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In oduc ion
Obesi y is one o he main ac o s o he de elopmen
o incisional he nia. In addi ion, su gical epai o en al
he nias (VHs) in obese pa ien s is clea ly associa ed wi h a
highe a e o complica ions and ecu ences (1). Among he
di e en complica ions ha may occu a e en al he nia
epai (VHR), we can ind wound in ec ion, e isce a ion,
h omboembolic e en s o ecu ence. Inc eased abdominal
ci cum e ence, amoun o a y issue, ype 2 diabe es
and inc ease o in a-abdominal p essu e a e obesi y-
ela ed ac o s ha clea ly in luence he highe numbe o
in ec ions and ecu ence a e in hese pa ien s.
Abdominal wall su ge y is one o he mos equen
p ocedu es pe o med by su geons in ou hospi als.
Nowadays he e is a high p e alence o obesi y, which
makes his su ge y inc easingly challenging. P eope a i e
op imiza ion o pa ien s is pa amoun o dec ease he isk
o pos ope a i e complica ions and include s op smoking,
imp o e he nu i ional s a us and lose weigh among
o he s.
Ce ainly, one o he key poin s included in he
Re iew A icle
Abdominal wall su ge y in ba ia ic pa ien s
Sal ado Mo ales-Conde1,2, Eugenio Lica die2, Ma ía Socas1, An onio Ba anco1, F ancisco López Be nal1,
Isaías Ala cón1,2
1Uni o Inno a ion in Minimally In asi e Su ge y, Depa men o Su ge y, Uni e si y Hospi al Vi gen del Rocío, Uni e si y o Se illa, Se illa,
Spain; 2Uni o Gene al and Diges i e Su ge y, Hospi al Qui onsalud Sag ado Co azón, Se illa, Spain
Con ibu ions: (I) Concep ion and design: S Mo ales-Conde, E Lica die; (II) Adminis a i e suppo : M Socas, F López Be nal; (III) P o ision o
s udy ma e ials o pa ien s: S Mo ales-Conde, I Ala cón; (IV) Collec ion and assembly o da a: S Mo ales-Conde, E Lica die; (V) Da a analysis and
in e p e a ion: S Mo ales-Conde; (VI) Manusc ip w i ing: All au ho s; (VII) Final app o al o manusc ip : All au ho s.
Co espondence o: Isaías Ala cón. Uni o Inno a ion in Minimally In asi e Su ge y, Depa men o Su ge y, Uni e si y Hospi al Vi gen del Rocío,
Uni e si y o Se illa, A . Concejal Jimenez Bece il 15 4-1, 41009 Se ille, Spain. Email: [email p o ec ed].
Abs ac : Mo bid obesi y is one o he main ac o s ela ed o he nia ecu ences a e an open epai ,
while lapa oscopic app oach has o e ed excellen esul s in his ype o pa ien s. Concomi an lapa oscopic
ba ia ic p ocedu e and en al he nia epai (VHR) wi h in ape i oneal mesh has been desc ibed as a sa e
op ion, bu he need o place a mesh in ape i oneally has a isen some conce ns. Howe e , he li e a u e
does no show good esul s wi h he use o ans ascial su u e nei he o p ima y closu es no wi h biological
meshes. The e is s ill no enough e idence o each a consensus ega ding when is he bes ime o pe o m
he he nia epai on pa ien s unde going ba ia ic su ge y, simul aneously o di e ing he he nia epai . Fo
ha eason, i seems ha an indi idualized app oach is ecommended, in o ming he pa ien o he isks and
bene i s o each op ion. The ype o ba ia ic su ge y, he ype and loca ion o he he nia, p e ious su ge y
in case o an incisional he nia, symp oms ela ed o he he nia and he su gical app oach a e ac o s o be
analyzed. I is necessa y o conside epai ing simul aneously a en al he nia (VH) in he pa ien who is
going o unde go a ba ia ic p ocedu e o di e ing i in o de o pe o m simul aneously a concomi an
epai (CR) and he de molipec omy needed a e weigh loss. Fo his eason, only clea symp oma ic
he nias a e ecommended o be epai du ing he ba ia ic p ocedu e. Finally, i is impo an o in o m
p ope ly he pa ien abou possible changes in aope a i ely o he ba ia ic p ocedu e because exis ing
indings, especially due o he p esence o adhesions.
