what do you do for this patient? l male or female l age: 30-70 l large midline abdominal wall hernia...
TRANSCRIPT
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)