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Comment on: Management of ventral hernias during laparoscopic gastric bypass
D. M. Herron / Surgery for Obesity and Related Diseases 4 (2008) 757–758
Conclusions We do not advocate primary repair for clinically significant hernias, and we believe good techniques are available to allow for the deferred management of select hernias. We also believe mesh infection rates are not common when performed concomitantly with LGB. Synthetic mesh materials should be considered in the repertoire of techniques to repair ventral hernias during gastric bypass surgery. Disclosures The authors claim no commercial associations that might be a conflict of interest in relation to this article. References [1] Sugerman HJ, Kellum JM Jr, Reines HD, DeMaria EJ, Newsome HH, Lowry JW. Greater risk of incisional hernia with morbidly obese than steroid-dependent patients and low recurrence with prefascial polypropylene mesh. Am J Surg 1996;171:80 – 4. [2] Eid GM, Mattar SG, Hamad G, et al. Repair of ventral hernias in morbidly obese patients undergoing laparoscopic gastric bypass should not be deferred. Surg Endosc 2004;18:207–10. [3] Jin J, Rosen MJ, Blatnik J, et al. Use of acellular dermal matrix for complicated ventral hernia repair: does technique affect outcomes? J Am Coll Surg 2007;205:654 – 60. [4] Gupta A, Zahriya K, Mullens PL, Salmassi S, Keshishian A. Ventral herniorrhaphy: experience with two different biosynthetic mesh materials, Surgisis and Alloderm. Hernia 2006;10:419 –25. [5] Quebbemann BB, Dallal RM. The orientation of the antecolic Roux limb markedly affects the incidence of internal hernias after laparoscopic gastric bypass. Obes Surg 2005;15:766 –70. [6] Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 2000;343:392– 8. [7] Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 2004;240:578 – 85.
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[8] Novitsky YW, Cobb WS, Kercher KW, Matthews BD, Sing RF, Heniford BT. Laparoscopic ventral hernia repair in obese patients: a new standard of care. Arch Surg 2006;141:57– 61. [9] Eid GM, Prince JM, Mattar SG, Hamad G, Ikrammudin S, Schauer PR. Medium-term follow-up confirms the safety and durability of laparoscopic ventral hernia repair with PTFE. Surgery 2003;134: 599 – 604. [10] Pierce RA, Spitler JA, Frisella MM, Matthews BD, Brunt LM. Pooled data analysis of laparoscopic vs. open ventral hernia repair: 14 years of patient data accrual. Surg Endosc 2007;21:378 – 86. [11] Williams MD, Champion JK. Experience with routine intraabdominal cultures during laparoscopic gastric bypass with implications for antibiotic prophylaxis. Surg Endosc 2004;18:755– 6. [12] Geisler DJ, Reilly JC, Vaughan SG, Glennon EJ, Kondylis PD. Safety and outcome of use of nonabsorbable mesh for repair of fascial defects in the presence of open bowel. Dis Colon Rectum 2003;46: 1118 –23. [13] Kelly ME, Behrman SW. The safety and efficacy of prosthetic hernia repair in clean-contaminated and contaminated wounds. Am Surg 2002;68:524 –9. [14] Birolini C, Utiyama EM, Rodrigues AJ Jr, Birolini D. Elective colonic operation and prosthetic repair of incisional hernia: does contamination contraindicate abdominal wall prosthesis use? J Am Coll Surg 2000;191:366 –72. [15] Simon E, Kelemen O, Knausz J, Bodnar S, Batorfi J. Synchronically performed laparoscopic cholecystectomy and hernioplasty. Acta Chir Hung 1999;38:205–7. [16] Stringer RA, Salameh JR. Mesh herniorrhaphy during elective colorectal surgery. Hernia 2005;9:26 – 8. [17] McLanahan D, King LT, Weems C, Novotney M, Gibson K. Retrorectus prosthetic mesh repair of midline abdominal hernia. Am J Surg 1997;173:445–9. [18] Strzelczyk J, Czupryniak L. Polypropylene mesh in prevention of postoperative hernia in bariatric surgery. Ann Surg 2005;241:196 –97. [19] Schuster R, Curet MJ, Alami RS, Morton JM, Wren SM, Safadi BY. Concurrent gastric bypass and repair of anterior abdominal wall hernias. Obes Surg 2006;16:1205– 8. [20] Helton WS, Fisichella PM, Berger R, Horgan S, Espat NJ, Abcarian H. Short-term outcomes with small intestinal submucosa for ventral abdominal hernia. Arch Surg 2005;140:549 – 62.
