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1. HERNIA IN THE OBESE !!!
Challenges n Management
Strategies
HERNIACON 2013 @AHEMADABAD

2.  Dr Sumeet Shah ,Delhi
 Dr Apoorva Vyas , Ahemadabad
 Dr Chirag Desai , Ahemadabad
 Dr Parag Khandelwal ,Ahemadabad
 Dr Sunil Popat ,Ahemadabad
 Dr Jayasshree Todkar , Pune

3. IS IT REALLY DIFFERENT ???

4. Target:
Leg ulcers to heal,
Leg edema to be less,
Breathlessness less,
Drugs less, Play with children

10. INCIDENCE
ETIOLOGY

11.  Over 10,000 cases in India annually
 Incidence: 2%~11% of all the laparotomies,
15%~20% after abdominal surgery in the obese,
23% of the infected incisions
 Risk factors: obesity, aged, anemia,
smoking, infection, history of operation,
long incision, incision site, emergency
operation, increasing IAP, diabetes
mellitus, some drugs
 Recurrence: 10%~50%

12. Umbilical hernia in adults
 Acquired umbilical hernia
 Increased IAP: obesity, heavy lifting
 Long history of coughing
 Multiple pregnancies
 Three times more common in women
 Higher risk of strangulation

13.  Various factors are responsible
 More than one factor may co-exist in a given patient
1) Poor Surgical technique :
Inadequate fascial bites
Tension of fascial edges
Tight closure
2) Post-op wound infection
3) Age slower in old age
4) General debility, Cirrhosis, Carcinoma, Chronic Wasting disease
5) Obesity
6) Post-Operative Pulmonary Complications
7) Intra Operative blood loss more than 1000ml
8) Failure to close fascia of trocar sites over 10mm size

14. a) Associated morbidity secondary to
incarceration, strangulation
b) Relative loss of abdominal domain with adverse
effects on postural maintenance, respiration,
micturition , defecation
c) Patients are forced to alter their lifestyle, their
ability to work becomes impaired
d) A cosmetic deformity, detrimental to patients
self-esteem

15. 1. Primary Suture Repair
2. Mesh Repair by Open technique
3. Component separation
4. Flap reconstruction
5. Tissue expansion
6. Laparoscopic method
7. Combination of any methods

16. Use of synthetic mesh in Ventral Hernia Repair has increased since 1987
Advantages :
a) Tension free restoration of structural integrity of the abdominal wall
b) Easy availability ( thanks to industry )
c) Absence of donor site morbidity
Ideal Prosthesis should be
a) Non-toxic
b) Non-immunogenic
c) Non-reactive
d) Should get incorporated into the surrounding tissue
e) Tensile strength is rarely a problem with available materials
Failures with mesh occurs Laterally at mesh tissue interface

17.  Gaining Popularity
 Prosthetic material is placed in pre-peritoneal space
or subperitoneal space ( i.e. Intra peritoneal Onlay
Mesh Repair )
 Large prosthetic support is secured with transfixing
sutures or tackers
 Sutures are placed at 4-5cm distance
 Tackers are placed at 1cm distance
 Alone tackers may lead to recurrence thus few
transfixing sutures required

18. 1. All advantages of minimally access surgery
2. Intra abdominal adhesion can be separated
3. If enterotomy or serosal injury can be sutured
4. Mesh placement to be delayed if enterotomy
but later on, can be completed laparoscopically
5. Multiple hernias ( swiss cheese defects ) can be
tackled

19. 1. Seromas
2. Potential risk to intestinal injuries
3. Bleeding from abdominal wall vessels
4. Pain due to tackers & transfixing Sutures
5. Open repair provides opportunity to revise
scarred abdomen & abdominoplasty in selected
cases
6. Cost

22.  TECHNIC : OPEN / LAP

23.  Open technique

34.  PORT POSITION, PATIENT POSITION

35.  Different
choice of
trocar
site base
on hernia
site
 Lateral
abdomen

39.  Synthetic Nonabsorbable
 Coated Nonabsorbable
 Partially absorbable
 Biological

40.  Polypropylene - causes intense inflammation
- causes adhesions
 Polyesters - degradable ?
 PTFE - no invasion of tissues
- encased in fibrosis
- more shrinkage
- more prone to infection ?

