VENTRAL HERNIAS IN HIGH BMI PATIENTS Update in General Surgery April 10, 2014 Laz Klein, Humber River Hospital ANSWERS I WOULD LIKE TO KNOW: • What is the effect of obesity on: • Risk of developing a hernia • Rate of hernia progression • Surgical risk • SSI • Recurrence HOW CAN I OPTIMIZE? • Diet • Optifast • Bariatric surgery • Hernia repair before, during, after WILL IT AFFECT MY DECISION • To operate • Use mesh • Choose open or laparoscopic • Use component separation RISK OF GETTING A HERNIA • Obesity worse than chronic steroids • Open gastric bypass vs colectomy for UC • 20% vs 4% • Sugerman HJ et al, Am J Surg, 1996 RECURRENCE • Known risk factors • • • • • • • Size of hernia Multiple previous repairs Obesity DM Infection Lower abdominal incision COPD RECURRENCE • Direct effect • Elevated intra-abdominal pressure • 18 mmHg vs 5.1 mmHg • Indirect effect • More wound infections • More DM • Bigger hernias • Raftopoulos R, Journal of Laparoendoscopic, 2002 RECURRENCE • Risk of recurrence rate ratio 1.10 / unit BMI • BMI 50 rate is 2.42 higher than BMI 25. • Series of 160 pts with overall recurrence of 11% • Risk of recurrence is 26% • Sauerland S, et al, Hernia, 2004 LAP VS OPEN • In obese patients, laparoscopic is safe and effective • Y Novitsky, et al, JAMA Surgery, 2006 • In obese patients, laparoscopy is safe, not so effective • Raftopoulos A, Surgical Endoscopy, 2007 • Tsereteli Z, et al, Hernia, 2008 MESH? • Even small umbilical hernias require mesh in obese patients – and should be done laparoscopically. • Colon MJ, American Journal of Surgery, 2013 PATIENT OPTIMIZATION DIET • Requires significant patient motivation. • Long term results are poor • Short term results are variable. • Curioni C, International Journal of Obesity, 2005 OPTIFAST • Very low calorie diet • 900 kcal/day • After 6 weeks • 43% reduction in liver fat • EWL of about 15% • Difficult compliance • 6 weeks is maximum tolerated • Useful for immediate preop. BARIATRIC SURGERY BEFORE, DURING AFTER? • Our dogma: • Don’t even look at the hernia • Repair 1 year later BARIATRIC SURGERY BEFORE, DURING AFTER? • 4 Options (3 retrospective, 123 patients) • Defer • 35.7% SBO in 150 days • Primary repair • Recurrence: 22-100% • Biomesh • 0% recurrence, 0% infection • Synthetic mesh • 0-9% recurrence, 0% infections (at 14 months) • Raiche I, SAGES 2012. CASE REPORT • 35 year old female • BMI 55 • Ventral hernia repair x 3 • Now, infected mesh with draining sinus x 3 • Unchanged x 2 years CASE REPORT Trailer Park MULTIPLE CHOICE What should be done next? A) Laparotomy, mesh explant, primary repair. B) Bariatric referral, then deal with hernia C) Open component separation, mesh explant, biomesh repair D) Laparoscopic ventral hernia repair E) Move from trailer park to vegan collective STEP 1 • Gastric Bypass • ….. 1 year later….. STEP 2: COMPONENT SEPARATION FINAL RESULT No Trailer Park! COMING SOON….
© Copyright 2024 ExpyDoc
