Surgery, Gastroenterology and Oncology

Introduction: Abdominal hernias are more frequent in obese patients, associating more complications and worse therapeutic outcomes. These patients require a multidisciplinary treatment approach, including bariatric and hernia teams, and carried out in a specialized center.

Objective: To present the case of a 42yo obese patient with giant ventral hernia, and to discuss our therapeutic approach. This is a video presentation of a case report and literature review about the state of the art for hernia repair in obese patients.

Case report: 42 year-old female patient with previous history of surgical repair of esophageal atresia during childhood and long term feeding gastrostomy until adolescence. Laparotomic cholecystectomy in 2002 and laparotomic appendectomy in 2010.
Presenting the following comorbidities: asthma, hypertension and renal lithiasis. Who consulted the bariatric team for morbid obesity (BMI 51), associating a giant ventral hernia as well as a 3cm hiatal hernia and severe gastroesophageal reflux disease. She underwent complete preoperative evaluation for both, bariatric and hernia repair procedures.
This evaluation showed moderate esophagitis in the upper GI endoscopy. The hernia was partially reducible, with no incarceration history. The CT showed a giant hernia sac, containing transverse colon and small bowel loops, with a 12 cm ring.

Procedure: Laparoscopic approach of the abdominal cavity. Hernia sac dissection, releasing it from the anterior abdominal wall adhesions. Reintroduction of the hernia content, including transverse colon and small bowel loops. Then a laparoscopic gastric bypass was performed according to our center standard technique, without intraoperative complications. The parietal repair was deferred. Good postoperative recovery; upper gastrointestinal X-ray series with gastrografin showed no leaks and good passage through the anastomosis 24 hours after the procedure.
No pain associated to the ventral hernia, no incarceration, fully reducible at discharge on the 5th postoperative day.

Conclusion: Ventral hernias in obese patients are a challenging condition during laparoscopic gastric bypass. A multidisciplinary approach is recommended, but the best therapeutic strategy is still to be determined in the literature.

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