Keywo ds: Ven al he nia (VH); incisional he nia; ba ia ic su ge y; mo bid obesi y
Recei ed: 29 Feb ua y 2020; Accep ed: 11 Augus 2020; Published: 20 July 2021.
doi: 10.21037/ales-20-50
View his a icle a : h p://dx.doi.o g/10.21037/ales-20-50
9
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op imiza ion o pa ien s ha imp o e he esul s o his
abdominal wall su ge y is p eope a i e weigh loss. In mos
cases, i is ecommended o de e elec i e su ge y un il
achie ing an op imal weigh , assuming he isk o inc easing
he de ec , which will make he p ocedu e mo e di icul in
he u u e, o he isk o s angula ion.
Based on hese issues, he ques ion ha a ises is i we
should o e o hese pa ien s a ba ia ic p ocedu e and
di e he he nia su ge y, o i he wo su ge ies should be
pe o med simul aneously. The e o e, he deba e is open
o discussion: should he he nia be epai ed concomi an o
he ba ia ic p ocedu e? Which ba ia ic p ocedu e should
be pe o med? Should he he nia be epai ed oge he wi h
he emo al o he excess o skin once he pa ien has los
weigh a e he ba ia ic p ocedu e?
The e a e many a gumen s in di e en di ec ions,
equi ing an ex ensi e analysis o he li e a u e and o
he expe ience by di e en g oups o de e mine he mos
app op ia e way o p oceed.
Special conside a ions o he ea men o VHs
in pa ien s wi h mo bid obesi y
The e a e se e al ac o s ha ha e been di ec ly associa ed
wi h he de elopmen o ecu ences a e con en ional open
VHR. Among hese ac o s we migh iden i y some ela ed
o he he nia, such as he size and loca ion, he numbe o
p e ious epai s o he p esence o non-palpable de ec s; and
o he s ela ed o local condi ions o he su gical wounds, such
as he p esence o ch onic in ec ion o is ulas; and inally
some ela ed o he pa ien , such as age, gende , smoking
habi , nu i ional s a us o he pa ien s and mo bid obesi y.
Rega ding obesi y, i has been epo ed ha ecu ence
a e a e open he nia epai is 25% in pa ien s wi h body
mass index (BMI) below 25, and ises up o 39% in pa ien s
wi h BMI o e 25. Howe e , wi h lapa oscopic epai , his
a e dec eases signi ican ly, and no di e ences a e obse ed
be ween obese and non-obese pa ien s. In his sense,
Bi gisson e al. (2) epo ed 64 pa ien s who unde wen a
lapa oscopic VH and no signi ican di e ences be ween
pa ien s wi h a BMI less han 29, be ween 30 and 39 and
o e 40. Subsequen s udies ha e shown simila esul s wi h
lowe ecu ences a es in lapa oscopic epai . These esul s
a e ela ed o he p esence o lowe incidence o su gical si e
in ec ions a e lapa oscopic epai , making he lapa oscopic
app oach a clea indica ion o VHRs in obese pa ien s.
Mo eo e , we ha e ound ha minimally in asi e
app oach allows o iden i y non-palpable o occul de ec s
on clinical examina ion, which is ano he o he mos
impo an ac o s ha could in luence his dec ease o
ecu ences (Figu e 1). In addi ion, lapa oscopic app oach
also allows o ein o ce he en i e p e ious incision a ound
he he nia de ec . P e ious incision is a weak a ea whe e a
new he nia can be de eloped, as i has been demons a ed
in se e al s udies. This comple e ein o cemen o
en i e p e ious incision and non-palpable de ec s can be
pe o med by lapa oscopy a oiding an ex ensi e dissec ion
o subcu aneous and musculoaponeu o ic issues educing
he o e all wound- ela ed mo bidi y, which is ela ed o
he nia ecu ence.
On he o he hand, se oma is a e y common condi ion
a e bo h open and lapa oscopic he nia epai . Risk o
se oma in ec ion is lowe in he lapa oscopic app oach,
since he access o he ca i y wi h he oca s is a om
whe e his luid is and emains s e ile. While, in open
su ge y, incision is pe o med o e he de ec , in di ec
con ac wi h he se oma, inc easing he possibili y o
becoming con amina ed.