Editorial comment
Comment on: Management of ventral hernias during laparoscopic gastric bypass As bariatric surgeons, what should we do when we find a previously unsuspected ventral hernia during gastric bypass? Dr. Dallal’s group from the Albert Einstein Medical Center addresses this interesting and practical question with a retrospective review of their operative experience. When we encounter an unsuspected ventral hernia during the performance of gastric bypass, we have 3 surgical options. The simplest option—and the 1 taken by many bariatric surgeons—is to do nothing. The presence of the hernia is merely noted, and its formal repair deferred until several months or more after the bypass. Such an approach follows the dictum of “first do no harm” and offers several potential benefits. First,
the placement of mesh into a clean-contaminated field is avoided. Second, the surgeon does not perform a procedure for which the patient has not given explicit consent. Finally, this approach allows time for the patient to lose weight, making the ultimate hernia repair more technically facile and potentially secure. The downside to this deferral of definitive repair is that it leaves the patient with the potential for incarceration and obstruction, which could in turn lead to the blowout of the proximal or distal anastomosis or 1 of the gastric staple lines. The second option is to hedge one’s bets and repair the hernia primarily, with suture material only. An informal poll of the bariatric surgeons at my institution suggested that this
758
D. M. Herron / Surgery for Obesity and Related Diseases 4 (2008) 757–758
might be the currently favored approach. As with the first option, this strategy sidesteps the issue of mesh placement in a clean-contaminated field. However, it provides the additional benefit of reducing the risk of an incarcerated or strangulated hernia. The final option is to definitively repair the hernia defect with mesh. This is an appealing option, because it provides for a secure and permanent repair of the defect while minimizing the risk of a postoperative incarceration or strangulation. Additionally, it eliminates the need for a subsequent return to the operating room. However, only limited data are available regarding the safety of mesh placement in a cleancontaminated field. If the mesh were to become infected, it would mandate ⱖ2 return trips to the operating room: first to remove the mesh and a second to formally repair the hernia once the infection had resolved. This concern, although theoretical, is substantial enough that mesh placement concomitant with bypass is certainly not the preferred “Board answer” to the question. In this study, the authors report the results of an algorithmic approach to ventral hernia management that includes all 3 of these options. Asymptomatic hernias containing omentum only were left alone. Symptomatic hernias, or those interfering with the performance of the gastric bypass, were repaired. Hernias ⱕ2 cm in diameter were repaired with suture only, and larger ones were treated with the intraperitoneal placement of coated permanent mesh. This report presents 3 interesting results. First, the authors found that ventral hernias are quite common in the gastric bypass population. Of the 325 patients in this series, 26 had a ventral hernia, for an incidence of 8%, or nearly 1 in 12. Second, the authors report that primary hernia repair with suture—an approach favored by many bariatric surgeons—might be the least appealing of the 3 options. Of the 8 patients who underwent such a repair, 2 (25%) developed a postoperative small bowel obstruction at the ventral hernia repair site. Finally, the authors describe excellent outcomes in the patients treated with permanent mesh repair. This report is an important addition to the small body of published data concerning this serious problem. In 2004, Eid et al. [1] retrospectively reviewed the Pittsburgh experience. As did the Einstein group, they noted an unacceptably high rate of recurrence (22%) with primary repair. Unlike the Einstein group, they found that deferral of definitive repair resulted in a very high rate of small bowel obstruction from incarceration. This led the Pittsburgh group to conclude that “all incarcerated ventral hernias
