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Fig. 3 Types of products
used for buttressing
S. Taha264
Carbonate buttress material (Seamguard Bioabsorbable, W. L. Gore & Associates)
adds a total thickness of 0.5 mm while the absorbable Glycolide Diaxonone
Trimethylene Carbonate product that comes integrated\pre-loaded onto the
Stapler Cartridge (Covidien) adds a total thickness of 0.14 mm. Consideration of
the additional thickness of the buttressing material used is of paramount relevance
to the safety of the procedure since stapling through a “tissue plus buttress” complex that is too thick for the chosen stapler height will result in deformed staple
formation and\or tissue injury, while deploying a stapler on a “tissue plus buttress” complex that is too thin for its height can result in instantaneous staple line
leakage [15–17].
3 Buttressing for Bleeding
The other major complication of LSG is post-operative bleeding which can be
either intra- or extraluminal. Intraluminal bleeding from the staple line is rather
uncommon and usually presents with signs and symptoms of upper gastrointestinal bleeding including hematemesis and\or melena stools depending on the
severity and duration of the bleeding [22]. Diagnosis and management of intraluminal bleeding follows the standard algorithm for upper gastrointestinal bleeding,
including blood transfusion, if needed.
Buttressing the Sleeve
Fig. 4 Levels of evidence
265
Extraluminal bleeding can present as an “acute” episode with full blown clinical picture of hypovolemia and\or significant serial drop of hemoglobin or assume
a subclinical course that presents mainly as relative tachycardia, mild pallor and
dizziness, especially on standing up quickly.
Acute bleeding is reported with a frequency that ranges from 1.7% [23] to
2.8% [24] and usually requires return to the operating room (OR) with some sort
of operative intervention, mostly laparoscopic. Subclinical bleeding, on the other
hand, occurs in up to 7.7% of cases [24] and is managed quite effectively in a conservative manner.
Although some studies concluded that buttressing didn’t produce a favorable
effect on bleeding following LSG [25, 26], most investigators, by far, agree that
buttressing of the staple line in LSG reduces bleeding compared to patients that
receive no buttressing [8, 12, 27–29]. Some studies showed more favorable results
for some types of buttressing materials against the others when it comes to bleeding [30, 31] but there were too many variables involved in those studies to support this finding. It is noteworthy that such a superiority was not reproduced in
several other similar studies. When compared to over sewing, the other technique
that reduces staple line bleeding in LSG, buttressing was found to produce similar,
or better, hemostatic outcomes without the inherent complications of over sewing,
namely longer operative time [12, 27] and stenosis of the sleeve tube lumen [32].
Over sewing was also found to be associated with a significantly higher rate of
post-operative nausea and vomiting to the point that it increased the duration of
S. Taha266
the symptoms during the first hours after surgery and prevented early oral intake
compared to buttressing [33].
Furthermore, buttressing of the staple line was reported not only to reduce the
rate of staple line bleeding itself directly, but also significantly reduced the number
of surgical clips required to achieve hemostasis [34, 35] and the overall rate of
post-LSG complications [6] including bleeding-related re-operation [29].
4 Buttressing for Leaks
Unlike bleeding, the role of buttressing in reducing the incidence of leak from the
staple line has been, for a long time, controversial. Several investigators reported
that buttressing the staple line didn’t improve the outcome when it came to leaks
[26, 36, 37]. There has been, however, growing evidence lately that buttressing
actually reduces the incidence of staple line leak in LSG, with an increasing number of researchers reporting a significant improvement in leak rates with buttressing of the staple line when compared to non-buttressing [6, 38–42].