In conclusion, la es me a-analyses ha e shown ha
lapa oscopic VHR is associa ed wi h a lowe a e o wound-
ela ed mo bidi y such as in ec ions, hemo hagic e en s
and he need o mesh emo al (3) ega dless o pa ien
BMI. These esul s ha e led expe s o ecommend he use
o he lapa oscopic app oach o obese pa ien s in he la es
clinical guidelines published (4), since hey a e one o he
g oups whe e he lapa oscopic he nia epai p esen s he
mos bene i s.
Howe e , as in non-obese pa ien s, no all VHs in
obese pa ien s a e sui able o a minimally in asi e epai .
I is necessa y o es ablish p ope indica ions o his
app oach o ob ain he bes possible esul s. The need o
Figu e 1 Occul de ec s no de ec ed by clinical examina ion in an
obese pa ien .
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a concomi an de molipec omy, ophic skin diso de s o
a gian de ec wi h loss o domain a e some o he cases in
which an open app oach is ecommended e en in obese
pa ien s. Fo his eason, an accu a e diagnosis is necessa y
being ecommended o pe o m a CT-scan, since physical
examina ion is di icul in hese pa ien s.
Conside a ions o he ea men o VH in obese
pa ien s who is planning a ba ia ic p ocedu e
A signi ican pe cen age o pa ien s unde going ba ia ic
su ge y p esen a concomi an VH. In mos cases i is
a p ima y umbilical he nia, al hough incisional he nia,
e en wi h mul iple p e ious epai s, could also be
p esen . Some imes, hese he nias may be he ini ial
pa ien ’s conce n and he eason o medical consul a ion
being e e ed o a ba ia ic uni o weigh loss p io o
abdominal wall econs uc ion.
Unde hese ci cums ances, se e al di e en scena ios
a e conside ed, and mus be analyzed in o de o answe
doub s ha a ise.
Is i sa e o pe o m bo h su ge ies concomi an ly by
lapa oscopy?
Cu en ly, lapa oscopic app oach is conside ed he gold
s anda d o ba ia ic p ocedu es. Unde his ci cums ance,
one o he main conce ns epai ing a VH is he sa e y
o placing a mesh in aabdominally du ing a ba ia ic
p ocedu e. Mos common ba ia ic p ocedu es, gas ic
bypass and slee e gas ec omy, a e pe o med by ca ying
ou gas oin es inal su u es and anas omosis, and a e
conside ed as clean-con amina ed su gical p ocedu es,
and he e o e, heo e ically he e is a isk o po en ial
con amina ion o he mesh placed inside he abdominal
ca i y ha could be inc eased in case o a leak o an abscess.
The dilemma o pe o ming bo h p ocedu es
simul aneously had p ac ically no place in he pas , when
ba ia ic su ge y was pe o med by open app oach. Then he
epai o he abdominal wall was manda o y, gi en he need o
access he abdominal ca i y h ough he he nia, conside ing
also ha he mesh was placed in he p epe i oneal o p e-
ascial space, no being in con ac wi h he isce a. In his
sense, i was ecommended o use meshes p ophylac ically
du ing he closu e o all lapa o omies ha we e pe o med in
obese pa ien s o p e en incisional he nia.
Based on p e ious conside a ions, nowadays i could
e en be ecommended o pe o m an open app oach o
he ba ia ic p ocedu e in case o a concomi an VH.
This ecommenda ion would e en make mo e sense o
sup aumbilical incisional he nias, no being ecommended
in pa ien s wi h p ima y sup aumbilical o umbilical he nias
o incisional he nias loca ed pe i o in a-umbilical o in
la e al loca ions. Bu he cu en mo bidi y associa ed wi h
lapa oscopic ba ia ic su ge y, wi h low incidence o leaks
and mo ali y, echnical skills de eloped by su geons and
he echnological ad ances, make hese app oaches sa e .
Cu en ly, he e is no da a o con aindica e he placemen
o an in ape i oneal mesh du ing a ba ia ic p ocedu e.
