Case report of ventral hernia complicating bariatric surgery.

Ventral hernias (VHs) are common in the bariatric population with incidence of around 8% of patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB). The factors contributing to the incidence of VH includes high intra-abdominal pressures, previous histories of abdominal surgeries, defects in fascial structure and reduced healing tendency. There is a high index of suspicion in BS patients with VH for hernia complications which can be lethal after LRYGB. Here, we present a case where VH complicated the LRYGB surgery.

INTRODUCTION

Ventral hernias (VHs) are common in the bariatric population with incidence of around 8% of patients undergoing laparoscopic Roux-en-y gastric bypass (LRYGB).[1]

The factors contributing to the incidence of VH includes high intra-abdominal pressures, previous histories of abdominal surgeries, defects in fascial structure and reduced healing tendency. There are also few studies which have associated obstructive sleep apnoea as a risk factor for VH in bariatric population.[2]

Despite the frequent incidence, currently, there is no consensus on the management and timing of VHs in patients with obesity undergoing bariatric surgery (BS). Current literature is divided based on whether to perform VH repair (VHR) at a later stage after optimal weight loss and improvement of weight-related co-morbid diseases or concomitantly with BS.[3] There is a high index of suspicion in BS patients with VH for hernia complications, particularly small bowel obstruction, associated disruption of the gastro-jejunostomy (GJ), jejuno-jejunostomy (JJ) or gastric remnant perforation which can be lethal after LRYGB. This report describes a case in which VH complicated BS.

CASE REPORT

A 53-year-old morbidly obese female (body mass index [BMI] – 45.2) with co-morbidities of hypertension, diabetes and obstructive sleep apnoea with failed attempts to lose weight came to our private hospital for BS. There was a past surgical history of open mesh hernioplasty performed 2 years back for VH. On clinical examination, recurrence of VH was noticeable. The patient was explained and counselled about delayed repair of VH after LRYGB. Intraoperatively, VH was seen with 2.5 cm defect [Figure 1], having omentum as content along with bowel adhesion to abdominal wall. To proceed for LRYGB, intraoperatively, omentum was reduced and bowel adhesions were removed. The patient underwent LRYGB for her morbid obesity in which side-to-side GJ and JJ anastomosis were done using single linear stapler and hand-sewn closure of enterotomy. Intraoperative methylene blue leak test was negative; VH defect was closed using 1–0 prolene as figure of eight suture. The patient was stable and was ambulatory on the same day.

Figure 1

The ventral hernia defect

Oral methylene blue test was negative on 1st post-operative day. The patient was started on clear liquid diet and recovery was uneventful. On 3rd post-operative day, the patient developed tachycardia, abdominal pain with fever and episodes of vomiting subsequently. Her blood parameters showed WBC count of 19,000 with 91% polymorphs. The drain colour suggested enteric content. Immediately, re-laparoscopy was planned. On re-laparoscopy, it was found that sutures used for closing hernial defect had given away. Small bowel was seen herniating through umbilical defect causing intestinal obstruction [Figure 2]. There was an evidence of peritonitis due to disruption of GJ anastomosis with major collection in peri-gastric region [Figure 3]. The obstructed small bowel was reduced and found to be gangrenous [Figure 4]. Hence, resection anastomosis of the bowel was done laparoscopically.

Figure 2

Small bowel herniation through defect

Figure 3

Disrupted gastro-jejunostomy anastomosis

Figure 4

Gangrenous bowel

Thorough peritoneal lavage was done, and drains were placed in peri-gastric and pelvic region. In view of friable gastric and jejunal tissue, no sutures were taken on GJ leak. A feeding gastrostomy was done in the remnant stomach for decompression of remnant gastric pouch and enteral feeding. The VH defect was closed by multiple interrupted non-absorbable sutures.