5 Results from the MBSAQIP
One extremely controversial report that caused a lot of noise, when published in
2016, was the first report from the Metabolic and Bariatric Surgery Accreditation
and Quality Improvement Program (MBSAQIP) [43]. The researchers went
through the MBSAQIP data registry for 189,477 LSG cases that were performed
from 2012 to 2014, assessed the effect of various surgical techniques used in them
on the 30-day outcomes, and evaluated their impact on weight loss and comorbidities one year following the procedure. From that report, they were able to conclude that staple line reinforcement (SLR) was associated with an increased leak
rate. So many variables, however, were involved in the design of this study, which
questioned the credibility of this conclusion. More than 1600 surgeons, each with
their own different techniques and preferences, performed the procedures at 720
centers, each with their own different protocols and set up. Furthermore, a wide
range of different consumables were used by different surgeons\centers, making
it very difficult to identify the factor(s) that could have contributed to the relatively higher rate of leak reported in this study following LSG with SLR (0.96%)
compared to no SLR (0.65%). Strangely enough, the researchers reported that staple line leak was directly, and significantly, related to a bougie size; that is less
than 38 F (0.96%) compared to more than 38 F (0.80%), but they still managed
to contribute the higher incidence of leak to buttressing the staple line. It is worth
mentioning that a later, well-structured study of the MBSAQIP database proved
that this, rather surprising conclusion was actually unfounded. The researchers
went through the MBSAQIP Participant Use File data for 198,339 primary LSG
cases that were performed during the years 2015–2016, assessed all the variables
that were related to leak rate and used multiple bivariate analyses to evaluate the
Buttressing the Sleeve
30-day outcomes. They concluded that buttressing was associated with reduced
rates of bleeding and reoperations but not with a higher incidence of leak [29].
267
6 Previous Evidence
Cesana et al., in 2018, published the results of their analysis of the predictors of
leak in 1738 consecutive LSG procedures and concluded that buttressing of the
staple line significantly reduced the risk of bleeding (P < 0.05) [44]. Gagner and
Kemmeter studied the leak rate following LSG with 5 different staple line reinforcement methods though a systemic review of all the papers that were published
between 2012 and 2016 and concluded that buttressing was not only associated
with a lower rate of leak compared with no reinforcement, but also that its effectiveness was significantly better when compared to that of over-sewing or sealants
[45].
7 Conclusion
8 Types of buttressing materials that are coomercially
available (Fig. 3)
The main buttressing materials that are currently used in bariatric surgery are
(alphabetically):
– Neoveil, an absorbable polyglycolic acid felt; Gunze Medical. This is the mate-
rial that is used in Medtronic’s latest released “Pre-loaded” Reinforced car-
tridges with Tristapler technology.
– Peristrips Dry; permanent bovine pericardial strips; Baxter Healthcare
(Formerly Synovis)
– Peristrips Dry with Veritas; remodelable collagen matrix strips; Baxter
Healthcare (Formerly Synovis)
– Seamguard; a synthetic bioabsorbable glycolide trimethylene carbonate copoly-
mer; WL Gore & Associates.
– Surgisis Biodesign; Remodelable small intestinal submucosa strips that are
coated with fructose self-adhesive; Cook Medical.
However, it is important to note that very few direct comparisons of one material
to another have been reported. In one, nonrandomized, study, bovine pericardial
strips were compared with polyglycolide/trimethylene carbonate buttress material. This study found a significantly greater incidence of leaks in the latter group;
but importantly, the authors used the same stapler (3.5 mm staple height) in both
groups [46] and, because the polyglycolide/trimethylene carbonate product is significantly thinner than the bovine pericardial product, the increased leak rate may
S. Taha268
be attributable to their use of the same stapler with buttress materials of significantly different thicknesses.*
Other large series that compared essentially the same products reported contradicting outcomes with varying levels of evidence [31, 45]; Fig. 4.
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Sleeve and Ventral Hernias
Meshari Almuhanna and Wei-Jei Lee
1 Introduction
Obesity is a major risk factor for many metabolic diseases, including diabetes,
cardiovascular disease, sleep apnea, musculoskeletal disorders and some cancers.
The number of obese people is increasing worldwide; according to WHO since the
number of obese people nearly tripled [1]. Surgical treatment of Obesity (Bariatric
Surgery) is concomitantly increasing worldwide [2]. Bariatric surgeries that are
most commonly performed are laparoscopic sleeve gastrectomy (LSG) followed
by Roux-en-Y gastric bypass (RYGB) [3].
There is a strong association between developing ventral hernia and obesity
[4, 5]. Furthermore, obesity in itself also increases the risk and failure of ventral
hernia repair. Being obese and having ventral hernia makes performing bariatric
surgery a challenge. Can it be done in concomitant with LSG is the question. In
this chapter we will focus on what is the best approach for an obese patient with
ventral hernia who has chosen to undergo an LSG.