In his sense, Sha ma e al. (5) published he esul s o
159 pa ien s who unde wen a concomi an ba ia ic and
abdominal wall su ge y be ween 2004 and 2015. Median age
o he pa ien s was 53 yea s, wi h a mean BMI o 48.2 kg/m2,
and 101 emales (64%). Como bidi ies associa ed o he
pa ien s o his se ies included: high blood p essu e (n=124,
78%), ype 2 diabe es (n=103, 65%), hype lipidemia
(n=100, 63%), obs uc i e sleep apnea (n=98, 62%) and
e lux disease (n=54, 34%). P e ious VHR was eco ded
in 41 pa ien s (26%) and 69 pa ien s (44%) had p e ious
abdominal su ge y. Nine y-one pe cen o he in e en ions
we e comple ed lapa oscopically (9,144 pa ien s) while 12
(7%) pa ien s we e con e ed o open su ge y. Only 3 (2%)
pa ien s unde wen bo h p ocedu es by open app oach.
Di e en echniques we e used o epai he he nia: p ima y
su u e in 115 (72%) and mesh epai in 44 pa ien s (28%).
Ea ly pos ope a i e complica ions (<30 days) a e was 10%:
supe icial wound in ec ion (n=9), in es inal occlusion (n=2),
ma ginal ulce (n=2), DVT (n=1) and pneumonia (n=1). In
e ms o ecu ences, a 5 yea s ollow up, he nia ecu ence
a es we e 31% in p ima y epai and 34.8% in mesh epai
g oups. A 12 mon hs o ollow-up, he median BMI and
pe cen age o excess weigh loss was 34.2 kg/m2 (IQR:
29.5–40.9) and 59.6% (IQR: 44.9–74.8%), espec i ely.
Acco ding o his s udy, he exis ing da a in he li e a u e
ha e demons a ed ha he ba ia ic p ocedu e, ei he
a slee e gas ec omy o a gas ic bypass, pe o med
concomi an ly wi h he placemen o an in aabdominal
mesh o epai a VH (6), is a sa e echnique ha does
no inc ease he mo bidi y o he p ocedu e and is no
associa ed wi h a highe a e o ecu ences han se ies o
VHRs in obese pa ien s.
When is he bes ime o epai a VH in an obese pa ien
unde going ba ia ic su ge y?
Bu despi e he good esul s published on he epai o VHs
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concomi an ly wi h he ba ia ic p ocedu e, he e a e s ill
doub s whe he hey should be epai ed du ing he same
p ocedu e o i is ecommended o de e he he nia epai
o a oid he isk o con amina ion o he mesh. On he
o he hand, i should be conside ed o pe o m he he nia
epai once ha op imal weigh loss has been achie ed,
since i would be possible o pe o m he he nia epai in
combina ion wi h an abdominoplas y in mos cases by open
app oach.
The e o e, he easons o conside de e ing he he nia
su ge y a ises om h ee conside a ions: i s , due o he
possible con amina ion o he mesh placed in ape i oneally,
ei he due o a dehiscence o a leak, o om a con amina ion
o he abdominal ca i y du ing he anas omosis; second,
weigh loss equen ly leads o an abdominal lap wi h
edundan skin ha will equi e an abdominoplas y and
p e ious epai could make such su ge y mo e di icul ;
and, hi d, because he e a e da a ha show be e esul s,
in e ms o ecu ences, when a he nia epai is pe o med
a e pa ien ’s weigh loss.
On he o he side, hose g oups who conside pe o ming
bo h su ge y a he same ime a gue ha he e is a po en ial
isk ha he he nia may equi e an eme gency epai
because o an acu e s angula ion a e ba ia ic su ge y and
du ing he weigh loss pe iod. Eid e al. (7), analyzed 84
pa ien s wi h VH candida es o ba ia ic su ge y. Se en y-
one pa ien s unde wen a simul aneous ba ia ic and he nia
epai su ge y, while in 14 pa ien s he he nia epai was
de e ed. This g oup p esen ed a 37.5% o eme gen
su ge y due o small bowel occlusion du ing he weigh
loss pe iod. Howe e , in he se ies published by Newcomb
e al. (8), only 3.7% o he 27 pa ien s wi h de e ed he nia
epai a e ba ia ic su ge y equi ed eme gency su ge y.
Chandeze e al. (9) analyzed e ospec i ely 41 ba ia ic
pa ien s wi h VH; 30 wi h concomi an su ge y (29 wi h
mesh and 1 wi hou a mesh) and 11 who i s unde wen
ba ia ic su ge y and hen he nia epai a e weigh loss.
They analyzed he a e o ecu ence and obse ed a
lowe ecu ence in he g oup in which he he nia epai
had been de e ed (6.7% s. 24%), wi h no di e ences in
pos ope a i e mo bidi y and a sho e hospi al s ay lowe in
g oup 2 (6.2 s. 10.7 days).
