Perioperative optimization of a hernia patient

Smoking

The numerous effects of smoking have been widely studied and described in the literature. Smoking has been shown to reduce blood and tissue oxygenation, as well as to impair collagen deposition in healing wounds, thereby adversely affecting surgical outcomes. Animal models and multiple human studies have shown that smoking is associated with an increased risk of SSI following VHR compared to nonsmokers. ^{, ,} Smoking has also been shown to increase the risk of incisional hernias and other postoperative complications following gastrointestinal and other abdominal procedures. Due to the complexity of many ventral hernias, repairs frequently require the use of prosthetic mesh or tissue flap dissections, in combination with concomitant gastrointestinal procedures, thereby reinforcing the importance of smoking cessation prior to elective hernia repair. It has been well studied and shown that within 4 weeks of smoking cessation, patients benefited by decreasing many of the deleterious effects of the tissue microenvironment caused by smoking. Interestingly, nicotine replacement therapy seemed to attenuate inflammation, but the effect was very marginal. Despite short-term smoking cessation being effective in tissue microenvironment, the adverse effects on cellular proliferation and remodeling remained. Others studies analyzing smoking versus nicotine patch substitution 4 weeks preoperatively and 4 weeks postoperatively in patients undergoing multiple surgeries, including primary hernia repairs, showed almost a 50% reduction in total complications in the smoking cessation group. Therefore due to the high-quality literature supporting the detrimental effects of smoking as well as the benefits of smoking cessation, we require patients undergoing elective complex VHR to cease all smoking activity for at least 30 days before surgery. We allow patients the use of nicotine supplements (such as gum, patches, and lozenges) for smoking cessation.

Obesity

Obesity is one of the most important factors to take into consideration when dealing with patients indicated for hernia repair. Obesity has been associated not only with an increased risk of post-incisional hernia development, but also with an increased risk of hernia recurrence following hernia repair. A linear correlation has been reported between hernia recurrence and each point increase in body mass index (BMI), regardless of the surgical technique after VHR. ^, In our practice, we have also found that patients with a BMI of ≥50 kg/m have unacceptably high rates of hernia recurrence and morbidity. Therefore we no longer perform elective herniorrhaphies in these high-risk patients, unless they present with acutely worsening symptoms concerning for bowel compromise (e.g., obstruction, strangulation, and ischemia). These patients undergo laparoscopic, robotic, or open repair with bowel resection and primary suture repair of the hernia defect. Sometimes, a bridged mesh is needed; however, a formal AWR with component separation is deferred until sufficient weight loss is achieved and the patient has been optimized.

Because of the challenges involved in patients with obesity in whom hernia repair is indicated, counseling on methods for weight loss (e.g., dietary changes, increasing physical activity, nutrition consult, and bariatric surgery referral) are a major pillar during clinic visits. Unfortunately, obesity is the result of lifetime practices of poor eating habits, insufficient physical activity, and other factors that make weight loss very challenging. Therefore, following the discussion of weight loss strategies during clinic visits, rational goals and objectives should be set. In our practice, we usually set weight loss goals (e.g., 15–30+ lbs) and have the patient return to clinic in 3–6 months for re-evaluation and arrange a dietary consult for nutritional support. Follow-up is a crucial aspect to preoperative optimization, as many patients require interval status updates to confirm and encourage weight loss and other factors for success. Patients in whom surgical weight loss intervention is indicated and patients who failed medical weight loss management goals are appropriately referred to our bariatric surgery colleagues for further evaluation and possible bariatric surgery. For patients undergoing a bariatric procedure with a concomitant ventral hernia, we usually perform the simplest hernia repair at the time of the operation (e.g., primary facial closure), deferring more complex hernia repairs until sufficient weight loss is achieved. Some colleagues have advocated the use of concomitant VHR and sleeve gastrectomy rather than gastric bypass, as this combination strategy presents fewer risks for nutrition, wound morbidity, and hernia recurrence.