Hernia (2022) 26:1605–1610

https://doi.org/10.1007/s10029-022-02581-2

ORIGINAL ARTICLE

Body Mass Index impact on Extended Total Extraperitoneal Ventral

Hernia Repair: a comparative study
C. Sánchez García1 · I. Osorio1 · J. Bernar2 · M. Fraile2 · P. Villarejo1 · S. Salido1

Received: 13 December 2021 / Accepted: 22 February 2022 / Published online: 10 March 2022
© The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature 2022

Abstract
Purpose Obesity is a risk factor for developing abdominal wall hernias and is associated with major postoperative compli-
cations, such as surgical site infection, delayed wound healing and recurrent hernia. Therefore, treating incisional hernia in
this patient subgroup is a challenge.
Methods We conducted a comparative, prospective study on patients who underwent primary ventral hernia surgery or inci-
sional hernia surgery through the extended totally extraperitoneal pathway, with body mass indices (BMIs) ≤ 30 (no obesity)
and BMI > 30 (with obesity). We collected demographic data, preoperative and intraoperative variables, complication and
recurrence rate, hospital stay and follow-up as postoperative data.
Results From May 2018 to December 2020, 74 patients underwent this surgery, 38 patients without obesity and 36 with
obesity. The median area of the hernia defect measured by CT was 57 c­ m2 and 93 ­cm2 in patients without and with obesity,
respectively (p = 0.012). The median follow-up was 16 months. One patient without obesity experienced some postoperative
complication compared with four patients with obesity (p > 0.05). No patient without obesity had recurrent hernia compared
with two patients with obesity (p > 0.05).
Conclusions There were statistically significant differences between patients with and without obesity in the size of the
hernia defect. However, there were no significant differences in terms of complications, hospital stay, postoperative pain
or relapses. Therefore, the minimally invasive completely extraperitoneal approach for patients with obesity appears to be
a safe procedure despite our study limitations. Studies with longer follow-ups and a greater number of patients are needed.

Keywords Hernia · Ventral hernia repair · Extraperitoneal approach · Minimally invasive surgery · Obesity

Introduction Abdominal wall hernias are one of the most common

Obesity has been increasing worldwide in recent decades,
becoming a true epidemic in the Western world. Patients
with obesity are more likely to have comorbid medical con-
ditions with increased perioperative complications, includ-
ing cardiac events, adverse pulmonary outcomes, thrombo-
embolic events, wound complications and infections.
* C. Sánchez García
csgmaldo@gmail.com
1
Endocrine, Breast and Minimally Invasive Abdominal Wall
Surgery Unit, General Surgery Department, Fundación
Jiménez Díaz University Hospital, Avenida de los Reyes
Católicos, 2, 28040 Madrid, Spain
2
Endocrine, Breast and Minimally Invasive Abdominal Wall
Surgery Unit, General Surgery Department, Villalba General
Hospital, Madrid, Spain
issues addressed by general surgeons. However, there is sig-
nificant variability in surgical management. Ventral hernia
repair (VHR) remains a challenge in the population with
obesity. Obesity is an independent risk factor for postop-
erative complications from hernia repair, such as increased
length of stay (LOS), increased hernia recurrence and a two-
fold risk of wound-related complications [1–4]. A structured
prehabilitation program to achieve preoperative weight loss
can serve as a strategy to reduce perioperative morbidity in
patients with obesity after VHR [5].
Minimally invasive surgery (MIS) has been developed in
recent decades to improve clinical outcomes. Current evi-
dence reports higher morbidity and mortality in patients with
obesity who undergo open ventral hernia repair (OVHR);
thus, this population might benefit from MIS [1, 6, 7].
Leblanc and Booth described the first laparoscopic ven-
tral hernia repair (LVHR) in 1991 [8]. The intraperitoneal

