Debating the Best Approach to Obese Patients With Ventral Hernias

At the most recent Clinical Congress of the American College of Surgeons, surgeons debated how best to serve obese patients with ventral hernias, discussing the role of weight loss and the possibility of performing bariatric surgery and complex hernia repair concomitantly. The opinions presented ranged from skepticism about the success rate of encouraging preoperative weight loss to advocacy for concomitant bariatric surgery and hernia repair in certain cases.

Preoperative Weight Loss: Yea or Nay?

Mike Liang, MD, a general surgeon with North Houston Specialty Surgery and Bariatrics, in Kingwood, Texas, made the case that these problems ought to be addressed separately. Protracted preoperative weight loss programs, he said, have no clear clinical benefit at scale and create potential risks for both the patient and practitioner (Ann Surg 2022;275[2]:288-294). He advocated for shared decision-making to evaluate the patient’s motivation and willingness to pursue weight loss, rather than prescribing weight loss ahead of hernia repair in every case.

“Elective ventral hernia repair in morbidly obese patients should be performed at high-volume, high-acuity centers, by surgeons who are doing a hundred procedures or more per year,” Dr. Liang said during his ACS presentation. “[Weight loss] is not [hernia surgeons’] burden to carry; obesity needs to be tackled on multiple fronts, including policy change, culture shift, social changes and healthcare shifts.”

A more moderate position was taken by Benjamin T. Miller, MD, an assistant professor of surgery at the Cleveland Clinic Lerner College of Medicine, who argued in favor of asking patients above a certain body mass index (BMI) threshold to lose weight prior to hernia repair. Dr. Miller presented evidence indicating that patients with obesity undergoing ventral hernia repair suffer from increased wound morbidity (Hernia 2015;19:103-111; Surgery 2024;175[3]:806-812), but pointed out mixed evidence at best for increased hernia recurrence in obese patients and improved quality of life in patients who undergo weight loss beforehand (“Are There Really No Downsides to Delaying Surgery to Prehab Patients?” General Surgery News, December 2023).

“In fact, patients with obesity have a greater change in quality of life, indicating that they benefit just as much, if not more, from hernia repair,” he said.

Dr. Miller also presented data showing longer operative times for complex ventral hernia repairs in patients with a BMI higher than 35 kg/m², demonstrating quantitatively what he and other surgeons present agreed with anecdotally, that these procedures are simply more difficult to perform in obese patients (Surgery 2024;175[3]:806-812).

“There are a few reasons, some data-driven and some not, that we ask patients to lose weight, or deny patients hernia repair if they’re obese,” he said. “When people are heavier, that makes the operation more mentally and physically challenging. It’s more difficult to move tissue around and to identify structures. We not only know this anecdotally and from experience, but we have data to support it as well.”

Concomitant Surgery: Necessary in Certain Cases?

In her presentation, Kaela Blake, MD, an assistant professor in the Department of Surgery at the University of Tennessee Graduate School of Medicine, in Knoxville, advocated for a specific population for whom concomitant bariatric and hernia surgery might be the last best option—possibly even their only chance at breaking out of the cycle of obesity and recurrent hernias.

“There are patients with nonemergent but symptomatic hernias that are causing partial bowel blockages and/or a lot of pain, but they are at a BMI higher than 50, and physically unable to focus on going through a weight loss protocol,” she said. “The guidelines do not recommend hernia repair for these patients because the recurrence risk is too high. So, what do we do with these people who really need a life-changing operation to improve their quality of life and potentially avoid an emergent situation?”

As it stands now, Dr. Blake said, the healthcare system is simply not set up to serve these patients until they inevitably require emergency surgery.

“We have these patients who are simmering with symptoms, and we know that since they are highly symptomatic, they’ll have to come in for a hernia repair sooner or later,” she said. “So, why not set up a system so these patients can get the information they need to prepare for bariatric surgery at the same time? We can condense all the psychological and dietary education they need into a month or two, and when [we] bring them in for hernia surgery, do a simple sleeve gastrectomy. That would get them on the road to decreasing their weight and hopefully decreasing their risk of hernia recurrence.”

Dr. Blake added that, given the proven safety of bariatric surgery and the rising tide of obesity, the time is right for pushing the boundaries to not only offer the procedure to more patients who might benefit, but to consider performing it concomitantly with other procedures as well.

“There are patients who need partial liver resections whose BMI is 50 or higher, patients who have cancer or need a hysterectomy,” she said. “We’ve clearly established that bariatric surgery is very, very safe. These patients are already going to be coming in for surgery, and they really need the help to get back on track.”

Concomitant Procedures, Present and Future

Simultaneous bariatric surgery and simple hernia repair is relatively common, and while performing bariatric surgery concomitantly with complex ventral hernias or other complex procedures is less common, it’s not entirely unheard of. In recent years, the Department of Surgery at The University of Texas Health Science Center at San Antonio (UTSA) has been performing sleeve gastrectomies concomitantly with living donor liver transplant, according to Richard Peterson, MD, MPH, the chief of metabolic and bariatric surgery and president-elect of the American Society for Metabolic and Bariatric Surgery, who is also on the editorial advisory board of General Surgery News.

Liver transplantation and sleeve gastrectomy are a particularly apt pairing, Dr. Peterson said, given that metabolic dysfunction–associated steatohepatitis, or MASH—a disease process closely associated with obesity—has become a leading cause of liver transplants in the United States. For an experienced team at a well-equipped center like UTSA, the two procedures are also convenient to perform concomitantly, he noted.

“Our liver transplant team is so coordinated that while one team is harvesting the donor liver, the other team is removing the liver from the recipient,” Dr. Peterson said. “They’ll bring it in, connect the blood supply, and then call our team in. There’s a routine hour-long gap at that point while they wait for the liver to perfuse, and we utilize that time to come in and do the sleeve. And by the time we’re done, that’s about when they would be coming back anyway to make sure the liver is looking good and do the anastomosis to the biliary tree.”

Dr. Peterson added that complex ventral hernia repairs are also performed concomitantly with sleeve gastrectomies at UTSA, but are relatively rare, with maybe five cases per year.

“We’re very selective about it. I would say typically it’s best to avoid doing a complex hernia repair and a sleeve concomitantly, but our partners are not averse to doing it,” he said. “In our practice, we hold a preoperative conference to discuss all of our patients and make the determination as a group if we think that’s a good approach.”

Dr. Blake said UTSA’s approach is a step in the right direction, adding that if concomitant procedures are to become more common on a larger scale, there will need to be special designations for patients undergoing them, with different standards for evaluating performance.

“As a center of excellence, we can’t have too many complications because it reflects poorly on the center,” she said. “We need to create a category for patients undergoing concomitant bariatric and other surgeries, so that a patient with a BMI of 37 and hypertension isn’t being compared to someone with a BMI of 60 who needs two different surgeries.”