Hernia repair in the bariatric patient: a systematic review and meta-analysis

Background: Repair options for ventral hernias in bariatric patients include performing a staged approach in which bariatric surgery is performed before definitive hernia repair (BS-first), a staged approach in which hernia repair is performed before bariatric surgery (HR-first), or a concomitant approach. Objectives: This meta-analysis aims to determine which surgical approach is best for bariatric patients with hernias. Setting: PubMed, CENTRAL, and Embase databases. Methods: A comprehensive search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to screen for all studies that focused on outcomes of patients who underwent both hernia repair and bariatric surgery, either simultaneously or separately. Exclusion criteria included hiatal and inguinal hernia studies, case reports, and case series. Results: 27 studies fit our inclusion criteria after identifying 1584 studies initially. Seven comparative studies were included, enrolling 8548 staged patients (6458 BS-first) and 3528 concomitant patients. A total of 7 single-arm staged studies and 13 single-arm concomitant studies were also included. Data on hernia recurrence, mesh infection, reoperation, surgical site infections, seroma, bowel complications, and mortality were abstracted. The concomitant approach was associated with decreased odds of experiencing surgical site infections, reoperation, and seromas. The staged approach (BS-first) was associated with decreased odds of mesh infection. The single-arm studies suggest a lower incidence of hernia recurrence in a staged BS-first approach than in a concomitant approach. Conclusions: The data suggest a concomitant approach is appropriate for hernias that the surgeon feels do not require mesh, while the staged (BS-first) approach is more appropriate if the hernia requires mesh placement. (Surg Obes Relat Dis 2024;20:184-201.) (c) 2024 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.