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mesh placement to bridge the hernia defect, which is known
as intraperitoneal onlay mesh (IPOM), demonstrated the
safety and feasibility of LVHR. As the use of this procedure
expanded, reductions in wound morbidity compared with the
open approach became clear [9]. Nonetheless, this technique
had rare but serious complications, such as adhesive bowel
obstruction, mesh erosion and enterocutaneous fistula [10].
In non-closure of fascial defects, recurrence rate and bulging
have been reported more frequently [11]. With greater expe-
rience, some surgeons began incorporating primary closure
of the defect in LVHR (IPOM plus).
To address the limitations of classical laparoscopic and
open ventral hernia repair, several minimally invasive endo-
scopic, laparoscopic and robotic extraperitoneal techniques
have been developed with the goal of combining the ben-
efits of traditional open sublay repair with those of MIS.
The Transabdominal Preperitoneal (TAPP) approach and
endoscopic Transverse Abdominis Release (TAR) prevented
direct mesh contact with viscera. However, there is not yet
a consensus regarding the best approach for ventral hernia
repair, and the decision is typically individualized.
The enhanced or extended-view total extraperitoneal
preperitoneal (eTEP) approach was developed by Daes for
endoscopic inguinal hernia repair in complex cases [12].
This novel technique provides an augmented preperitoneal
space, and it has been used to perform midline and off-
midline VHR. To date, there have been several studies with
preliminary and satisfactory outcomes [13–16]. Belyansky
et al., in a recent study, compared outcome data on patients
with and without morbidly obesity [17].
Therefore, we sought to evaluate the impact of body mass
index (BMI) on postoperative outcomes after the eTEP
technique.
Methods
The Institutional Review Board approved this protocol, and
written informed consent was obtained from all patients. A
retrospective review of a prospectively maintained database
was conducted of all patients who underwent eTEP from
April 2018 to December 2020 at Villalba General Hospi-
tal and Fundación Jiménez Diaz Hospital in Madrid, Spain.
Patients were divided into 2 groups according to BMI: obese
(BMI > 30 kg/m2) and not obese (BMI ≤ 30 kg/m2), and the
surgeries were performed by a single surgeon. The outcomes
of these two groups of patients were compared.
The measurements of the hernia defect were determined
following the model outlined by the European Hernia Soci-
ety (EHS) [18]. Patients with midline and lateral primary
and incisional abdominal wall hernias over 3–10 cm in width
(W1 and W2 according to the EHS classification) and several
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Hernia (2022) 26:1605–1610
abdominal wall hernias with a total size defect > 3 cm were
enrolled in the study.
Emergency cases, patients with loss of domain, skin infec-
tions, skin fistulas and active infection were excluded from
the analyses.
The database included age, sex, BMI, American Society of
Anesthesiologists (ASA) classification and comorbid condi-
tions as demographic information. Preoperative data included
primary or incisional ventral hernia, previous abdominal sur-
geries, hernia location and defect size and area. Intraoperative
and perioperative data included associated TAR, conversion
to laparotomy, operative time, mesh area, postoperative com-
plications, LOS and follow-up based on clinical and radiologic
findings.
Patients who smoked tobacco within 1 month of surgery
were considered to be active smokers. The defect and mesh
area ­(cm2) were determined using a mathematical formula for
an oval or circle. Postoperative complications were reviewed
from follow-up visit notes of the surgeon as well as medical
records and were categorized according to the Clavien–Dindo
classification system. Recurrent hernia was a contour abnor-
mality associated with a fascial defect detected by physical
examination and/or computed tomography (CT) scan. Post-
operative pain scores were determined by visual analog scale
(0: no pain, 10: worst pain) performed by the surgeon before
hospital discharge.
Patients underwent a detailed history and physical exami-
nation in outpatient clinics. An abdominopelvic CT was rou-
tinely obtained to further assess patient anatomy, to evaluate
the defect size and for planning the surgery and the type of
component separation technique, if needed.
A prophylactic cefazolin 1-g dose was given prior to sur-
gery. Any defects in the posterior layer were closed with 2–0
absorbable sutures in a running fashion. Our preference was
lightweight microporous polypropylene mesh, and no fixation
was used. Deep vein thrombosis prophylaxis was given 12 h
after surgery on a case-by-case basis. The standard operative
technique was performed, as described by Salido et al. [16].
The statistical analyses were performed using SPSS (Sta-
tistical Package for Social Sciences for Windows Version
22). Qualitative variables were expressed as counts and fre-
quencies, and the Chi-squared test was applied. Quantitative
variables were indicated as medians and ranges, Student’s t
test was used for normal distributions and Fisher’s exact test
was employed for non-normal distributions. A p value less
than 0.05 was considered statistically significant.
Results
A total of 74 patients were included in the study. According
to BMI, 38 patients were classified as not obese and 36 as
obese. A summary of relevant patient demographic data is
Hernia (2022) 26:1605–1610 1607