K i an e al. (10) ecen ly published a se ies o 106
pa ien s who unde wen a concomi an ba ia ic and he nia
epai su ge y (26 incisional and 80 p ima y he nias). They
analyzed he ype o app oach (open s. lapa oscopic), he
ype o epai (p ima y closu e s. mesh epai ), de ec size
(<5, 5–10, >10 cm), ype o he nia (p ima y s. incisional).
Rega ding he ype o app oach, hey ound a ecu ence o
8.47% in concomi an lapa oscopic app oach s. a 14.89%
in pa ien s wi h open app oach. They obse ed ha 75% o
pa ien s who showed a ecu ence had de ec s la ge han
5, all o hem had a BMI o e 45. In espec o mo bidi y, i
could be obse ed ha open incisional he nia epai showed
a highe a e o in ec ion and hema oma compa ed o
lapa oscopic epai o bo h incisional and p ima y he nias,
being se oma mo e equen a e a lapa oscopic epai .
Au ho s conclude ha concomi an epai (CR) o a VH
simul aneously wi h a ba ia ic p ocedu e is easible wi h a
low ecu ence a e, showing he lapa oscopic app oach has
lowe complica ion a es han open su ge y.
Sai e al. (11) published a sys ema ic e iew ocused on
he analysis o he ideal ime o pe o m a VHR in a pa ien
who is going o unde go a ba ia ic p ocedu e. Conclusions
o he e iew we e no consis en since, as we p e iously
obse ed, some au ho s ecommend CR wi h he use o a
mesh, while o he s conclude ha he nia epai should be
pe o med a e ba ia ic su ge y. The s udies compiled in
his e iew, wi h he excep ion o he one by Da a e al. (12),
show ha he isk o s angula ion o he he nia equi ing
eme gency su ge y, appea s o inc ease when he he nia
su ge y is de e ed. The mos equen eason o delay he
epai wi h a syn he ic mesh men ioned in his e iew is he
po en ial isk o con amina ion, and he e o e o in ec ion
and emo al o he mesh. Howe e , he s udies analyzed
in his sys ema ic e iew showed ha he isk o in ec ion
using a pe manen p os he ic mesh may be lowe han
expec ed, since h ee o he i e s udies did no epo mesh
ela ed su gical si e in ec ions.
Bu , beside hese da a, i is e iden ha we should no
gene alize and include all pa ien s in he same g oups, since
no all VHs a e simila , exis ing di e en loca ions, la e al
o medial and sup aumbilical o in aumbilical, being some
o hem symp oma ic while o he s emain asymp oma ic.
The e a e also di e ences ega ding he con en ; ei he
omen um, small bowel o colon. Di e en he nia
cha ac e is ics and loca ions may change he app oach and
he ecommenda ion o pe o m a simul aneous p ocedu e
(13,14), e en being able o in luence on he selec ion o he
ba ia ic p ocedu e o be pe o med.
In ha sense, some ecommenda ions can be es ablished
based on di e en ci cums ances (Figu e 2). Pa ien s
wi h symp oma ic VHs, should unde go a concomi an
p ocedu e in o de o a oid a epai in a sho pe iod o
ime a e su ge y. On he con a y, asymp oma ic pa ien s
could be di ided wo g oups: hose wi h inca ce a ed
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omen um (Figu e 3), whe e su ge y can be de e ed, being
ecommended no o emo e con en inca ce a ed, as i has
been demons a ed by Da a e al. (12); o hose wi h bowel
inca ce a ed, whe e a epai migh be necessa y be o e
weigh loss. In o de o be able o ollow his algo i hm,
besides ca ying ou p ope clinical examina ions and
me iculous analysis o he medical his o y o he pa ien ,
i is ecommended o pe o m a CT scan o de e mine he
cha ac e is ics o he nia and i s con en .
Wha is he bes way o epai a VH in an obese pa ien
who is unde going a ba ia ic su ge y?
I has been desc ibed ha i is sa e o pe o m he epai
o he VH simul aneously wi h a ba ia ic p ocedu e,
bu he e a e s ill doub s abou how o echnically do i
because o he conce ns o lea ing a mesh in ape i oneally.
