Best evidence topic: Should ventral hernia repair be performed at the same time as bariatric surgery?

Abstract

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In morbidly obese patients undergoing bariatric surgery, when a ventral hernia is picked up in clinic or intraoperatively is concurrent repair of the hernia better than delayed repair after weight loss with regards to complication rates? Using the reported search, 179 papers were found. 5 studies were deemed to be suitable to answer the question.All 5 studies assessed were non randomised studies either retrospective or prospective and the overall quality of these studies was poor. The outcomes assessed were incidence of complications associated with hernia repair (recurrence, infection) and deferral of repair (small bowel obstruction). The patient's symptoms and anatomy is important in determining the timing of repair.The evidence does not provide a consensus for the optimal timing of ventral hernia repair for patients undergoing bariatric surgery, with some of the selected studies contradicting each other. However, the studies do affirm the risk of small bowel obstruction if hernias are left alone. The reported rate of surgical site infection is low when mesh repair is performed at the same time as weight loss surgery.Until large volume, high quality randomized control trials can be performed, a case by case approach is best, where the patients' symptoms, anatomy, type of bariatric surgery and their personal preferences are considered, and an open discussion on the risks and benefits of each approach is undertaken.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures – 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

“…(2008*). Timing of repair of abdominal wall hernias is debatable, with insufficient evidence for a recommendation; strategy would depend on the hernia size, location, and type .…”

Clinical Practice Guidelines For The Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures – 2019 Update: Cosponsored By American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society For Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

“…. Timing of repair of abdominal wall hernias is debatable, with insufficient evidence for a recommendation; strategy would depend on the hernia size, location, and type (826).…”

Innovative Approaches to Address the Technical Challenge of Hernial Sac Distension Due to Pneumoperitoneum in the Synchronous Management of Complex Hernias in Individuals With Morbid Obesity

“…Recognizing the significance of performing both procedures concurrently is apparent, as the alternative, i.e., postponing VeH repair after BS, may decrease the likelihood of recurrence and simplify hernia repair but is linked to a higher incidence of unresolved hernia complications [14]. Comprehensive studies have scrutinized complications associated with simultaneous BS and VeH repair [15]. In one of the largest series (n = 503), Spaniolas et al [8] suggested that synchronous VeH repair is only linked to an elevated surgical-site infection rate, not overall morbidity.…”