In a preoperatively detected ventral hernia, the patient can undergo repair of the hernia after bariatric surgery. Two main advantages of this approach exist. Firstly, a lengthy and difficult primary combined procedure is avoided. Secondly, at the time of subsequent surgery patient will be optimized by weight loss and resolution of co-morbid conditions decreasing both operative risk and possibly risk of recurrence.

Though some suggest that subsequent hernia repair may be easier, studies have shown that patients who were once morbidly obese then become a unique challenge to hernia repair, because of larger fascial defects and extreme amounts of abdominal wall laxity [8]. Post-bariatric surgery ventral hernia repair can be done during abdominoplasty as an open procedure or can also be done laparoscopically when body contouring procedures have not been planned. The superiority of laparoscopic ventral hernias is already known from existing literature. Abdominoplasty can be also be safely combined with ventral hernia repairs. Downey et al. reported a series of 50 patients who had undergone fascial plication and midline mesh placement. They found only minor wound problems and no recurrence [8]. Borud et al. reported a series of 50 patients with ventral hernias after bariatric surgery. Twelve had large hernias and underwent a component separation technique with abdominal wall plication and onlay mesh placement. Borud et al. reported a high rate of major and minor wound complications but only one recurrence [9]. Saxe et al. reported 71 patients who underwent concomitant ventral hernia repair with abdominoplasty, 40 with prosthetic mesh. Wound complications were increased but no patient sustained a wound complication that required mesh removal [10].

This approach conforms to the basic teaching of ‘treating the precipitating factor before a hernia is repaired to avoid recurrence’. Though this principle may hold good for precipitating factors like chronic bronchitis, benign prostatic hypertrophy (BPH), or chronic constipation, as these are correctable in a few days to few weeks it may not be scientifically right to postpone the hernia repair for months until the obesity factor is addressed by surgical means. Also the risk of leaving a hernia unrepaired is the development of small bowel obstruction. Reducing the hernia without repair resulted in 33 % of the patients developing obstruction in the series by Eid et al. [6]. In cases where laparoscopic roux-en-Y gastric bypass (LRYGB)/anastomotic techniques are performed the risk of delayed diagnosis exists if the bilio-pancreatic limb is obstructed [11]. Thus when no repair has been done, the patient should be closely followed up to detect obstructive symptoms. Another possible option will be to leave the hernia unrepaired with incarcerated omentum plugged in at the time of bariatric surgery and plan for a mesh repair at a later date. In the series by Datta et al., incarcerated asymptomatic hernias confirmed to contain only omentum and outside the operating field were left untouched. This was shown to have no complications after an average follow-up of 14 months. But, this may not always be possible as it will be required to reduce the contents of the hernial sac to facilitate the bariatric procedure especially where a LRYGB is undertaken and for upper abdominal hernias. Another option as was suggested by Datta et al. for hernia contents blocking the operative field, was to maintain the plug of omentum but transect the omentum using ultrasonic shears starting at the mid-transverse colon and lift the free “leaf” of the omentum over the transverse colon to access the bowel. Newcomb et al. preferred to leave large hernias untouched, without reducing even the small bowel because they believed that the risk of bowel obstruction was reduced if the bowel did not need to reorganize during the period of rapid weight loss [12].

In a recent study Eid et al. attempted to recommend an approach based on patient and hernia characteristics. Hernias were classified based on anatomy into favourable anatomy (BMI <50 kg/m², gynecoid body habitus, reducible hernias found in a central location, abdominal wall thickness less than 4 cm, and the defect <8 cm). and unfavourable anatomy (BMI >50 kg/m², android body habitus, irreducible hernias, hernias in a lateral location, abdominal wall thickness more than 4 cm, and the defects >8 cm) and based on symptoms into symptomatic and asymptomatic. Unfavourable anatomy were those who were more likely to need an open approach to repair of hernia. They recommended that patients who were asymptomatic with unfavourable anatomy were the patients who were likely to benefit from bariatric surgery followed by ventral hernia repair. All symptomatic hernias should have their hernias addressed first [13].

Conventional open ventral hernia repairs (OVHRs) in the obese population has traditionally been marked by high failure rates exclusive of other factors [14]. Studies have reported improved results with laparoscopic ventral hernia repairs (LVHRs) perhaps because of tension free repairs with intra-peritoneal prosthetic meshes with a low rate of wound complications [15]. A study by Ching et al. showed that the morbidly obese did not have a significant difference in the complication rate, including recurrence after laparoscopic ventral hernia repair, compared with the non-morbidly obese. The median follow-up period was 19 months (range 6–62) [16]. A study by Birginsson et al. showed that though the operative times were longer in morbidly obese patients, surgery can be performed with minimal morbidity and had no recurrences at a follow-up period ranging from 1 to 35 months comparable to non-obese patients [17]. A study by Novitsky et al. showed that the operative time, hospital stay, and incidence of complications were not influenced by the BMI when the patients undergoing ventral hernia repair were stratified according to the BMI [18].

However a study by Heniford et al. showed that morbidly obese patients had higher recurrence rates and higher incidence of complications [19]. Raftopolous et al. reported hernia repairs have higher recurrence rates in morbidly obese patients [20]. A study by Tsereteli et al. reported that the complication rates were not greater although the rate of recurrence was significantly greater in the morbidly obese [21]. Therefore there is no consensus found in the literature as to the long-term effectiveness and durability of laparoscopic ventral hernia repair (LVHR) in morbidly obese patients. Additional randomized controlled studies are needed to prove the safety and efficacy of ventral hernia repair in the morbidly obese before weight loss.