Biological patch repair of abdominal hernia and key clinical points

Laparoscopic transfascial suturing can close larger areas of fascia, making it a highly attractive option. During the primary procedure, if omental entrapment occurs, it is relieved by blunt dissection. A 2mm puncture is made above the umbilicus to insert the tip of the Carter-Thomason stapler.

Using this device, under direct vision, non-absorbable sutures are placed on one side of the abdominal hernia defect. The sutures are then passed through the device and pulled out from the other side of the defect. At least three untied sutures cross the fascial defect. After all sutures have been placed, pneumoperitoneum is released, and the sutures are then tied. The incision is closed with intradermal sutures, and the knots are buried subcutaneously.

For patients who incidentally discover one or more abdominal hernias during laparoscopic gastric bypass surgery, all current treatment options are less than ideal. The recognized failure rate for primary repair is 22%–49%, and the use of synthetic materials in contaminated areas carries the risk of implant infection and subsequent surgical failure. Delaying hernia repair until significant weight loss has resulted in small bowel obstruction in 36% of patients within 6 months, demonstrating the inherent risks of this approach.

The recurrence rate of hernias using absorbable mesh can reach 75%, so it may not be a suitable option.

The development of new biomaterial patches may improve the success rate of abdominal hernia repair in these patients. This novel patch features a collagen framework containing several growth factors, stimulating the ingrowth of autologous tissue into the collagen matrix, where it is gradually and completely reabsorbed. Its low likelihood of becoming a source of infection makes it more suitable for use in contaminated surgical fields.

The largest study on the management of abdominal hernias in patients undergoing laparoscopic gastric bypass surgery showed that the recurrence rate was lowest with the use of biological patches compared to primary suture repair. Postoperative seroma formation is common, and most cases resolve spontaneously without specific treatment. Approximately 8% of patients developed wound cellulitis, which healed with antibiotic treatment.

After thorough preoperative and postoperative evaluation and consistent treatment, the treatment outcomes were satisfactory. Two patients experienced focal, persistent wound pain, which subsided after one or two local treatments with bupivacaine.

In this study, umbilical hernias with a diameter of less than 3–4 cm were repaired in one stage using a transabdominal through-suture method, consistent with the 12 mm trocar closure approach. Unfortunately, the recurrence rate using this method was 22%. However, in patients with hernias smaller than 2 cm, no recurrence was observed during the 36-month follow-up. These results suggest that for umbilical hernias with defects larger than 2 cm, the Rives-Stoppa tension-free repair technique using biomaterial implants may be a better option.

**Clinical Key Points**

Treatment of abdominal hernias in morbidly obese patients remains challenging. It is important to make morbidly obese patients aware that an abdominal hernia may be discovered incidentally during surgery, and that repairing it carries a high risk of recurrence. Furthermore, repairing incisional hernias that develop after bariatric surgery in morbidly obese patients is crucial, especially in cases of omental incarceration, as the risk of postoperative strangulated intestinal obstruction is high.

To reduce the recurrence rate of hernias, biomaterial patches can be used to reinforce all defects. If the hernia defect is small, it can be repaired using a Carter-Thomson suture with a figure-of-eight suture. If the hernia defect is large, using a biomaterial patch may be a reasonable option when repair and gastric bypass surgery are performed simultaneously.

However, for hernias larger than 5 cm in diameter, the authors recommend a standard hernia repair procedure using the double-layer mesh described in previous literature, at least 3 months prior to gastric bypass surgery. The PTFE side should face the abdominal cavity to minimize adhesions during reoperation.

**Body Reshaping After Weight Loss Surgery**

Dennis Hurwitz

Minimally invasive gastrointestinal bypass surgery has achieved good clinical results in the treatment of morbid obesity. Last year alone, the University of Pittsburgh Bariatric Surgery Center performed more than 1,000 such surgeries. The demand for body reshaping after weight loss surgery is also increasing rapidly. After significant weight loss, these patients have developed unsightly sagging skin tags and oddly shaped, rolled-up skin fat.

While bariatric surgery successfully reduces weight and alleviates the health risks associated with obesity, it also brings various problems that can lead to a decline in patients' quality of life. Our center's staff anticipated these issues and encourages patients to regain their quality of life through our professional body contouring surgery.

For decades, many plastic surgeons have considered circumcision and lower body lift to be the best way to deal with excess skin on the torso and thighs. However, surgical outcomes have been mixed, and there has been little consensus on the techniques involved. Meanwhile, there is a dearth of literature on body contouring surgery following significant weight loss, and no literature on the postoperative outcomes of minimally invasive weight loss surgery.

Therefore, I explored various surgical methods, approaches, and localizations, resulting in an innovative surgical technique. We discovered a consistency in the characteristics of these patients, and based on this, we considered individualized surgical approaches. These extensive and complex surgeries all require general anesthesia, typically lasting 6–12 hours, and carry significant risks.

Through careful evaluation of the results of various surgeries and summarizing reports from academic conferences, we have developed orthopedic surgery to the point where it can be tailored to each patient's deformity and requirements. A comprehensive assessment and consideration of the patient's physical deformity is crucial. The entire surgical technique is based on the integrated application of plastic surgery principles such as artistry, efficiency, strong suturing, and minimizing tissue damage.

Between March 2000 and July 2003, I performed 208 surgeries on 54 patients who underwent significant weight loss. These included abdominoplasty, lower body lift, upper body lift, inner thigh reshaping, longitudinal inner thigh reshaping, upper arm reshaping, breast reshaping/breast reconstruction, facelift, gynecomastia correction, and other plastic surgeries. None of these patients had a BMI exceeding 35. Due to the high risk of surgical complications in severely obese patients, we did not treat these severely obese patients.