M. Almuhanna (*)
Bariatric & Metabolic Surgery Unit, Department of General Surgery, Jaber Al-Ahmad
Al-Sabah Hospital, Kuwait, Kuwait
e-mail: almuhanna@moh.gov.kw
M. Almuhanna · W.-J. Lee
Asia-Pacific Endoscopic Bariatric and Metabolic Surgical Center, Min-Sheng General
Hospital, Taoyuan, Taiwan
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2021
S. Al-Sabah et al. (eds.), Laparoscopic Sleeve Gastrectomy,
https://doi.org/10.1007/978-3-030-57373-7_29
271
M. Almuhanna and W.-J. Lee272
2 Prevalence, Incidence and Cost of Ventral Hernia
Ventral hernia (VH) is defined as an anterior abdominal wall fascia defect with
protrusion of internal content [6]. Incidence of VH is increased between the 3rd
and 6th decade of life and highest between 41–50 years of age. Incisional hernia and umbilical hernia are both the most common type of VH. Umbilical hernia is common in male (M:F – 1.5:1) where incisional hernia is more common in
females (F:M 2.3:1) [4]. It has also been proven that there is a significant association between smoking, alcohol, obesity and VH.
Obesity is a major risk factor for developing VH but the incidence of VH varies by location due to different etiological factors [4]. Incisional hernia is a common long-term complication of abdominal surgery with an incidence of 3–13% of
laparotomy incisions [5]. Priti Prasad et al. reported a series of 200 cases of VH
of hospital admissions and found the most common type to be incisional hernia
(41%) followed by umbilical (32%), paraumbilical (17%) and epigastric (10%) [4].
In another report, Jaykar, R.D. et al. also found that the most common VH is incisional hernia with an incidence of 41% of hospital admission [5]. Infra-umbilical
incisional hernia (42%) was the most common site of incisional hernia followed by umbilical incisional hernia (32%). He found the mean age of VH to be
41 years of age, with male to female ratio 1:1.9. Other than obesity, constipation
was the major predisposing risk factor of developing VH. They also noticed that
small defects (<2 cm) presented early with complication [5]. Poulose BK et al.
found the number of inpatient VH repairs (VHR) in the United States increased
from 126,548 in 2001 to 154,278 in 2006. Furthermore, an estimate of 348,000
outpatient VHRs were done in 2006 [7]. This is burden on healthcare systems,
although the majority of cases were performed as an emergency [8]. The cost of
VHR for 2006 in US was $3.2 billion. Incidence of VHR is rising, and by reducing
the recurrence rate alone, it would save $32 million dollar in the US alone for each
1% reduction in operation [7]. Raquel Maia et al. in their review article, confirmed
that obesity alone is a risk factor for both primary and incisional hernia. Further,
obese individuals are at a high risk of having co-morbidities which significantly
increase the risk of perioperative complications and recurrence rates of VHR [9].
In addition, there is a positive correlation between the size of the hernia defect
and obesity: the higher the body mass index (BMI), the bigger the defect size [9].
Similarly, the recurrence rate is also higher in obese people with a higher BMI [9,
10]. Furthermore, obesity itself is an independent risk factor of longer hospital stay,
surgical site infection, recurrence and re-admission after VHR [11, 12].
3 Diagnosis and Classification of Ventral Hernia
in Obese Patients
The clinical presentation of ventral hernias varies depending on the size and
location of the hernia and weather it is symptomatic (pain, bulge, discomfort) or
asymptomatic. A complete history and physical examination are very important
Sleeve and Ventral Hernias
273
for obese patients with ventral hernias. In non-obese patients, ventral hernia can be
easily diagnosed but in obese patients it usually requires additional imaging studies to diagnose. Murphy KP et al. found in his study that physical examination of
obese patients with suspected ventral hernia are difficult to diagnose and the best
modality for diagnoses is to do abdominopelvic computed tomography (CT) [13].
It helps identifying the hernia site, size and the content of the hernia sac in both
acute and elective circumstances (Figs. 1 and 2).
In classification of VH, they are classified into primary abdominal wall hernia and incisional hernia bases on the recommendation of the European Hernia
Society (EHS) classification [14, 15].
4 Primary Abdominal Wall Hernia
The classification of primary abdominal wall hernia is based on localization and
size of the hernia (Table 1).
Fig. 1 CT scan of obese patient with ventral hernia showing omental content without sign of
complication