrence Easier Better AWR Combine with abdominoplasty

BUT NOT ALL AGREEVARIES WITH PATIENT DESIRESVARIES WITH SIZE OF HERNIAVARIES WITH OPERATIVE TECHNIQUE

Open vs lap RYGB vs band/sleeve

Bariatric Surgery in AWRSummary of Presentation

Recurrence of hernia after AWR is in morbid obesity Complications of AWR are increased in morbid obesity,

(esp as an open procedure) Lap AWR does not medialize rectus muscles Recurrence after primary repair of hernias in morbid obesity

approaches 100% Risk of SBO is increased when bariatric surgery performed

first and herniated contents are reduced No consensus on bariatric surgery

Hernia 1st

Simultaneous Staged procedure (bariatric then AWR)

Bariatric Surgery in AWRQuestion 1

DOES MORBID OBESITY

PREDISPOSE TO

RECURRENCE AFTER AWR?

Bariatric Surgery in AWRDoes Morbid Obesity Predispose to

Recurrence after Ventral Herniorraphy?YES

Laparoscopic repair 8% (vs 2%)a

Laparoscopic repair 0%b

Combined repairs 19%c

RR-1.1 per unit BMI!d

Other considerations Wound complications (esp with open operation) Co-morbidity of obesity Patching vs medialization of recti If adding components separation, wound complications

aHeniford et al, Ann Surg 2003 – 850 repairsbBirgisson et al, Surg Endosc 2001 – 16 repairscRaftopoulos and Courcoulas, Surg Endosc 2007 – 27 repairsdSauerland, Hernia 2004

Bariatric Surgery in AWRAWR in Patients with Morbid Obesity

SUMMARY Recurrence rate is increased (~10%) Laparoscopic repair is best Appropriate if patient refuses bariatric surgery BUT-this speaker’s opinion (bias) is that:

These patients benefit by bariatric surgery ( co-morbidities)

Subsequent hernia repair better/easier Better overall management The huge hernias are BEST treated by bariatric

surgery 1st

Bariatric Surgery in AWRRemainder of Talk

Morbid Obesity With Large Ventral Hernia

(not a “small” one)

Bariatric Surgery in AWRQuestion 2

Timing of AWR and Bariatric Surgery

BEFORE

? DURING ?

AFTER

Bariatric Surgery in AWRAWR at Time of Bariatric Surgery - 1

Pros 1 operation/1 anesthetic 1 convalescence Already intraperitoneal Prevents future SBO if

herniated content requires reduction for bariatric procedure

Older age patients

Cons Clean-contaminated

procedure (? alloplastic prosthesis)

Known risk hernia postop Hernia “patching,” no AWR Wound infection (open) More difficult operation Will need separate

abdominoplasty

Bariatric Surgery in AWRAWR at Time of Bariatric Surgery - 2

Considerations Can bariatric operation be done laparoscopically

Access Gastric sleeve/band? RYGB or DS/BPD? Need to reduce herniated content?

Reason for AWR Intermittent SBO Laborer – needs stable, functional AWR

AWR must be done as an open procedure Reconsider AWR

Bariatric Surgery in AWRAWR at Time of Bariatric Surgery - 3

Bariatric procedure – band/sleeve Clean case, less argument Philosophy regarding results of herniorraphy Bonatti* - 9 patients at time of band; no recurrences Rarely reported – probably done often, umbilical

hernia What about very large hernias?

Simultaneous? Delayed repair?

*Obes Surg, 2004

Bariatric Surgery in AWRAWR at Time of Bariatric Surgery - 4

Bariatric procedure – RYGB Eid*

12 patients, all Surgisis (SIS) repairs No recurrences; 26-mo follow-up 59 patients, all primary repair (suture) 22% recurrences – (small hernias) These were no HUGE hernias

*Surg Endosc, 2004: no data on size/type of hernia

Bariatric Surgery in AWRAWR at Time of Bariatric Surgery - 5

Bariatric procedure – RYGB Schuster*

12 patients (2 open, 10 lap) 11/12 prosthetic mesh 2/12 recurrences (~20%) (F/U 1 yr) No mesh infection

Herbert** 16 patients (all open) Intraperitoneal mesh (prophylactic) 3/16 infected mesh (20%)

recurrence rates, mesh infection?

*Schuster et al, Obes Surg, 2006**Herbert et al, Am J Surg, 2009

Bariatric Surgery in AWRAWR at Time of Bariatric Surgery - 6

My experience with alloplastic repairs during open bariatric surgery

3 of 8 mesh infections 1 explant of mesh 2 chronic sinus tracts

Bariatric Surgery in AWRQuestion 3

BARIATRIC SURGERY FIRST

LOSE WEIGHT

AWR AFTER WEIGHT LOSS

Bariatric Surgery in AWRStaged AWR – Bariatric Procedure FirstConsiderations – Size of hernia Risk of SBO before AWR Hernia may in size/complexity* Need for abdominoplasty More adhesions

BUT AFTER WEIGHT LOSS Easier repair Can add components separation Healthier patient Less chance recurrence Adequate skin coverage Combined with abdominoplasty Timing of AWR

*Esp if open procedure required!

Bariatric Surgery FirstWhat if an OPEN procedure is required?

How to deal with an abdominal wall defect? Just close the skin/hernia sac? Absorbable mesh closure? Bioprosthetic closure?

*Multiple prior repairs, adhesions, no access, etc.

Bariatric Surgery First OpenHow to deal with the abdominal wall defect?

Considerations Just close skin/sac – WORRY OF

EVISCERATION Absorbable mesh – hernia recurs at 3 months

(and then gets bigger!) Bioprosthesis – expensive but may allow greater

weight loss before hernia occurs – NO ONE EXPECTS A PERMANENT REPAIR

? DO THEY ?

Bariatric Surgery in AWRSimultaneous Prosthetic-Based AWR and

Abdominoplasty Is there an increased rate of prosthetic infection?

Author # patients Mesh removedDowney 2005 50 0Fotopoulos 2000 9 2Saxe 2008 41 0Iljin 2008 14 1

Studies Short term follow-up Wound complication rate ~40%

Argues against onlay repair

MeshInfection

3%

Bariatric Surgery in AWRSummary of Presentation

Recurrence of hernia after AWR is in morbid obesity Complications of AWR are increased in morbid obesity,

(esp as an open procedure) Lap AWR does not medialize rectus muscles Recurrence after primary repair of hernias in morbid obesity

approaches 100% Risk of SBO is increased when bariatric surgery performed

first and herniated contents are reduced No consensus on bariatric surgery

1st

Simultaneous Staged procedure (bariatric AWR)