41.  C – Qur – polypropylene coated with omega 3 fatty
acids does not cause adhesions for 120 days ?
 Glucamesh - coated with oat beta glucan
 Timesh – titanium coated causes collagen 1
synthesis ?

42. i. Sepramesh
Macro porous polypropylene coated on one
side with a bio-resorbable. Nonimmuogenic
membrane of sodium hyaluronate and
Carboxymethyl cellulose on the other side.
ii. Parietex
Multifilament polyester mesh with a purified,
oxidized bovine atelesllagen type I coating
covered by an absorbable, antiadhesion film
of polyethylene glycol and glycerol.
iii. Parientene
Polypropylene coated with same anti
adhesive barrier as above.
Prosthesis With Absorbable Barrier
SEPRAMESH

43. iv. Proceed Surgical Mesh
Lightweight monofilament polypropylene mesh encapsulated
with laminated of polydioxanone coated on one side with the
absorbable barrier material oxidized regenerated cellulose.
Multilayered tissue separating Mesh

44. vi. GORE – TEX Dual Mesh
It has two surfaces; one is very
smooth micro porous to face visceral
organs and other rough surface for
tissue in-growth.
e - PTFE Microscopic view

45. Operating Factors Influencing Mesh
Choice :

48.  REVIEW OF LITERATURE

49. CONCLUSION: No significant difference in the
incidence of peri operative complications or
recurrence after LVHR was observed between
the morbidly obese patients and the non-
morbidly obese patients.

50.  The only predictor for an increased length of
hospital stay was hernia repair with mesh
(odds ratio 9.2, P = .002). The average follow-
up was 14 months (range 4-30 months). Of the
8 patients who had undergone primary repair, 2
presented with a postoperative small bowel
obstruction at the site of their VHR. None of
the patients who underwent VHR with
prosthetic mesh developed an obstruction or
clinical evidence of recurrence or infection

51. CONCLUSIONS: For morbidly obese
patients, LVHR is safe and effective, but
it is associated with higher likelihood of
recurrence, and patients should be
appropriately informed.

52.  CONCLUSION: Biomaterial mesh (SIS)
repair of ventral hernias concomitant with
LRYGB resulted in the most favorable
outcome albeit having short follow-up.
Concomitant primary repair is associated
with a high rate of recurrence. All
incarcerated ventral hernias should be
repaired concomitant with LRYGB, as
deferment may result in small bowel
obstruction.

53. CONCLUSION: Gastric bypass prior to
staged ventral hernia repair in morbidly
obese patients with complex ventral
hernias is a safe and definitive

54.  Concomitant repair of ventral hernia with
bariatric surgery is safe. Deferred
treatment predisposes to higher
complication rate.
 Prosthetic repair is better than primary
repair
 Biological, dual, PTFE or other composite
meshes can be safely used
 In selected cases judicious use of surgeons
discretion is warranted.

55.  ? SIMULTANAEOUS : WHEN
 : WHEN NOT
 ? NOT SIMULTANAEOUS : HERNIA FIRST
 : BARIATRIC FIRST
 WHEN IS THE RIGHT TIME FOR SECOND PROCEDURE
 TECHNIC : OPEN / LAP
 ANATOMICAL / MESH REPAIR
 PORT POSITION, PATIENT POSITION
 MESH CHOICE
 FIXATION DEVICE
 SPECIAL PRECAUTIONS
 TYPICALLY SIGNIFICANT SITUATION : HIATUS HERNIA / INT HERNIA
 DRAIN OR NOT ?
 DOES HERNIA INFLUENCE THE TYPE OF BA SX PROCEDURE TO BE DONE


56.  ? SIMULTANAEOUS : WHEN
 : WHEN NOT

57.  ? NOT SIMULTANAEOUS
: HERNIA FIRST
 : BARIATRIC FIRST

58. WHEN IS THE RIGHT TIME FOR
SECOND PROCEDURE

59.  ANATOMICAL
when
why
 MESH REPAIR
when
why

60. MESH CHOICE
FIXATION DEVICE

61.  SPECIAL PRECAUTIONS

62. TYPICALLY Special considerations
:HIATUS HERNIA
:INTERNAL HERNIA

63.  DRAIN OR NOT ?

64.  DOES HERNIA INFLUENCE THE
TYPE OF BA SX PROCEDURE TO
BE DONE

65.  THANK YOU ………
 jayatodkar@gmail.com , +919823090505