From the Guidelines
Obesity significantly increases the risk of complications during and after umbilical hernia repair surgery, and weight loss is generally recommended for patients with a BMI over 30 kg/m² before proceeding with elective surgery. The guidelines for the peri-operative management of obese surgical patients, as outlined in the study by the Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia 1, emphasize the importance of specialized care for obese patients. Key recommendations include:
- Identifying central obesity and metabolic syndrome as risk factors
- Considering sleep-disordered breathing and its consequences
- Using experienced anaesthetic and surgical staff
- Having additional specialized equipment available
- Planning a robust airway strategy
- Using regional anaesthesia when possible
- Basing drug dosing on lean body weight
- Providing appropriate prophylaxis against venous thromboembolism (VTE) and early mobilisation
For patients with a BMI over 35 kg/m², the risks of wound complications, hernia recurrence, and anesthetic complications increase substantially, and weight reduction to achieve a BMI below 35 kg/m² is strongly advised before surgery 1. Preoperative weight loss of 5-10% of total body weight can significantly improve surgical outcomes. This recommendation is based on the mechanical stress excess weight places on the repair site, increased technical difficulty of the procedure in obese patients, and higher rates of wound infections due to poor vascularization of adipose tissue. Some surgeons may require documented weight loss efforts or referral to bariatric surgery for morbidly obese patients (BMI >40 kg/m²) before considering hernia repair. However, emergent umbilical hernia repairs for incarceration or strangulation must proceed regardless of BMI, with the understanding that complication rates will be higher. Patients should be counseled that weight maintenance after repair is also crucial to prevent recurrence.
From the Research
Guidelines for Obesity and Surgical Risk in Umbilical Hernia Repair
- The optimal approach for umbilical hernia repair in obese patients is still debated, with studies comparing laparoscopic and open repair techniques 2, 3, 4, 5.
- A study published in 2021 found that there is likely no benefit to laparoscopy over open umbilical hernia repair with mesh in obese patients with regard to wound morbidity 2.
- However, another study from 2021 suggested that a simultaneous approach to umbilical hernia repair during laparoscopic sleeve gastrectomy may be beneficial in morbidly obese patients, with lower overall morbidity and no difference in recurrence rate 3.
- A 2013 study found that the laparoscopic approach was associated with a significantly lower rate of postoperative infection and no hernia recurrence in obese patients 4.
- A 2020 study using the National Surgical Quality Improvement Program database found that laparoscopic umbilical hernia repair was associated with decreased post-operative wound complications compared to open repair in patients with obesity 5.
- The use of hernia patches, such as the Proceed Ventral Patch, has also been shown to be effective and safe in the management of obese patients with small and medium size umbilical hernias 6.
Key Considerations
- Obese patients with umbilical hernias may be at higher risk for wound complications and recurrence 2, 4, 5.
- Laparoscopic repair may be associated with lower wound complication rates, but may not necessarily reduce recurrence rates 2, 4, 5.
- Simultaneous repair during laparoscopic sleeve gastrectomy may be a viable option for morbidly obese patients 3.
- The use of hernia patches may be an effective and safe alternative for small and medium size umbilical hernias in obese patients 6.