Concurrent Panniculectomy and Ventral Hernia Repair in Overweight and Obese Patients: A Retrospective Assessment of Clinical Outcomes, Cost, and Quality of Life

Purpose:

Overweight and obese patients suffering from ventral hernias represent a unique cohort of patients, where the combination of these morbid disease processes result in a shared surgical challenge. Abdominal wall reconstruction combining ventral hernia repair (VHR) with panniculectomy (VHR-PAN) in the overweight or obese patient has been highly debated. Advantages of the combined procedure include removal of inflamed or infected soft tissue, complete abdominal wall exposure for an efficient intraoperative repair, and the avoidance of a second surgical procedure. Disadvantages include the risk of higher complication rate and unplanned reoperations. Existing literature fails to integrate clinical outcomes with cost and patient-reported outcomes from both a cosmetic and functional perspective. Due to increased prevalence of obese patients with ventral hernia, we present a comprehensive comparison between VHR-PAN and VHR alone in overweight or obese patients by examining clinical outcomes, cost, and quality of life (QoL).

Methods:

A retrospective review was conducted for eighty-three patients with body mass index (BMI) > 25.0 kg/m² who underwent VHR-PAN (n=51) or VHR alone (n=32) between September 1, 2015 and May 30, 2017 by a single surgeon at the University of Pennsylvania. QoL was assessed using the Hernia-related Quality of Life Survey (HerQLes). Cost was calculated using hospital billing data. Patient demographics were collected and statistical analyses were performed using Fisher’s exact tests, Mann-Whitney U tests, and regression modeling. 

Results:

Mean BMI of the VHR-PAN and VHR alone group was 38.9 kg/m² and 33.5 kg/m², respectively. Hernia defect size (p=0.516), mesh placement (p=0.644), component separation (p=0.5063) and hernia recurrence rates (p=1.000) were similar in both cohorts. Additionally there was no significant difference in operative time (p=0.834) or days to drain removal (0.711) between both groups. Rate of prior bariatric surgery (p=0.0533) trended towards significantly different in the VHR-PAN group. 64% of patients completed QoL surveys, showing significant improvement from pre- to post-operative scores, regardless of whether a panniculectomy was performed (p < 0.02). Mean direct hospitalization costs were not significantly different between the two groups (p=0.165), as well as mean hospital stay (p=1.00). After regression modeling, the procedure performed did not significantly contribute to differences in cost, wound complications, including wound dehiscence and SSI, or hernia recurrence between the two groups. Higher wound class (p=0.0105) and longer hospital length of stay (p=0.0481) were independently associated with an increase in total direct cost, while higher BMI trended towards significance (p=0.0501) with increasing total direct cost.

Conclusions:

The addition of a panniculectomy to VHR does not significantly increase cost or complication rates, including wound events or hernia recurrence. This study highlights the safety and efficacy of performing concurrent ventral hernia repair with panniculectomy in obese and overweight patients, as evident through equal improvements in QoL, post-operative outcomes, and cost. Furthermore, a prospective, randomized controlled trial is needed to continually assess long-term outcomes of VHR-PAN.