should be repaired concomitant with [gastric bypass].” However, it should be noted that the Pittsburgh group followed a somewhat different therapeutic algorithm that did not include leaving omentum in situ within the hernia sac to preclude subsequent bowel incarceration. The importance of concomitant ventral hernia repair is supported by a case report by Sukeik et al. [2] in which a 5-cm umbilical hernia was identified during laparoscopic gastric bypass in a 50-year-old man. The omentum within the hernia sac was reduced to facilitate completion of the bypass, and the defect was left open at that time. The patient was readmitted to the hospital 1 day after discharge with a small bowel obstruction from an incarceration at the umbilical site. Although the patient was promptly returned to the operating room for surgical intervention, he aspirated on induction of anesthesia and ultimately died of sepsis 7 days later. The report by Dallal et al. recommends that we leave ventral hernias alone only if the sac is safely plugged with viable omentum. When this is not possible, formal repair with permanent mesh appears to be a safe and effective alternative. Given the small size of their study, we need to interpret its conclusions cautiously. However, it could be ultimately turn out that our current concerns regarding the use of mesh during gastrointestinal surgery are overstated. Disclosures The author claims no commercial associations that might be a conflict of interest in relation to this article. Daniel M. Herron, M.D., F.A.C.S Department of Surgery Mount Sinai School of Medicine Division of Bariatric Surgery Mount Sinai Medical Center New York, New York
References [1] Eid GM, Mattar SG, Hamad G, et al. Repair of ventral hernias in morbidly obese patients undergoing laparoscopic gastric bypass should not be deferred. Surg Endosc 2004;18:207–10. [2] Sukeik M, Alkari B, Ammori BJ. Abdominal wall hernia during laparoscopic gastric bypass: a serious consideration. Obes Surg 2007; 17:839 – 42.
Conclusions We do not advocate primary repair for clinically significant hernias, and we believe good techniques are available to allow for the deferred management of select hernias. We also believe mesh infection rates are not common when performed concomitantly with LGB. Synthetic mesh materials should be considered in the repertoire of techniques to repair ventral hernias during gastric bypass surgery. Disclosures The authors claim no commercial associations that might be a conflict of interest in relation to this article. References [1] Sugerman HJ, Kellum JM Jr, Reines HD, DeMaria EJ, Newsome HH, Lowry JW. Greater risk of incisional hernia with morbidly obese than steroid-dependent patients and low recurrence with prefascial polypropylene mesh. Am J Surg 1996;171:80 – 4. [2] Eid GM, Mattar SG, Hamad G, et al. Repair of ventral hernias in morbidly obese patients undergoing laparoscopic gastric bypass should not be deferred. Surg Endosc 2004;18:207–10. [3] Jin J, Rosen MJ, Blatnik J, et al. Use of acellular dermal matrix for complicated ventral hernia repair: does technique affect outcomes? J Am Coll Surg 2007;205:654 – 60. [4] Gupta A, Zahriya K, Mullens PL, Salmassi S, Keshishian A. Ventral herniorrhaphy: experience with two different biosynthetic mesh materials, Surgisis and Alloderm. Hernia 2006;10:419 –25. [5] Quebbemann BB, Dallal RM. The orientation of the antecolic Roux limb markedly affects the incidence of internal hernias after laparoscopic gastric bypass. Obes Surg 2005;15:766 –70. [6] Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 2000;343:392– 8. [7] Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 2004;240:578 – 85.