Lapa oscopic p ima y closu e o he de ec wi h ans ascial
su u es was conside ed as an al e na i e (Figu e 4A,B),
as he mesh is a oided, bu a high a e o ecu ence has
been epo ed, anging om 22% o 100%, compa ed o
a 0 o 9% when a mesh is used. Fu he mo e, he use o
his in ape i oneal mesh is no ela ed o an inc ease o
mo bidi y, being ecommended he use o an in ape i oneal
Figu e 2 Algo i hm o decision-making o pa ien s wi h a en al he nia (VH) unde going a ba ia ic p ocedu e.
Figu e 3 Ven al he nia (VH) wi h omen um inca ce a ed.
Figu e 4 (A,B) T ans ascial su u es o closing he de ec du ing
lapa oscopic en al he nia epai (VHR).
A
B
Pa ien unde going a ba ia ic p ocedu e
who has a en al he nia
Symp oma ic He nia Asymp oma ic He nia
is he e any indica ion
o lapa oscopic epai ?
Concomi an open
epai
Concomi an lapa oscopic
epai
TAC
No Yes Inca ce a ed bowel loops Inca ce a ed omen um
Only pe o m he ba ia ic p ocedu e
by lapa oscopic app oach

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mesh in case ha a concomi an lapa oscopic app oach is
conside ed (Figu e 5) (7,12,15), being summa ize in Table
1. In his sense, Raziel e al. (16) published 54 concomi an
lapa oscopic VHRs using in ape i oneal meshes du ing a
slee e gas ec omy o gas ic bypass wi h excellen esul s.
In a me a-analysis ha included 17,117 pa ien s
unde going slee e gas ec omy o gas ic bypass, i was
obse ed ha hose pa ien s who unde wen simul aneous
he nia epai had a sligh inc ease o supe icial in ec ions
a he su gical si e, bu wi hou obse ing an inc ease in
o e all mo bidi y. Rega ding he ype o concomi an
ba ia ic p ocedu es, no di e ences we e obse ed be ween
hem in e ms o complica ions (17).
Some au ho s ha e sugges ed he use o a biological
mesh when a concomi an p ocedu e is pe o med, since
hese ypes o meshes ha e been ecommended in in ec ed,
con amina ed o po en ially con amina ed ields. Howe e ,
al hough he e is no speci ic da a o he use o hese
p os he ic ma e ials du ing a ba ia ic p ocedu e, he use
o biological meshes by lapa oscopy is associa ed wi h an
Table 1 Summa y o a icles ea u ing mo bidi ies and ecu ence a es
Se ies N Ba ia ic
su ge y
Time o
VHR VHR p ocedu e Pe iope a i e mo bidi y
Long- e m
ein e en ions
o BO
Recu ences
Eid e al. (7), 2004,
su gical endoscopy
85 LGB: 85 DR (n=14) Lapa oscopic
mesh epai
– 35.7% (n=5) 0
CR (n=71) CRS (n=59) – – 22%
CMR (n=12) Celluli is: 3 (25%); se oma: 4
(33.3%)
– 0
Newcomb e al. (8),
2008, he nia
27 OGB: 22;
LGB: 5
DR (n=20) Repa ación con
malla
– 5% (n=1) 0
CR (n=7) CRS (n=4) – – 100%
CMR (n=3) Mesh in ec ion: 1 (33%);
ein e en ion h ough dehiscence
o biological mesh: (25%)
– 100%
Da a e al. (12),
2008, su ge y o
obesi y and ela ed
diseases
26 LGB: 26 DR (n=8) Lapa oscopic
mesh epai
– 0 –
CR (n=18) CRS (n=8) BO in he pos -ope a i e
pe iod: 1 (12.5%)
1 (12.5%) 25%
CMR (n=10) – – 0
K i an e al. (10),
2019, su gical
endoscopy
106 LGB: 97;
OGB: 1;
LSG: 8
DR (n=0) – – – –
CR (n=106) CRS (n=43) – – 11.6%
CMR (n=63) Wound in ec ion: 5; hema oma: 4;
se oma: 1
– 11%
Chandeze e al. (9),
2019, su ge y o
obesi y and ela ed
diseases
41 LSG: 19;
LGB: 18;
gas ic
band: 4
DR (n=30) Open mesh epai – 0 6.7%
CR (n=60) CRS (n=8) Wound in ec ion: 2; se oma: 3;
hema oma: 1; (no de ails be ween
p ima y closu e and mesh)
– 24% (no de ails
be ween p ima y
closu e and mesh)
CMR (n=52) – – –
VH, en al he nia; CR, concomi an epai ; DR, de e ed epai ; CRS, concomi an epai su u e; CMR, concomi an mesh epai ; VHR,
en al he nia epai ; LGB, lapa oscopic gas ic bypass; OGB, open gas ic bypass; LSG, lapa oscopic slee e gas ec omy; BO, bowel
obs uc ion.
