Concomitant intraperitoneal onlay mesh repair with endoscopic component separation and sleeve gastrectomy.

Bariatric surgery can be safely combined with laparoscopic intraperitoneal onlay mesh (IPOM) repair. In case of large ventral hernias, laparoendoscopic component separation can also be combined to achieve tension-free closure of the defect. Concomitant bariatric surgery and hernia repair also offer the additional benefit of reduction in recurrence of hernias as obesity, one of the risk factors, is treated in the process. We present a case of 60-year-old man with a body mass index of 45.3 kg/m2 with a large recurrent ventral hernia. We performed a lap sleeve gastrectomy with laparoendoscopic anterior component separation with IPOM. The operative steps included hernia contents reduction, conventional sleeve gastrectomy, anterior component separation on either side, intra-corporeal closure of hernia defect and placement of a composite mesh. Patient recovery was uneventful. Concomitant bariatric surgery with laparoendoscopic component separation with IPOM may be safe, but more studies are required.

INTRODUCTION

Obesity is a risk factor for recurrence after ventral hernia repair.[1] Bariatric surgery reduces this risk by treating obesity. In our institute, we routinely combine bariatric surgery with laparoscopic intraperitoneal onlay mesh repair (IPOM) without any complications.[23] Large ventral hernias, especially in patients who are morbidly obese, are challenging to treat. Laparoendoscopic component separation offers the advantage of a tension-free repair of such large hernia along with additional benefits restoration of the structural and functional integrity of the abdominal wall and optimal cosmetic outcome.[45]

We report the first case of concomitant laparoscopic sleeve gastrectomy with laparo-endoscopic anterior component separation with IPOM in a morbidly obese patient with large recurrent ventral hernia.

CASE REPORT

A 67-year-old man with a body mass index of 45.3 kg/m2 presented with a large recurrent ventral hernia. He had undergone laparoscopic IPOM repair 2 years back at a peripheral centre and subsequently developed a mesh infection for which he underwent a laparotomy and mesh removal in the postoperative period. When he presented to us, he had a large ventral hernia with bowel and omentum as contents. The size of the defect was approximately 10 cm.

As the defect was very large and the patient was morbidly obese, we offered the patient the option of combined bariatric surgery with ventral hernia repair. After workup and discussion with the patient, we planned a laparoscopic sleeve gastrectomy along with a laparoendoscopic anterior component separation with an IPOM.

Operative technique

The patient lies supine with both arms abducted with a 10°–15° Trendelenburg position. Surgeon stands at the head end near the right shoulder, and camera assistant stands near the left shoulder. Pneumoperitoneum was created using Veress needle. A 10 mm port was placed in the subxiphoid position followed by two 5 mm working port in the midclavicular line on either side. The contents of the hernia were small bowel and omentum. There were extensive adhesions between the contents and the sac and adhesion were lysed to reduce the hernia contents completely. The size of the defect was assessed and it was found to be about 10 cm which could not be approximated without performing a component separation [Figure 1]. Thereafter, sleeve gastrectomy was performed by conventional 5 port technique (previously published) using a 38 French gastric calibration tube. Anterior component separation was then performed first on the right side, then on the left side.

Figure 1

Image showing the large ventral hernia defect

A 1.5 cm incision was made just below the costal margin at the anterior axillary line. Subcutaneous tissue was dissected to expose the external oblique aponeurosis. A small incision was made on the external oblique aponeurosis, and a 10 mm port (without the trocar) was placed under vision posterior to it, anterior to the internal oblique. The telescope was then introduced, and insufflation started under vision. Initial dissection was done telescopically similar to the totally extra-peritoneal approach to create space for introducing a 5 mm working port about 2 cm lateral to the camera port. A monopolar hook diathermy was then used to create the space between the external and internal oblique aponeuroses extending from the costal margin to the iliac crest. The external oblique aponeurosis which forms the roof of this space was incised with hook from the iliac crest to as close to the camera port as possible [Figure 2]. Some dissection was done in the subcutaneous space along the lateral cut margin of the external oblique aponeurosis to achieve maximum advancement of the rectus abdominis muscle towards the midline. Same steps were repeated on the left side.

Figure 2

Image showing the lateral incised margin (arrow heads) of the external oblique aponeurosis

Pneumoperitoneum was recreated, and the defect was reassessed for closure intraperitoneally. We raised a lower peritoneal flap to push the bladder down. We achieved adequate advancement for closure, and hence, we closed the hernia defect intracorporeally using No. 1 loop Ethilon suture in a continuous fashion taking a few bites in the hernia sac in the process to obliterate the hernia cavity. Thereafter, a 20 cm × 30 cm composite mesh (Parietex) was placed and fixed with transfascial sutures and mesh fixation device (Securestrap). Omentum was positioned over the bowel, and pneumoperitoneum was deflated, thus, completing the procedure.

As per our institutional protocol, the patient was started on oral clear liquids 4 h after surgery and was discharged on the 3rd postoperative day on liquid diet for 15 days. There were no complications.

DISCUSSION

Laparoscopic IPOM repair is the standard of care for ventral hernia repair both in the obese and nonobese patient.[6] Obese patients who present with ventral hernia can be offered both bariatric surgery and laparoscopic ventral hernia repair in the same sitting, safely, without having to undergo the two operations separately. Ramirez et al. in their study described the component separation technique for large (recurrent/loss of domain) ventral hernia.[5] Component separation is of two types as follows: anterior component separation and posterior component separation. Both have been performed laparoscopically.

Laparoendoscopic anterior component separation has the advantage of less wound-related complications and skin necrosis as compared to the open approach. However, the degree of advancement achieved is also 1–2 cm less.[7] Thus, proper selection of patient is essential for an adequate tension-free closure of the defect.

CONCLUSION

Combining laparoendoscopic component separation with bariatric surgery is feasible and may be safe in selective patients. It provides the patient benefits of hernia repair as well as reduction of recurrence risk due to obesity along with other metabolic benefits of bariatric surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.