Purpose: Abdominal wall hernias frequently occur following open bariatric surgical procedures. The defects are often quite large and not amenable to simple primary closure. Standard methods of repair with synthetic mesh may be suboptimal with a recurrence rate as high as 50%. Patients often seek repair of these hernias in conjunction with abdominal body contouring procedures following a period of substantial weight loss. The purpose of this report is to determine whether the technique of components separation followed by abdominal wall plication is effective in treating large hernias in the postbariatric population.
Methods: In 66 consecutive patients undergoing abdominal surgery following open bariatric surgery, abdominal wall hernias of some size were found in 50 patients. In 65 of these patients, panniculectomy was performed simultaneously. In one patient with a previous panniculectomy, only ventral hernia repair was performed. The majority of these hernias could be closed primarily in conjunction with abdominal wall plication (38/50 or 76%). In 12 patients (24% of hernias), the defects were too large (median 10.8cm) or located too close to the xiphoid to permit primary closure without undue tension. Using a components separation technique, without the use of a permanent mesh, primary fascial closure was attempted in 12 patients. The technique was modified to include abdominal wall plication above and below the repaired hernia defect and the use of an absorbable mesh onlay.
Results: In all 12 patients with hernias too large to primary repair, components separation and abdominal wall plication was successful in permitting fascial closure under minimal tension. While these patients had a high (50%) rate of minor or major superficial wound complications, all wounds subsequently closed without additional operative procedures. Despite the high risk nature of this group, ventral hernia recurred in only 1/12 patients (8.3%) after a median followup period of 16 months. The single recurrence occurred in one of two patients with the largest diameter (15cm) hernias in the series.
Conclusion: Components separation with abdominal wall plication is the preferred technique for the repair of large hernias not amenable to primary repair in patients after open gastric bypass. Since this technique avoids placement of permanent mesh, it is particularly advantageous in the post-bariatric patients at high risk for wound dehiscence and infection.