757
[8] Novitsky YW, Cobb WS, Kercher KW, Matthews BD, Sing RF, Heniford BT. Laparoscopic ventral hernia repair in obese patients: a new standard of care. Arch Surg 2006;141:57– 61. [9] Eid GM, Prince JM, Mattar SG, Hamad G, Ikrammudin S, Schauer PR. Medium-term follow-up confirms the safety and durability of laparoscopic ventral hernia repair with PTFE. Surgery 2003;134: 599 – 604. [10] Pierce RA, Spitler JA, Frisella MM, Matthews BD, Brunt LM. Pooled data analysis of laparoscopic vs. open ventral hernia repair: 14 years of patient data accrual. Surg Endosc 2007;21:378 – 86. [11] Williams MD, Champion JK. Experience with routine intraabdominal cultures during laparoscopic gastric bypass with implications for antibiotic prophylaxis. Surg Endosc 2004;18:755– 6. [12] Geisler DJ, Reilly JC, Vaughan SG, Glennon EJ, Kondylis PD. Safety and outcome of use of nonabsorbable mesh for repair of fascial defects in the presence of open bowel. Dis Colon Rectum 2003;46: 1118 –23. [13] Kelly ME, Behrman SW. The safety and efficacy of prosthetic hernia repair in clean-contaminated and contaminated wounds. Am Surg 2002;68:524 –9. [14] Birolini C, Utiyama EM, Rodrigues AJ Jr, Birolini D. Elective colonic operation and prosthetic repair of incisional hernia: does contamination contraindicate abdominal wall prosthesis use? J Am Coll Surg 2000;191:366 –72. [15] Simon E, Kelemen O, Knausz J, Bodnar S, Batorfi J. Synchronically performed laparoscopic cholecystectomy and hernioplasty. Acta Chir Hung 1999;38:205–7. [16] Stringer RA, Salameh JR. Mesh herniorrhaphy during elective colorectal surgery. Hernia 2005;9:26 – 8. [17] McLanahan D, King LT, Weems C, Novotney M, Gibson K. Retrorectus prosthetic mesh repair of midline abdominal hernia. Am J Surg 1997;173:445–9. [18] Strzelczyk J, Czupryniak L. Polypropylene mesh in prevention of postoperative hernia in bariatric surgery. Ann Surg 2005;241:196 –97. [19] Schuster R, Curet MJ, Alami RS, Morton JM, Wren SM, Safadi BY. Concurrent gastric bypass and repair of anterior abdominal wall hernias. Obes Surg 2006;16:1205– 8. [20] Helton WS, Fisichella PM, Berger R, Horgan S, Espat NJ, Abcarian H. Short-term outcomes with small intestinal submucosa for ventral abdominal hernia. Arch Surg 2005;140:549 – 62.
Editorial comment
Comment on: Management of ventral hernias during laparoscopic gastric bypass As bariatric surgeons, what should we do when we find a previously unsuspected ventral hernia during gastric bypass? Dr. Dallal’s group from the Albert Einstein Medical Center addresses this interesting and practical question with a retrospective review of their operative experience. When we encounter an unsuspected ventral hernia during the performance of gastric bypass, we have 3 surgical options. The simplest option—and the 1 taken by many bariatric surgeons—is to do nothing. The presence of the hernia is merely noted, and its formal repair deferred until several months or more after the bypass. Such an approach follows the dictum of “first do no harm” and offers several potential benefits. First,
the placement of mesh into a clean-contaminated field is avoided. Second, the surgeon does not perform a procedure for which the patient has not given explicit consent. Finally, this approach allows time for the patient to lose weight, making the ultimate hernia repair more technically facile and potentially secure. The downside to this deferral of definitive repair is that it leaves the patient with the potential for incarceration and obstruction, which could in turn lead to the blowout of the proximal or distal anastomosis or 1 of the gastric staple lines. The second option is to hedge one’s bets and repair the hernia primarily, with suture material only. An informal poll of the bariatric surgeons at my institution suggested that this
758
D. M. Herron / Surgery for Obesity and Related Diseases 4 (2008) 757–758