Postoperatively, the patient was shifted to intensive care unit and was kept on intravenous antibiotics and parenteral nutrition. Gastrostomy feeding was started on 4th post-operative day and the patient was shifted to ward. On 12th post-operative day, pelvic drain was removed, and the patient was discharged with peri-gastric drain and gastrostomy for enteral feeds. There was a gradual decline in drain output to around 20–30 ml at 6 weeks. Gastrografin study was done at 6 weeks which showed no evidence of leak. The ultrasonography of the abdomen showed no residual collection. The patient was started on oral liquids after 7 week along with gastrostomy feeds. Drain output remained low for the next 2 weeks. At 9 weeks post-surgery, peri-gastric drain and gastrostomy were removed. The patient was gradually shifted to soft diet and then to normal diet in the next 3 weeks. Further follow-ups and tests on the patient in the next visits were normal. Patient blood sugar levels were under control with oral hypoglycaemic agents. BS resulted in good weight reduction of the patient and BMI of 30.8 was achieved. The patient has also been advised to undergo proper mesh repair for VH at a later date.

DISCUSSION

Current literature is divided based on whether to perform VHR at a later stage after optimal weight loss and improvement of weight-related co-morbid diseases or concomitantly with BS. Complexity of the combined procedure, longer operative time as well as the risk of mesh infection in a clean-contaminated case are some of the factors responsible for the uncertainty around concomitant approach.[4] Patients with diabetes have a higher risk of developing wound complications secondary to glycosylated white blood cells and microangiopathy, which can be a source of mesh infection.[5]

Staged repair of VH after BS has potential advantages of weight loss in VHR which makes staged repair less technically challenging procedure, decreased risk of recurrence and less peri-operative morbidity due to resolution of co-morbid conditions such as diabetes.

Raftopoulos et al. described their experience with VHR in the obese, reporting a 25.9% complication rate and 18.5% recurrence rate (in a relatively short follow-up time of 15 months). In their cohort, almost half (48%) underwent concomitant VHR and LRYGB.[6] These results are suggestive of postponing the VHR to a more favourable time. Newcomb et al. carried out a retrospective analysis of 27 patients that had gastric bypass surgery.[7] All 7 patients that had hernia repair at the time of bypass suffered recurrence; on the other hand, none of the patients in which staged repair was performed had recurrence or any infection. The study concluded that hernia repair should be performed after bypass surgery as a staged repair. However, delaying repair of an existing hernia may result in early post-operative small bowel obstruction, which may result in anastomotic or staple-line disruption as seen in our case. Eid et al. encountered a very high rate of small bowel obstruction from incarceration when the hernia was left in place and thus concluded that deferral of definitive repair should be avoided.[8] Thus, the results of these multiple studies done are not consistent to define a standard treatment protocol.

The protocol followed by our institution is staged repair of VH (after 12–18 months) in the patients undergoing BS with VH. If the hernia contents are not reduced intraoperatively, the defect remains as such, and on the other hand, if the hernia contents are reduced intraoperatively, it is advisable to suture close the defect as it was also done for the same case. However, one needs to weigh the pros and cons with respect to hernia complications that could occur in patients, particularly small bowel obstruction and associated disruption of the GJ, JJ or gastric remnant perforation. We suggest that a case by case approach is best. Clinical and radiological assessment of the hernia can be useful in determining the risk of recurrence or incarceration. The symptoms of the hernia and the patients’ wishes with regard to these risks are important considerations. Hence, a bariatric surgeon should have a high index of suspicion in these patients postoperatively and should have low threshold for re-laparoscopy in such patients as this can be lifesaving for them, as seen in our case.

CONCLUSION

VH are commonly encountered in the bariatric population. There is insufficient evidence to conclude the best timing for VHR in patients undergoing BS. Repair with sutures alone is likely to only benefit those with small hernias, whereas the strategies of performing simultaneous mesh repair or deferring may carry risks to patients. The risks and benefits of concomitant repair or staged repair need to be discussed with the patient. Bariatric surgeon should always be aware and vigilant about VH complications that could occur in these patients.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.