Obesity increases the risk of complications in hernia surgery

 Globally, obesity is on the rise and is associated with a number of diseases, including diabetes, hypertension and heart problems. The link between obesity and hernias has come to light particularly in India where the prevalence of obesity is rising. This raises questions concerning the increased risk of hernias and surgical consequences for obese people.

Brief overview of hernias 

A hernia is a muscle gap that lets internal organs, like the bowel to bulge out. While some people feel no pain, emergencies can arise from bowel strangulation. This life-threatening situation requires immediate surgery to release the trapped bowel and fix the hernia with prosthetic material/suture.

The term "hernia" originates from Latin ("bulge") and in Greek ("rupture").

Factors like obesity, heavy lifting, chronic coughing, straining during bowel movements or urination, lung disease, and abdominal fluid can raise abdominal pressure, potentially leading to hernias. A family history of hernias also increases the likelihood of developing one.

Hernia Types

Hernias are categorised by their location, here are some,

• Inguinal Hernia: Common at the groin, where the thigh meets the abdominal wall. Incomplete inguinal hernia means it doesn't reach the scrotum. Complete inguinal hernia means it extends into the scrotum. Direct Herniae moves directly forward, often in older individuals and can be on both sides. Indirect Hernia means it passes through the inguinal canal, more common in men and usually starts at birth.
• Femoral Hernia: Occurs at the front of the thigh; more common in women than men.
• Umbilical Hernia: At the navel, linked to multiple pregnancies.
• Epigastric Hernia: Upper abdomen above the navel.
• Incisional Hernia: Develops through old incision scars or repaired hernial sites.

The connection between obesity and hernia repair complications

Recognising the link between hernias and obesity is vital for those managing weight and hernia concerns. Obesity increases hernia risk through various means:

• Abdominal Pressure: Excess abdominal fat heightens pressure, straining muscles and causing hernias.
• Muscle Weakness: Obesity weakens muscles fostering hernia vulnerability. Fat in the abdominal wall acts like a pile driver through the muscle and causes its breakdown.
• Healing Challenges: Obesity hampers tissue healing, increasing the likelihood of hernias at surgical sites.
• Respiratory Impact:Excessive coughing causes more stress to abdominal muscles, elevating hernia risk.
• Lifestyle Role: Chronic straining due to constipation escalates abdominal pressure, contributing to hernia formation.

Obesity as a Risk Factor in Hernia Repair Complications

Firstly, if your hernia becomes painful, and tender, and you can't push it back, go to the ER immediately. Strangulation of the intestine within the hernia can cause gangrene and bowel death in 6 hours.

Obesity complicates hernia repair due to several complexities.

• • Higher Risks in surgery : Obesity raises the chances of wound infections hence causing delayed healing, and seromas in the wound. Excess abdominal fat hampers proper visualisation and access during hernia surgery.
• Anaesthetic Complexities: Excess weight affects lung function, posing challenges for anaesthesia. Obesity increases risk of blood clots in the legs (deep venous thrombosis) and can lead to fatal consequences.
• Extended Recovery: slowing the healing process.
• Recurrence of hernia: Obesity heightens hernia recurrence post-surgery.

Overview of hernia repair procedures

Upon evaluation by a surgeon, patients are presented with two main options: Open and Laparoscopic Repair. The choice hinges on individual factors, with each approach carrying distinct benefits and considerations.

1. Prosthetic mesh is universally used for secure hernia repairs, with materials like Polypropylene, Polyester, PTFE, and composite meshes like Ultrapro.
2. Open inguinal hernia surgery uses local or regional anaesthesia, and 3D meshes are a recent advancement.
3. Glue closure is replacing stitches for wound closure.
4. Laparoscopic surgery involves key hole surgery with mesh placement

Strategies to Mitigate Complications in Obese Patients

Usually when an obese patient with a non-emergent hernia presents to a surgeon, the aim will be to mitigate the risks of surgery:

• Encouraging patient to lose weight systematically using a dietician’s services, a weight loss trainer and changing the mind set of the patient about obesity. These can be be done by motivating the patient with regular goals and continuous follow up.
• Preoperative physiotherapy with breathing exercises and walking helps mitigate risks of complications.
• Nutritional support with vitamins and protein rich diet.
• Skin care at the site of the hernia.
• Optimizing the patient’s other medical problems (diabetes/hypertension/cardiac ailments).
• DVT (deep venous thrombosis) prophylaxis with medications and graduated compression stocking.

In the end, surgery in obese hernia patients does carries risk, but these can be mitigated with optimising the patient with a multi-pronged approach.

 

Dr. Rajeev Premnath, General, Laparoscopic Surgeon and Endoscopist,

 Hitech Hernia Centre, Ramakrishna Hospital Jayanagar, Bengaluru