might be the currently favored approach. As with the first option, this strategy sidesteps the issue of mesh placement in a clean-contaminated field. However, it provides the additional benefit of reducing the risk of an incarcerated or strangulated hernia. The final option is to definitively repair the hernia defect with mesh. This is an appealing option, because it provides for a secure and permanent repair of the defect while minimizing the risk of a postoperative incarceration or strangulation. Additionally, it eliminates the need for a subsequent return to the operating room. However, only limited data are available regarding the safety of mesh placement in a cleancontaminated field. If the mesh were to become infected, it would mandate ⱖ2 return trips to the operating room: first to remove the mesh and a second to formally repair the hernia once the infection had resolved. This concern, although theoretical, is substantial enough that mesh placement concomitant with bypass is certainly not the preferred “Board answer” to the question. In this study, the authors report the results of an algorithmic approach to ventral hernia management that includes all 3 of these options. Asymptomatic hernias containing omentum only were left alone. Symptomatic hernias, or those interfering with the performance of the gastric bypass, were repaired. Hernias ⱕ2 cm in diameter were repaired with suture only, and larger ones were treated with the intraperitoneal placement of coated permanent mesh. This report presents 3 interesting results. First, the authors found that ventral hernias are quite common in the gastric bypass population. Of the 325 patients in this series, 26 had a ventral hernia, for an incidence of 8%, or nearly 1 in 12. Second, the authors report that primary hernia repair with suture—an approach favored by many bariatric surgeons—might be the least appealing of the 3 options. Of the 8 patients who underwent such a repair, 2 (25%) developed a postoperative small bowel obstruction at the ventral hernia repair site. Finally, the authors describe excellent outcomes in the patients treated with permanent mesh repair. This report is an important addition to the small body of published data concerning this serious problem. In 2004, Eid et al. [1] retrospectively reviewed the Pittsburgh experience. As did the Einstein group, they noted an unacceptably high rate of recurrence (22%) with primary repair. Unlike the Einstein group, they found that deferral of definitive repair resulted in a very high rate of small bowel obstruction from incarceration. This led the Pittsburgh group to conclude that “all incarcerated ventral hernias
should be repaired concomitant with [gastric bypass].” However, it should be noted that the Pittsburgh group followed a somewhat different therapeutic algorithm that did not include leaving omentum in situ within the hernia sac to preclude subsequent bowel incarceration. The importance of concomitant ventral hernia repair is supported by a case report by Sukeik et al. [2] in which a 5-cm umbilical hernia was identified during laparoscopic gastric bypass in a 50-year-old man. The omentum within the hernia sac was reduced to facilitate completion of the bypass, and the defect was left open at that time. The patient was readmitted to the hospital 1 day after discharge with a small bowel obstruction from an incarceration at the umbilical site. Although the patient was promptly returned to the operating room for surgical intervention, he aspirated on induction of anesthesia and ultimately died of sepsis 7 days later. The report by Dallal et al. recommends that we leave ventral hernias alone only if the sac is safely plugged with viable omentum. When this is not possible, formal repair with permanent mesh appears to be a safe and effective alternative. Given the small size of their study, we need to interpret its conclusions cautiously. However, it could be ultimately turn out that our current concerns regarding the use of mesh during gastrointestinal surgery are overstated. Disclosures The author claims no commercial associations that might be a conflict of interest in relation to this article. Daniel M. Herron, M.D., F.A.C.S Department of Surgery Mount Sinai School of Medicine Division of Bariatric Surgery Mount Sinai Medical Center New York, New York
References [1] Eid GM, Mattar SG, Hamad G, et al. Repair of ventral hernias in morbidly obese patients undergoing laparoscopic gastric bypass should not be deferred. Surg Endosc 2004;18:207–10. [2] Sukeik M, Alkari B, Ammori BJ. Abdominal wall hernia during laparoscopic gastric bypass: a serious consideration. Obes Surg 2007; 17:839 – 42.