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Patients undergoing complex ventral hernia repair (VHR) often present with significant medical comorbidities, the most prevalent of which is obesity. Although recent advancements in abdominal wall reconstruction techniques have provided the general hernia patient population with markedly improved recurrence and postoperative complication rates, many patients have been precluded from these procedures owing to excessive body mass index (BMI). In this study, we investigate the viability of complex ventral hernia repair with epigastric artery perforator sparing skin incisions, component separation, and wide-spanning retrorectus mesh reinforcement for patients with BMI of greater than or equal to 40 kg/m2 (class III obesity).
A single surgeon retrospective review of our prospectively maintained database was performed. We restricted this data to class III morbidly obese patients undergoing open VHR with component muscle separation and wide-spanning mesh reinforcement.
Between 2010 and 2017, 131 patients met the inclusion criteria for our study. The mean patient BMI was 46.7 kg/m2. Operative wounds were categorized according to the National Healthcare Safety Network Wound Class Definitions. There was no statistically significant association between wound class and postoperative complication rates. After our implementation of epigastric artery perforator sparing skin incisions in 2013, significantly less wound breakdown was observed (26.3%) as opposed to before (49.0%) (P < 0.01). Furthermore, significantly less cases required return to the operating room after this technique was implemented (31.3%) as compared with before (60.8%) (P < 0.001). Postoperatively, 28 patients developed an infection requiring antibiotic treatment (21.4%), and the overall hernia recurrence rate was 5.3%. Three patients expired.
Complex VHR with abdominal wall reconstruction may be a viable option for class III morbidly obese patients. Preliminary data suggest that implementation of epigastric artery perforator sparing skin incisions may reduce the risk of postoperative wound complications, and we have demonstrated hernia recurrence and wound complications comparable with those seen in the general population.

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