Optimization of surgical treatment of abdominal hernias in patients with obesity

Abstract

Introduction. Among patients with primary and postoperative ventral hernias, obesity of various degrees is observed in more than 50 % of patients. A severe complication of obesity is the development of panniculus – a skin-subcutaneous apron of varying severity. The hernia surgeon often performs a panniculectomy, which requires justification, taking into account both the positive and negative consequences.The objective was to improve the results of treatment of patients with hernias who are obese by developing a mathematical algorithm of indications for removing the skin-subcutaneous apron.Methods and materials. The analysis of surgical treatment of 253 obese patients with hernia aged 20 to 90 years was performed. There were 44 males (17.4 %) and 209 females (82.6 %). There are 2 groups: the first (comparison group) included 129 patients whom the hernia excision was performed without removing the skin-subcutaneous apron; the second (main group) – 124 patients who had the excision of the skin-subcutaneous apron during surgery. Indications for panniculus removal were based on the proposed mathematical algorithm, which took into account the size, clinical manifestations, associated complications, and possible consequences after surgeries while preserving it.Results. When considering the abdomen in patients with hernias and obesity from the side surface, the hanging apron in relation to the abdominal wall forms a truncated cone, or two conjugated cones that form significantly different moments of forces acting on the abdominal wall at different stages of development of the panniculus, and, therefore, can serve as the basis for the development of classification. Based on this mathematical model, the following classification of changes in the anterior abdominal wall in hernias and obesity is proposed: saggy belly; cutaneoussubcutaneous apron I, II, III degrees, which are based on calculated mathematical indicators and clinical manifestations of the disease. When treating patients with hernias and obesity during operations, the following tactical algorithms were followed: with a saggy stomach and panniculus of the 1st degree, the removal of the skin-subcutaneous apron can be refused; with the 2nd and 3rd degrees, its preservation contributes to the recurrence of the hernia due to the action of moments of forces that shift and pull the abdominal wall down.Conclusions. Clinical observations of patients with hernias and obesity have shown that the removal of the skinsubcutaneous apron did not lead to an increase in the frequency of wound and systemic complications, and therefore it should be considered a necessary stage of surgery.