Algorithm for the Management of Ventral Hernia in Morbidly Obese Patients

Abstract

Dear Sir,We read with interest the article of Eid et al. [1] about ventralherniasinmorbidlyobesepatientsandarereallyimpressedbythe algorithm in managing this dilemma that general andbariatric surgeons can face.We feel that the major points to consider regarding thisproblem are the following:1. Majority of these ventral hernias in morbidly obese pa-tients are paraumbilical hernias containing omentum,which is irreducible or partially reducible, and they areusually asymptomatic.2. Certainly, inserting an intraperitoneal mesh during laparo-scopic gastric bypass or sleeve gastrectomy will carry therisk of mesh infection, which we consider a surgical di-saster in this particular clinical scenario. The risk of meshinfection could reach5.56 % whena simultaneous gastro-intestinal division procedure was performed [2]. There isalso acontradictory opinion imposedby other authorsthatthe combined ventral hernia repair and bariatric surgerydid not result in any infection, but unfortunately, it hadincreased the incidence of small bowel obstruction [3].3. We have tried a variety of intraperitoneal meshes, and, inretrospect, all of them cause some degree of intraperito-neal adhesions that make further complex laparoscopicbariatric surgical intervention more difficult.Basedonthesepoints,wewouldliketosharewithyououralgorithm in managing this problem:1. Formorbidlyobesepatientswithaventralherniawhoarenot willing to undergo bariatric surgery, we will proceedwith laparoscopic repair of ventral hernia using non-absorbable mesh.2. For morbidly obese patients with asymptomatic ventralhernia who are willing to undergo bariatric surgery, wewill proceed with laparoscopic bariatric surgery and dur-ing the operation will leave the omentum untouched,plugging the defect in the abdominal wall. Reducing theomentum from this ventral hernia will create an opendefect that may incorporate the small bowel in the post-operative period and result in small bowel obstruction.3. For morbidly obese patients with symptomatic ventralhernia, they will have a CTscan of the abdomen to deter-mine whether the contents of the symptomatic hernia arebowel or omentum. If the contents are omentum, then wewill proceed as point 2 in the algorithm. If the contents arebowel, then we will reduce the contents of the hernialaparoscopically and repair the defect with interruptedPDSstitcheswithareducedpneumoperitoneumaftercom-pletion of the proposed laparoscopic bariatric procedure.We acknowledge that our algorithm is not based on astructured study like the study of Eid et al., but it is based onexperience of 30 years in general surgery and 15 years ofbariatric surgery practice.