Application of biological patches in the repair of abdominal hernias in obese patients

For patients who incidentally discover one or more abdominal hernias during laparoscopic gastric bypass surgery, all current treatment options are not ideal. The recognized failure rate for primary repair surgery is 22% to 49%, and the use of synthetic materials in contaminated areas carries the risk of implant infection and subsequent surgical failure.

Delaying hernia repair until after significant weight loss has resulted in small bowel obstruction in 36% of patients within 6 months, demonstrating the risks involved. The recurrence rate with absorbable mesh can reach 75%, making it potentially unsuitable.

The development of new biomaterial patches may improve the success rate of abdominal hernia repair in these patients. This novel patch features a collagen framework containing several growth factors, stimulating the ingrowth of autologous tissue into the collagen matrix, where it is gradually and completely reabsorbed. Its low likelihood of becoming a source of infection makes it more suitable for use in contaminated surgical fields.

The largest study on the management of abdominal hernias in patients undergoing laparoscopic gastric bypass surgery showed that the recurrence rate was lowest with the use of biological patches compared to primary suture repair. Postoperative seroma formation is common, and most cases resolve spontaneously without specific treatment.

Approximately 8% of patients developed wound cellulitis, which resolved with antibiotic treatment. With thorough pre- and post-operative evaluation and consistent treatment, the overall outcome was satisfactory. Two patients experienced focal, persistent wound pain, which subsided after one or two local treatments with bupivacaine.

In this study, umbilical hernias with a diameter of less than 3–4 cm were repaired in one stage using a transabdominal through-suture method, consistent with the 12 mm closure Trocar method. Unfortunately, the recurrence rate using this method was 22%.

In patients with hernias smaller than 2 cm, no recurrence was observed during the 36-month follow-up. These results suggest that for umbilical hernias with defects larger than 2 cm, the Rives-Stoppa tension-free repair technique using biomaterial implants may be a better option.

Clinical points

Treating abdominal hernias in morbidly obese patients remains challenging. It is important to make morbidly obese patients aware that an abdominal hernia may be discovered incidentally during surgery, and that repairing it carries a high risk of recurrence.

In addition, repairing incisional hernias that occur after weight loss surgery in patients with morbid obesity is also crucial, especially when omental incarceration occurs, as the risk of postoperative strangulated intestinal obstruction is very high.

To reduce the recurrence rate of hernias, biomaterial patches can be used to reinforce all defects. If the hernia defect is small, it can be repaired using a Carter-Thomson suture device with a figure-of-eight suture.

If the hernia defect is large, using a biomaterial mesh may be a reasonable option when performing repair and gastric bypass surgery simultaneously. However, for hernias larger than 5 cm in diameter, the authors recommend a standard hernia repair procedure using the double-layer mesh described in previous literature, at least 3 months prior to gastric bypass surgery. The PTFE side should face the abdominal cavity to minimize adhesions during subsequent surgery.

Body reshaping after weight loss surgery

Dennis Hurwitz

Minimally invasive gastrointestinal bypass surgery has achieved good clinical results in the treatment of morbid obesity. Last year alone, the University of Pittsburgh Bariatric Surgery Center performed more than 1,000 such surgeries, and the demand for body reshaping after bariatric surgery is also increasing rapidly.

After significant weight loss, these patients developed unsightly sagging skin tags and oddly shaped, rolled-up fat deposits. While bariatric surgery successfully reduced weight and alleviated the associated health problems associated with obesity, it also brought various issues that led to a decline in patients' quality of life.

Our center's staff took these issues into account in advance and encouraged patients to regain their health through our professional reshaping surgery.

For decades, many plastic surgeons have considered circumcision and lower body lift to be the best way to deal with excess skin on the torso and thighs. However, the results have always been mixed, and there has been a lack of consensus on the techniques involved.

Meanwhile, there are very few reports in the literature on body contouring surgery after significant weight loss, and no literature on the postoperative effects of minimally invasive weight loss surgery. Therefore, I explored various surgical methods, approaches, and localizations, thus developing an innovative surgical technique.

We found consistency in the characteristics of these patients, and based on this, we considered individualized surgical approaches. These extensive and complex surgeries all require general anesthesia, typically lasting 6–12 hours, and carry significant risks.

By carefully evaluating the results of various surgeries and summarizing reports from academic conferences, we have advanced orthopedic surgery to the point where it can be tailored to each patient's deformity and requirements. A comprehensive assessment and consideration of the patient's physical deformity is crucial.

The entire surgical technique is based on the comprehensive application of plastic surgery principles such as artistry, efficiency, firm suturing, and minimizing tissue damage.

Between March 2000 and July 2003, I performed 208 surgeries on 54 patients who underwent significant weight loss. These included: abdominoplasty, lower body lift, upper body lift, inner thigh reshaping, longitudinal inner thigh reshaping, upper arm reshaping, breast reshaping/breast reconstruction, facelift, male breast reduction, and other plastic surgeries.

None of these patients had a BMI exceeding 35. Due to the high risk of surgical complications in severely obese patients, we did not treat these severely obese patients.

Patient's general condition

Obesity is a stigma, especially among women, so the majority of patients seeking treatment are women. The increased demand for surgical treatment is attributed to good surgical outcomes and low complication rates, as well as word-of-mouth communication among patients, and the role of academic journals, the internet, and mass media.

Of all patients who sought surgical reshaping after significant weight loss, women accounted for 84%.

Most patients report that laparoscopic gastric bypass surgery is simple and causes less postoperative pain. Only 5 to 6 small abdominal wall incisions are needed, and the patient's peritoneal cavity can be exposed to the intestines after inflation. Gastrointestinal reconstruction can be completed in just 2 to 3 hours.

After laparoscopic bypass surgery, patients can be discharged within a few days and return to normal work within a week. However, for patients who are converted to open surgery due to surgical considerations, the postoperative recovery process is slightly prolonged, wound healing is delayed, and incisional hernias are more common.

Because the surgery reduces stomach capacity and bypasses an appropriate length of the small intestine, patients experience rapid weight loss post-surgery due to decreased food intake and nutrient absorption, as well as a rapid feeling of fullness after eating. Many patients may experience mild dumping symptoms after consuming small amounts of sugar and fat. Simultaneously, most patients lose interest in food, possibly due to hormonal changes.