What Do You Do For This Patient? l Male or female l Age: l Large midline abdominal wall hernia (>12x20 cm)* l S/P multiple repairs or l S/P colectomy, sigmoid diverticulitis/Hartmann’s procedures, THA/BSO, AAA repair, open Nissen, etc! l AND (of course) n Ht: 5’ 8” n 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, MD Professor of Surgery Mayo Clinic *Ventral hernias Role of Bariatric Surgery in AWR: Importance Timing Results

Bariatric Surgery in AWR 3 Questions Does recurrence of AWR  with morbid obesity (BMI>35)?

Bariatric Surgery in AWR 3 Questions Does recurrence of AWR  with morbid obesity (BMI>35)? Should bariatric surgery be done BEFORE, DURING, or AFTER the AWR?

Bariatric Surgery in AWR 3 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 AWR 3 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 AWR Staged AWR-Bariatric Surgery First In theory, MAKES THE MOST SENSE! l Healthier patient (benefits of weight loss-comorbidities) l Less risk occurrence l Easier l Better AWR l Combine with abdominoplasty BUT NOT ALL AGREE VARIES WITH PATIENT DESIRES VARIES WITH SIZE OF HERNIA VARIES WITH OPERATIVE TECHNIQUE l Open vs lap l RYGB vs band/sleeve

Bariatric Surgery in AWR Summary of Presentation Recurrence of hernia after AWR is  in morbid obesity l Complications of AWR are increased in morbid obesity, (esp as an open procedure) l Lap AWR does not medialize rectus muscles l Recurrence after primary repair of hernias in morbid obesity approaches 100% l Risk of SBO is increased when bariatric surgery performed first and herniated contents are reduced l No consensus on bariatric surgery n Hernia 1 st n Simultaneous n Staged procedure (bariatric then AWR)

Bariatric Surgery in AWR Question 1 DOES MORBID OBESITY PREDISPOSE TO RECURRENCE AFTER AWR?

Bariatric Surgery in AWR Does Morbid Obesity Predispose to Recurrence after Ventral Herniorraphy? YES l Laparoscopic repair 8% (vs 2%) a l Laparoscopic repair 0% b l Combined repairs19% c l RR-1.1 per unit BMI! d l Other considerations n Wound complications (esp with open operation) n Co-morbidity of obesity n Patching vs medialization of recti If adding components separation,  wound complications a Heniford et al, Ann Surg 2003 – 850 repairs b Birgisson et al, Surg Endosc 2001 – 16 repairs c Raftopoulos and Courcoulas, Surg Endosc 2007 – 27 repairs d Sauerland, Hernia 2004

Bariatric Surgery in AWR AWR in Patients with Morbid Obesity SUMMARY l Recurrence rate is increased (~10%) l Laparoscopic repair is best l Appropriate if patient refuses bariatric surgery l BUT-this speaker’s opinion (bias) is that: These patients benefit by bariatric surgery (  co- morbidities) n Subsequent hernia repair better/easier n Better overall management n The huge hernias are BEST treated by bariatric surgery 1 st

Bariatric Surgery in AWR Remainder of Talk Morbid Obesity With Large Ventral Hernia (not a “small” one)

Bariatric Surgery in AWR Question 2 Timing of AWR and Bariatric Surgery BEFORE ? DURING ? AFTER

Bariatric Surgery in AWR AWR at Time of Bariatric Surgery - 1 Pros l 1 operation/1 anesthetic l 1 convalescence l Already intraperitoneal l Prevents future SBO if herniated content requires reduction for bariatric procedure l Older age patients Cons l Clean-contaminated procedure (? alloplastic prosthesis) Known  risk hernia postop l Hernia “patching,” no AWR l Wound infection (open) l More difficult operation l Will need separate abdominoplasty

Bariatric Surgery in AWR AWR at Time of Bariatric Surgery - 2 Considerations l Can bariatric operation be done laparoscopically n Access n Gastric sleeve/band? n RYGB or DS/BPD? n Need to reduce herniated content? l Reason for AWR n Intermittent SBO n Laborer – needs stable, functional AWR l AWR must be done as an open procedure n Reconsider AWR

Bariatric Surgery in AWR AWR at Time of Bariatric Surgery - 3 Bariatric procedure – band/sleeve l Clean case, less argument l Philosophy regarding results of herniorraphy l Bonatti* - 9 patients at time of band; no recurrences l Rarely reported – probably done often, umbilical hernia l What about very large hernias? n Simultaneous? n Delayed repair? *Obes Surg, 2004

Bariatric Surgery in AWR AWR at Time of Bariatric Surgery - 4 Bariatric procedure – RYGB l Eid* n 12 patients, all Surgisis (SIS) repairs n No recurrences; 26-mo follow-up n 59 patients, all primary repair (suture) n 22% recurrences – (small hernias) n These were no HUGE hernias *Surg Endosc, 2004: no data on size/type of hernia

Bariatric Surgery in AWR AWR at Time of Bariatric Surgery - 5 Bariatric procedure – RYGB l Schuster* n 12 patients (2 open, 10 lap) n 11/12 prosthetic mesh n 2/12 recurrences (~20%) (F/U 1 yr) n No mesh infection l Herbert** n 16 patients (all open) n Intraperitoneal mesh (prophylactic) n 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 AWR AWR at Time of Bariatric Surgery - 6 My experience with alloplastic repairs during open bariatric surgery n 3 of 8 mesh infections n 1 explant of mesh n 2 chronic sinus tracts

Bariatric Surgery in AWR Question 3 BARIATRIC SURGERY FIRST LOSE WEIGHT AWR AFTER WEIGHT LOSS

Bariatric Surgery in AWR Staged AWR – Bariatric Procedure First Considerations – l Size of hernia l Risk of SBO before AWR Hernia may  in size/complexity* l Need for abdominoplasty l More adhesions BUT AFTER WEIGHT LOSS l Easier repair l Can add components separation l Healthier patient l Less chance recurrence l Adequate skin coverage l Combined with abdominoplasty l Timing of AWR *Esp if open procedure required!

Bariatric Surgery First What if an OPEN procedure is required? How to deal with an abdominal wall defect? l Just close the skin/hernia sac? l Absorbable mesh closure? l Bioprosthetic closure? *Multiple prior repairs, adhesions, no access, etc.

Bariatric Surgery First Open How to deal with the abdominal wall defect? Considerations l Just close skin/sac – WORRY OF EVISCERATION l Absorbable mesh – hernia recurs at 3 months (and then gets bigger!) l Bioprosthesis – expensive but may allow greater weight loss before hernia occurs – NO ONE EXPECTS A PERMANENT REPAIR l ? DO THEY ?

Bariatric Surgery in AWR Simultaneous Prosthetic-Based AWR and Abdominoplasty l Is there an increased rate of prosthetic infection? Author# patientsMesh removed Downey Fotopoulos Saxe Iljin Studies  Short term follow-up Wound complication rate ~40% Argues against onlay repair Mesh Infection 3%

Bariatric Surgery in AWR Summary of Presentation Recurrence of hernia after AWR is  in morbid obesity l Complications of AWR are increased in morbid obesity, (esp as an open procedure) l Lap AWR does not medialize rectus muscles l Recurrence after primary repair of hernias in morbid obesity approaches 100% l Risk of SBO is increased when bariatric surgery performed first and herniated contents are reduced l No consensus on bariatric surgery n 1 st n Simultaneous n Staged procedure (bariatric  AWR)