Table 1  Demographic data Table 2  Preoperative variables

Not obese Obese p Not obese Obese p

Gender Incisional Hernia 26 (68.4%) 30 (83.3%) 0.110

Male 21 (55.3%) 15 (41.7%) 0.174 Multiple Surgery 6 (15.8%) 12 (33.3%) 0.068
Female 17 (44.7%) 21 (58.3%) Incarcerated 121 ± 46 134 ± 45 0.526
Age 60 ± 20 61 ± 13 0.775 Defect location
BMI 26.7 (22–30) 33 (30–47) < 0.001 Medial 27 (71.1%) 25 (69.4%) 0.541
HT 17 (44.7%) 16 (44.4%) 0.583 Lateral 11 (28.9%) 11 (30.6%)
DM 5 (13.2%) 8 (22.2%) 0.237 Defect width CT (mm) 39 ± 17 53 ± 26 0.013
Tobacco 3 (7.9%) 7 (19.4%) 0.133 Defect area CT (­ cm2) 57 (3–442) 93 (6–539) 0.009
CVD 5 (13.2%) 6 (16.7%) 0.461
CT computed tomography
COPD 3 (7.9%) 4 (11.1%) 0.469
ASA
I 5 (13.2%) 2 (5.6%) 0.329 Table 3  Intraoperative variables
II 25 (65.8%) 22 (61.1%)
Not obese Obese p
III 8 (21.1%) 12 (33.3%)
TAR​ 14 (36.8%) 20 (55.6%) 0.083
BMI body mass index, HT arterial hypertension, DM diabetes mel-
litus, CVD cardiovascular disease, COPD chronic obstructive pulmo- Conversion to open proce- 2 (5.3%) 2 (5.6%) 0.672
nary disease dure
Surgery time (min) 121 ± 46 134 ± 45 0.210
Suture time (min) 18 (3–57) 18 (4–40) 0.793
Mesh area CT ­(cm2) 425 (100–900) 445 (25–1500) 0.342
presented in Table 1. The median BMI in the obese group
was 33 (p < 0.001), and 58.3% were women (p = 0.174). The CT computed tomography
two groups had a similar median age (60 ± 20 years among
those without obesity versus 61 ± 13 years in those with
obesity, p = 0.775). Comorbidities such as diabetes mellitus Table 4  Postoperative variables
(22.2%, p = 0.23), tobacco consumption (19.4%, p = 0.133), Not obese Obese p
cardiac disease (16.7%, p = 0.461) and chronic obstructive
pulmonary disease (11.1%, p = 0.469) were more common Complication 1 (2.7%) 4 (12.1%) 0.082
in the patients with obesity. Twelve (33.3%) patients with Recurrence 0 (0%) 2 (6%) 0.226
BMI > 30 kg/m2 were classified as ASA III (p = 0.329). VAS 3 (0–6) 3 (0–6) 0.789
Thirty (83.3%) patients with obesity had an incisional LOS 0.9 ± 1 1.9 ± 3 0.049
hernia (p = 0.110), and in 12 (33.3%) cases, there were previ- Follow-up (months) 16 (1–32) 16 (3–31) 0.901
ous abdominal surgeries (p = 0.068).
VAS visual analogue scale, LOS length of stay
The median defect width was 39 ± 17 mm in the patients
without obesity versus 53 ± 26 mm in the patients with
obesity (p = 0.013), and the median defect area was 57 ­cm2 the patients with obesity and no one in the patients with-
(3–442) versus 93 ­cm2 (6–539), respectively, which repre- out obesity, but no significant differences were observed
sented a significant difference (p = 0.009) (Table 2). (Table 4). No recurrence was reported on cases converted
TAR was performed on 20 patients with obesity to open surgery.
(p = 0.08). The median operative time and median mesh Three patients with obesity had hematoma as complica-
area as evaluated by abdominal CT were higher in patients tion (Dindo–Clavien grade 2). Two patients were classified
with obesity, but no significant differences were observed as Dindo–Clavien grade 3: one patient with obesity pre-
(Table 3). sented with a bowel perforation and one patient from the
We excluded cases converted to open surgery from non-obese group had a bowel obstruction.
results. There were two cases in each group. In obese Eight seromas were registered: 3 among those without
patients, two cases were excluded and one presented a com- obesity and 5 among those with obesity. Seromas were not
plication. In the non-obese group, two cases were excluded classified as complications, because none of them required
without any complication. any treatment and they were clinically asymptomatic.
At a median of 16 months of follow-up, complica- Both patient groups had similar low postoperative pain
tions were recorded in 1 patient without obesity and in scores (p = 0.789) and short LOS (0.9 ± 1 vs 1.9 ± 3 days,
4 with obesity (p = 0.082). There were 2 recurrences in p < 0.05) (Table 4).

