Purpose: Health benefits of weight loss achieved through diet and exercise or surgery cannot be denied. Bariatric surgery is a growing industry, with over 100,000 people undergoing surgery annually in the United States. A significant percentage of those people undergoing gastric bypass surgery succeed in massive weight loss, defined as a fifty percent reduction in excess weight by 18 months post surgery. Traditionally, gastric bypass has been performed through an upper midline incision, and the open approach is preferred for extreme BMI and revision patients. Open gastric bypass with subsequent massive weight loss may be complicated by hernia secondary to the abdominal wall incision, poor tissue quality, and weight changes that occur. We aim to present our series of weight loss patients who have undergone hernia repair. Methods and Materials: All patients undergoing abdominal panniculectomy combined with hernia repair by a single surgeon at an academic hospital from February 2001 to December 2003 were retrospectively studied. Forty patients including 9 men and 31 women had a hernia repair during abdominal panniculectomy, with some patients having additional lifting procedures. Average age was 42 years and average weight loss was 152 lb, with average BMI of 35.6 at the time of surgery. (Morbid obesity = BMI > 35) Abdominal panniculectomy was performed with conservative undermining, attempting to limit exposure to the suprapubic/hip incision. In some cases incisional hernias were adherent to overlying, thinned scar or the pannus was cumbersome, resulting in difficulty fully visualizing the hernia. In these cases the lower abdominal incision was combined with a midline incision, similar to a fleur-de-lis. Hernias were treated by the plastic surgeon in all but one case. Fascial edges were dissected in conjunction with lysis of adhesions, and approximated. Adjacent fascia was plicated overtop of the primary repair for reinforcement, allowed by the laxity of the fascia with the weight loss. Mesh was not used. Skin closure was performed in a layered fashion over 2 or 3 Jackson-Pratt drains. Ambulation was encouraged within 24 hours of surgery, and diet progressed as tolerated. Results: Average abdominal skin resection was 9.9 lb, ranging from 2 to 25 lb. Blood transfusion was necessary in 7 (17.5%) of the cases. Length of stay averaged 3 days. Hernia recurrence occurred in 1 patient after heavy lifting 1 year after surgery. Other complications included wounds requiring dressings, VAC therapy and/or delayed primary closure (20%); seroma requiring drain replacement or sclerotherapy (12.5%); suture abscess requiring surgical removal of suture (7.5%); bleeding ulcer (2.5%); postoperative bleeding requiring exploration (2.5%); and fatal PE (2.5%). Uncomplicated healing occurred in 60% of cases. Conclusions: Hernias that develop in the massive weight loss patient after gastric bypass surgery present a specific entity associated with a weakened incision closure, poor tissue quality, and weight changes with associated changes in abdominal wall capacity. We present our approach to these patients with acceptable results.