Title: Hernia Repair and Panniculectomy in Gastric Bypass Patients
Author: Michele A Shermak, MD
Health benefits of weight loss achieved through diet and exercise or surgery cannot be denied. Bariatric
surgery is a growing industry, with over 100,000 people undergoing surgery annually in the United
States. A significant percentage of those people undergoing gastric bypass surgery succeed in massive
weight loss, defined as a fifty percent reduction in excess weight by 18 months post surgery.
Traditionally, gastric bypass has been performed through an upper midline incision, and the open
approach is preferred for extreme BMI and revision patients. Open gastric bypass with subsequent
massive weight loss may be complicated by hernia secondary to the abdominal wall incision, poor tissue
quality, and weight changes that occur. We aim to present our series of weight loss patients who have
undergone hernia repair.
Method: All patients undergoing abdominal panniculectomy combined with hernia repair by a single
surgeon at an academic hospital from February 2001 to December 2003 were retrospectively studied.
(Table 1) Forty patients including 9 men and 31 women had a hernia repair during abdominal
panniculectomy, with some patients having additional dermatolipectomy procedures. Average age was
42 years and average weight loss was 152 lb, with average BMI of 35.6 at the time of surgery. (Morbid
obesity = BMI > 35)
Abdominal panniculectomy was performed with conservative undermining, attempting to limit exposure
to the suprapubic/hip incision. (Figure 1) In some cases incisional hernias were adherent to overlying,
thinned scar or the pannus was cumbersome, resulting in difficulty fully visualizing the hernia. In these
cases the lower abdominal incision was combined with a midline incision, similar to a fleur-de-lis.
Hernias were treated by the plastic surgeon in all but one case. Fascial edges were dissected in
conjunction with lysis of adhesions, and approximated. Adjacent fascia was plicated overtop of the
primary repair for reinforcement, allowed by the laxity of the fascia with the weight loss. Mesh was not
used. Skin closure was performed in a layered fashion over 2 or 3 Jackson-Pratt drains. Ambulation was
encouraged within 24 hours of surgery, and diet progressed as tolerated.
Results: Average abdominal skin resection was 9.9 lb, ranging from 2 to 25 lb. Blood transfusion was
necessary in 7 (17.5%) of the cases. Length of stay averaged 3 days. Hernia recurrence occurred in 1
patient after heavy lifting 1 year after surgery. Other complications included wounds requiring
dressings, VAC therapy and/or delayed primary closure (20%); seroma requiring drain replacement or
sclerotherapy (12.5%); suture abscess requiring surgical removal of suture (7.5%); bleeding ulcer
(2.5%); postoperative bleeding requiring exploration (2.5%); and fatal PE (2.5%). Uncomplicated
healing occurred in 60% of cases.
Conclusion: Hernias that develop in the massive weight loss patient after open gastric bypass surgery
present a specific entity associated with a weakened incision closure, poor tissue quality, and weight
changes with associated changes in abdominal wall capacity. We present our approach to these patients
with acceptable results.
Fig. 1 Photographs illustrating the sequence of hernia repair and panniculectomy. Hernia repair
includes dissection of the fascial edges with necessary lysis of adhesions and removal of attenuated
tissue, attempting to limit exposure to a standard abdominoplasty incision. The hernia is primarily
repaired with braided, permanent suture in an interrupted, figure of eight fashion. After the primary
repair is complete, a plication of adjacent fascia is performed over top, serving as autogenous
reinforcement, and from the umbilicus down to the pubis. Excess skin is removed and the incision is
closed over at least two #10 flat Jackson Pratt drains.
Table 1
Patient Population, n = 40
Age
Gender
Avg wt loss
Avg BMI
Operative
Abd skin resection
Blood transfusion
Length of stay, mean
Complications
Wound problems
Seroma
Suture abscess req surgery
Bleeding ulcer
Bleed req return to OR
Fatal PE
Recurrence hernia
22-59 yr old (mean = 42 yr old)
9 men/31 women
152 lb
35.6 (Morbid obesity = 35)
2 – 25 lbs (mean = 9.9 lbs)
7 (17.5%)
3 days
8 (20%)
5 (12.5%)
3 (7.5%)
1 (2.5%)
1 (2.5%)
1 (2.5%)
1 (2.5%)
References
1. Kopelman PG. Obesity as a Medical Problem. Nature 404: 635-43, 2000.
2. Dellon AL. Fleur-de-lis abdominoplasty. Aesthetic Plast Surg. 9(1):27-32, 1985.