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Discussion
Ventral hernias are one of the most common surgical
pathologies encountered by surgeons. Obesity is a risk fac-
tor for developing ventral hernias as well as postoperative
complications, most of which stem from wound complica-
tions. For this reason, nonoperative management can be an
option for certain surgeons due to the morbidity and mor-
tality in this patient population. In a survey of surgeons in
2012, morbid obesity (BMI > 40 kg/m2) was considered a
contraindication to VHR by 43.3% of surgeons [19].
Currently, the optimal management plan for patients
with obesity and ventral hernia remains unknown.
Furthermore, the benefits of preoperative physical
conditioning and weight loss programs have been dem-
onstrated in some patients, but there is no evidence on
patients undergoing VHR.
In a randomized controlled trial, Liang Mike et al. con-
cluded that patients undergoing a prehabilitation program
based on preoperative nutritional counseling and exercise
had a higher likelihood of being hernia-free and compli-
cation-free at 30 days postoperatively [5].
An expert consensus guided by a systematic review
of ventral hernia management considered individualized
preoperative intervention in elective VHR with BMI of
30–50 kg/m2 with a grade C recommendation. There was
no agreement on the BMI cutoff at which the benefits of
initial nonoperative management outweighed the risk of
elective VHR [20].
A durable repair with low morbidity and recurrence is
the goal of VHR [21]. To date, the OVHR approach has
been associated with wound-related complications, longer
hospitalization and higher immediate and long-term recur-
rence risk among patients with obesity compared with
those without obesity [22].
Over the last decade, minimally invasive surgery (MIS)
employing laparoscopic and/or robotic platforms has revo-
lutionized the treatment of complex hernia disease. The
majority of published studies demonstrate a reduction in
surgical site infections (SSIs) as one of the primary ben-
efits of LVHR.
LVHR minimized odds of all complications when com-
pared with OVHR for all weight classes [23].
Most studies report the rate of SSIs at less than 3% [10,
22, 24–26]. Due to the higher wound-related complication
rates in patients with obesity, these patients might benefit
from elective MIS in VHR.
Potential long-term complications related to intraperi-
toneal mesh placement have also limited its application
in some cases. IPOM is associated with an increased risk
of intestinal adhesions and increased morbidity in redo
surgery [27].
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Hernia (2022) 26:1605–1610
On the other hand, recurrence rates after LVHR are simi-
lar to those for OVHR and range from 1 to 17% [28]. The
risk is increased by a variety of modifiable factors, including
obesity.
Although some studies reported that IPOM does not pre-
sent advantages in terms of acute or chronic pain and quality
of life over OVHR [29], these data should be interpreted
carefully. In a recent propensity score-matched comparison
by Kockerling et al., there were no differences in terms of
chronic pain or recurrence after 1-year follow up. Neverthe-
less, IPOM would be preferable due to higher rates of surgi-
cal postoperative complications in OVHR [30].
Therefore, these limitations were a contributing factor
in the development of retromuscular ventral hernia repair
techniques such as eTEP. J. Daes conceptualized eTEP for
difficult inguinal hernias, for patients with obesity and for
the presence of previous surgical scars [12]. A novel appli-
cation of the eTEP approach for VHR was first reported by
Belyansky and later by others [13].
A prospective interventional study by Kumar et al. com-
paring IPOM plus versus eTEP for VHR showed that pain
scores and length of hospital stay after surgery were signifi-
cantly less in the eTEP group compared with the IPOM plus
group. Although the operative time was longer in the eTEP
group, the authors concluded that eTEP is a feasible and
safe procedure with results comparable to IPOM plus [31].
There have been encouraging short-term outcomes of the
eTEP technique as a treatment for primary and incisional
ventral hernia. Most studies report the need for a greater
number of patients and a longer follow-up to draw stronger
conclusions. Similarly, various authors consider that patients