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inc ease in ecu ence a es ha has e en led o cancel
p e ious andomized p ospec i e s udies (8,13).
May he p esence o a VH in luence he ype o ba ia ic
p ocedu e o be pe o med?
The p esence o a VH when pe o ming a ba ia ic p ocedu e
migh change he o iginal s a egy wi h an obese pa ien . The
i s ac o o be conside ed is whe he we a e dealing wi h a
p ima y o an incisional he nia. The mos common si ua ion
in hese pa ien s is o ind an asymp oma ic o minimally
symp oma ic p ima y umbilical he nias wi h omen um,
o in ape i oneal a o he ound ligamen inca ce a ed.
Acco ding o ecommenda ions, i is no indica ed o
epai hese he nias a he ime o he ba ia ic p ocedu e,
being e y impo an o a oid educing he con en o he
he nia sac o a oid bowel s angula ion du ing he ea ly
pos ope a i e pe iod. Also, he p esence o his ype o
he nias should no in luence he ype o ba ia ic p ocedu e
o be pe o med based on he p o ocol o each cen e . In
case o pe o ming a slee e gas ec omy, oca s should
be placed highe han con en ional p ocedu e (Figu e 6).
On he o he hand, i a gas ic bypass is planned, i is
ecommended o ansec he g ea e omen um, lea ing he
a ea inca ce a ed on he igh side o he pa ien , allowing
an adequa e access o he small bowel o pe o m he
anas omosis o he gas ic bypass.
In case o an epigas ic he nia, di e en op ions could
be conside ed depending on he size and he exac loca ion
o he he nia; om a oiding he a ea o he he nia o place
he oca s o place he op ic oca h ough he he nia
using and open access, epai ing he de ec a he end o he
p ocedu e wi h a plug- ype mesh, such as he Ven alex®
(Ba d, Da ol, Wa wick, RI, USA) o he PVP® (E hicon,
Johnson & Johnson, New B unswick, NJ, USA).
On he o he hand, in he p esence o an incisional
he nia i is impo an o conside a se ies o possible
scena ios ha may in luence he decision on he p ocedu e
o be pe o med. The ype o p e ious su ge y is a
pa amoun ac o o be conside ed, since he p esence
o mul iple adhesions could lead us o pe o m a slee e
gas ec omy ins ead o a gas ic bypass. In aumbilical
incisions wi h an incisional he nia should no in luence
he su gical s a egy. Howe e , when incisional he nias
a e ela ed o sup aumbilical and sup a-in aumbilical
incisions, an op ic oca should be placed a he le side
o he pa ien and e alua e he p esence o adhesions in
o de o ake he p ope decision. Once inside he ca i y, a
Figu e 5 In abadominal mesh placed o epai an incisional he nia
du ing a concomi an lapa oscopic ba ia ic p ocedu e.
Figu e 6 T oca placemen o a slee e gas ec omy in a pa ien
wi h a concomi an umbilical he nia.
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massi e adhesiolysis should be a oided. i he e is no o mal
con aindica ion, a slee e gas ec omy should be pe o med,
e en when o iginally i was planned o pe o m a de i a i e
su ge y. These p ocedu es should only be pe o med i he
pa ien does no ha e massi e adhesions when accessing he
ca i y o he e is a con aindica ion o a slee e gas ec omy.
Conclusions
The p esence o abdominal wall he nias in pa ien s who
a e candida es o ba ia ic su ge y is a equen p oblem.
The way we ace bo h pa hologies will ma k he long- e m
ou comes. To make a co ec decision, mul iple ac o s ha e
o be aken in o accoun ; ype and loca ion o he he nia
and he symp oms i p esen s. Bo h, simul aneous su ge y
and de e ing he nia su ge y, ha e hei place i a p ope
selec ion o pa ien s is pe o med.
