From the Guidelines
For morbidly obese patients needing weight loss prior to hernia surgery, a comprehensive approach including lifestyle modification and consideration of pharmacotherapy or bariatric surgery is recommended. This approach is based on the most recent and highest quality evidence, which emphasizes the importance of a multifaceted strategy to achieve significant weight loss and reduce surgical risks 1.
Key Components of the Approach
- Lifestyle modification through diet and exercise should always be recommended for all obese patients, as it is essential for achieving and maintaining weight loss 1.
- Pharmacotherapy options, such as orlistat, sibutramine, and phentermine, may be considered, but the choice of agent will depend on the side effects profile and the patient's tolerance of those side effects 1.
- Bariatric surgery should be considered as a treatment option for patients with a BMI of 40 kg/m^2 or greater who have instituted but failed an adequate exercise and diet program and who present with obesity-related comorbid conditions 1.
Considerations for Bariatric Surgery
- Patients should be referred to high-volume centers with surgeons experienced in bariatric surgery to minimize risks and optimize outcomes 1.
- The decision to undergo bariatric surgery should be a shared discussion between the physician and patient, taking into account the potential long-term side effects, such as possible need for reoperation, gall bladder disease, and malabsorption 1.
Goals of Weight Loss
- A weight loss of 5-10% is typically sufficient to reduce surgical complications and improve outcomes, as excess weight increases intra-abdominal pressure, complicates surgical access, and elevates risks of wound complications, recurrence, and anesthesia-related issues 1.
Monitoring and Follow-up
- Close monitoring by a multidisciplinary team throughout the weight loss process is essential for optimal outcomes, as it allows for timely adjustments to the treatment plan and minimizes the risk of complications 1.
From the FDA Drug Label
Phentermine Hydrochloride, USP 15 mg and 30 mg is indicated as a short-term (a few weeks) adjunct in a regimen of weight reduction based on exercise, behavioral modification and caloric restriction in the management of exogenous obesity for patients with an initial body mass index greater than or equal to 30 kg/m 2, or greater than or equal to 27 kg/m 2 in the presence of other risk factors (e.g., controlled hypertension, diabetes, hyperlipidemia).
Phentermine may be considered for morbidly obese patients needing weight loss prior to hernia surgery if they have a BMI greater than or equal to 30 kg/m^2 or greater than or equal to 27 kg/m^2 with other risk factors.
- Key points:
- Short-term use: a few weeks
- Adjunct to: exercise, behavioral modification, and caloric restriction
- BMI criteria: greater than or equal to 30 kg/m^2 or greater than or equal to 27 kg/m^2 with other risk factors 2
From the Research
Weight Loss Prior to Hernia Surgery
- Morbidly obese patients often require weight loss prior to hernia surgery to reduce the risk of perioperative morbidity and improve surgical outcomes 3.
- A multidisciplinary approach to medical weight loss, including collaboration with a medical weight loss specialist and a surgeon, can result in significant weight loss prior to complex abdominal wall reconstruction 3.
- The use of a protein sparing modified fast has been shown to be an effective method for weight loss in morbidly obese patients prior to hernia surgery, with a mean weight loss of 24 kg and a mean BMI reduction of 9 kg/m2 3.
Anti-Obesity Treatment
- Anti-obesity medications, such as phentermine/topiramate, liraglutide, and orlistat, can result in significant weight loss and improved cardiometabolism when used in combination with lifestyle interventions 4.
- However, these medications can be costly and may have adverse effects in some individuals, and their use should be tailored to specific patients based on their chronic conditions, comorbidities, and preferences 4.
Surgical Approaches
- Bariatric surgery, such as gastric bypass, can be an effective means of achieving weight loss prior to hernia repair, with a mean weight loss of 25-30% of total body weight in the first year 5, 6.
- Staged hernia repair preceded by gastric bypass has been shown to be a safe and definitive method for treating morbidly obese patients with complex ventral hernias, with no recurrences at an average follow-up of 20 months 6.
- Robotic hernia surgery may also be beneficial for obese patients, allowing for the implantation of mesh in a variety of extraperitoneal positions with low morbidity 5.