with obesity would benefit significantly from this technique.
One advantage of the eTEP technique in experienced hands
when compared with other surgical techniques (LVHR
or OVHR) is a low recurrence rate. Challenges of eTEP
include placing the mesh in the “ideal” position and restor-
ing abdominal wall functionality.
A benefit of eTEP is the possibility of extending the dis-
section laterally toward the semilunaris line, allowing TAR
to be performed. Therefore, this approach can achieve suf-
ficient overlap and a large mesh area. The ratio between the
defect area and mesh area is one of the strongest predictors
of recurrence [32, 33].
In the present study, both the defect area and mesh area
were higher among patients with obesity; however, we did
not observe statistically significant differences in terms of
recurrence.
There are few results on the use of robotic-assisted sur-
gery in treating ventral hernias. However, in patients with
obesity and in colorectal surgery, studies have shown a
quick recovery and low morbidity rates. Fahri Gokcal et al.
assessed the results of robotic-assisted surgery in patients
with morbid obesity. Fifty-two patients underwent surgery
Hernia (2022) 26:1605–1610
with TAPP or eTEP based on the size of the hernia defect,
as well as IPOM as a surgical option. The logistic regression
model determined that BMI was a risk factor for developing
major complications [34]. Tsereteli et al. employed LVHR
in a population with morbid obesity and observed slightly
increased recurrence rates (8.3% in 19 months of follow-
up) [7]. Birgisson et al. reported no cases of recurrence, but
their study included only 16 patients with morbid obesity
[1]. Belyansky et al. recently performed a comparative study
on the treatment of ventral hernias between patients with
BMI > 35 and BMI < 35, and found no statistically signifi-
cant differences at 1 year of follow-up [17]. Similarly, we
also found no statistically significant differences in terms
of recurrence in patients with obesity, which supports the
previous studies that have been conducted, showing that
MIS approach is cost-effective compared with open repairs,
despite patients having a higher BMI.
The strengths of this study include the use of a prospec-
tive database and the homogeneity of the data, given all
patients were operated on by the same surgeon. On the other
hand, limitations include the small sample size and the lack
of long-term outcome data.
Conclusions
Although eTEP is a relatively new technique which use is
not yet widespread, the preliminary results in various pub-
lished series, as well as in our experience, appear promis-
ing. On one hand, eTEP solves the limitations and problems
related to placing an intraperitoneal mesh. On the other, it
provides added benefits from minimally invasive surgery.
The population with obesity has higher comorbidities
and perioperative complications. Abdominal wall surgery
in these patients is a challenge, with a particular concern
regarding recurrence rates. Using laparoscopic surgery, the
surgical wound complication rate is reduced, as is postop-
erative pain.
Due to their anatomical condition, patients with obe-
sity represent a challenge for surgeons. Although eTEP is
a reproducible technique, the learning curve is long and is
essential for achieving good results.
In our comparative series, there were no statistically
significant differences in terms of hernia relapses in the
group with obesity compared with the group without obe-
sity. Despite the lack of published literature regarding the
use of eTEP in these patients, the short-term results are
encouraging.
Funding The authors declare that they have no financial ties to
disclose.
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Code availability Statistical analysis was performed.
Declarations
Conflict of interest The authors have no related conflicts of interest
to declare.
Ethical approval For this type of study, ethical approval is not required.
Human and animal rights All procedures performed in this study
involving human participants were in accordance with the 1964 Hel-
sinki declaration and its later amendments or comparable ethical stand-
ards. This article does not contain any study with animals performed
by any of the authors.
Informed consent Informed consent was obtained from all individual
participants of the study.
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