Acknowledgmen s
Funding: None.
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Re e ences
1. Pe na LIM, Pe na CH, Die enbach BV, e al. Wha is
he BMI h eshold o open en al he nia epai ? Su g
Endosc 2017;31:1311-7.
2. Bi gisson G, Pa k AE, Mas angelo MJ J , e al. Obesi y
and lapa oscopic epai o en al he nias. Su g Endosc
2001;15:1419-22.
3. Saue land S, Walgenbach M, Habe malz B, e al.
Lapa oscopic e sus open su gical echniques o en al
o incisional he nia epai . Coch ane Da abase Sys Re
2011;(3):CD007781.
4. Cuccu ullo D, Piccoli M, Ag es a F, e al. Lapa oscopic
en al incisional he nia epai : e idence-based guidelines
o he i s I alian Consensus Con e ence. He nia
2013;17:557-66.
5. Sha ma G, Boules M, Punchai S, e al. Ou comes o
concomi an en al he nia epai pe o med du ing
ba ia ic su ge y. Su g Endosc 2017;31:1573-82.
6. P a een Raj P, Sen hilna han P, Kuma a el R, e al.
Concomi an lapa oscopic en al he nia mesh epai and
ba ia ic su ge y: a e ospec i e s udy om a e ia y ca e
cen e . Obes Su g 2012;22:685-9.
7. Eid GM, Ma a SG, Hamad G, e al. Repai o
en al he nias in mo bidly obese pa ien s unde going
lapa oscopic gas ic bypass should no be de e ed. Su g
Endosc 2004;18:207-10.
8. Newcomb WL, Polhill JL, Chen AY, e al. S aged he nia
epai p eceded by gas ic bypass o he ea men o
mo bidly obese pa ien s wi h complex en al he nias.
He nia 2008;12:465-9.
9. Chandeze MM, Moszkowicz D, Beauche A, e al. Ven al
he nia su ge y in mo bidly obese pa ien s, immedia e
o a e ba ia ic su ge y p epa a ion: esul s o a case-
ma ched s udy. Su g Obes Rela Dis 2019;15:83-8.
10. K i an MS, Gio ga A, Ba eca M, e al. Concomi an
en al he nia epai and ba ia ic su ge y: a e ospec i e
analysis om a UK-based ba ia ic cen e . Su g Endosc
2019;33:705-10.
11. Sai MS, Som R, Bo g CM, e al. Bes e idence opic:
Annals o Lapa oscopic and Endoscopic Su ge y, 2021 Page 9 o 9
© Annals o Lapa oscopic and Endoscopic Su ge y. All igh s ese ed. Ann Lapa osc Endosc Su g 2021;6:33 | h p://dx.doi.o g/10.21037/ales-20-50
Should en al he nia epai be pe o med a he same ime
as ba ia ic su ge y? Ann Med Su g (Lond) 2016;11:21-5.
12. Da a T, Eid G, Nahmias N, e al. Managemen o en al
he nias du ing lapa oscopic gas ic bypass. Su g Obes
Rela Dis 2008;4:754-57.
13. Eid GM, Wikiel KJ, En abi F, e al. Ven al he nias
in mo bidly obese pa ien s: a sugges ed algo i hm o
ope a i e epai . Obes Su g 2013;23:703-9.
14. Rao RS, Gen ileschi P, Kini SU. Managemen o
en al he nias in ba ia ic su ge y. Su g Obes Rela Dis
2011;7:110-6.
15. Schus e R, Cu e MJ, Alami RS, e al. Concu en gas ic
bypass and epai o an e io abdominal wall he nias. Obes
Su g 2006;16:1205-8.
16. Raziel A, Sak an N, Szold A, e al. Concomi an ba ia ic
and en al/incisional he nia su ge y in mo bidly obese
pa ien s. Su g Endosc 2014;28:1209-12.
17. Spaniolas K, Kas en KR, Moze AB, e al. Synch onous
en al he nia epai in pa ien s unde going ba ia ic
su ge y. Obes Su g 2015;25:1864-8.
doi: 10.21037/ales-20-50
Ci e his a icle as: Mo ales-Conde S, Lica die E, Socas M,
Ba anco A, López Be nal F, Ala cón I. Abdominal wall su ge y
in ba ia ic pa ien s. Ann Lapa osc Endosc Su g 2021;6:33.