title: Complex hernias with loss of domain in morbidly obese patients: role of laparoscopic sleeve gastrectomy in a multi-step approach.
abstract: BACKGROUND
  Morbid obesity and its associated co-morbidities are risk factors for the development of abdominal hernias, add complexity to their repair, and increase perioperative risk. Repair of hernias with loss of domain (LoD) is further complicated by risk of abdominal compartment syndrome. A staged concept with an initial weight loss procedure might enable a reposition of the herniated viscera, improve co-morbidities for, and prohibit abdominal compartment syndrome in the subsequent repair.
  
  
  OBJECTIVE
  To evaluate a multistep treatment strategy that entails initial laparoscopic sleeve gastrectomy (LSG) followed by open repair in the treatment of complex hernias with LoD in morbidly obese patients SETTING: University hospital METHODS: Retrospective analysis of all patients (n = 15) with morbid obesity and hernias with LoD treated in a staged concept between April 2010 and December 2015 RESULTS: Median initial body mass index was 45 kg/m2. All hernias were recurrent incisional hernias with≥2 failed repairs. No major complications occurred during or after LSG. After a median of 185 days, the second stage at a median body mass index of 33.6 kg/m2was performed. No bowel resections were needed. The only major perioperative complication was pneumonia in 2 patients (13%). Within 24 months (6-68) after the second step, there were 3 reoperations (small recurrence [7%], infected seroma [7%], and infected mesh [7%]). One patient (7%) was lost to follow-up after 2 years.
  
  
  CONCLUSIONS
  A 2-step approach to treat massive hernias with LoD in morbidly obese patients is safe and effective. LSG as initial weight loss procedure addresses LoD successfully without a need for further preoperative measures to condition for hernia repair.
authors.affiliation: Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland. Electronic address: yves.borbely@insel.ch.
authors.forename: Yves
authors.initials: Y
authors.lastname: Borbély
authors.affiliation: Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland.
authors.forename: Jens
authors.initials: J
authors.lastname: Zerkowski
authors.affiliation: Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland.
authors.forename: Julia
authors.initials: J
authors.lastname: Altmeier
authors.affiliation: Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland.
authors.forename: Anna
authors.initials: A
authors.lastname: Eschenburg
authors.affiliation: Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland.
authors.forename: Dino
authors.initials: D
authors.lastname: Kröll
authors.affiliation: Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland.
authors.forename: Philipp
authors.initials: P
authors.lastname: Nett
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D005743:Gastrectomy / Q000379:methods*; D015390:Gastric Bypass; D046449:Hernia, Abdominal / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000150:complications*; D011300:Preoperative Care; D011446:Prospective Studies; D012189:Retrospective Studies
keywords: Abdominal wall; Adult; Bariatric surgery; Complex hernia; Giant hernia; Hernia; Loss of domain; Morbid obesity; Preoperative progressive pneumoperitoneum; Prostheses and implants; Sleeve gastrectomy; Staged