Preoperative Optimization Before Ventral Hernia Repair: A Systematic Review and Meta-analysis

Background: Obesity is associated with an increased risk of ventral hernia development and recurrence rates after ventral hernia repair (VHR). The metabolic derangements caused by obesity can also lead to many postoperative complications. Therefore, it is a common practice to attempt weight loss before VHR. However, there is still no consensus on optimal preoperative management for obese patients with a ventral hernia. This study aims to perform a meta-analysis to evaluate the effect of preoperative weight optimization on VHR outcomes. Methods: We performed a literature search of PubMed, Scopus, and Cochrane Library databases to identify studies comparing obese patients who underwent surgical or non-surgical weight loss interventions before undergoing hernia repair surgery to obese patients who underwent hernia repair surgery without prehabilitation. Postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I-2 statistics. Results: One thousand six hundred nine studies were screened and 13 were thoroughly reviewed. Five studies comprising 465 patients undergoing hernia repair surgery were included. No differences in hernia recurrence [odds ratio (OR) 0.66; 95% CI 0.23-1.89; P = 0.44; I-2 = 20%], seroma (OR 0.70; 95% CI 0.25-1.95; P = 0.50; I-2 = 5%), hematoma (OR 2.00; 95% CI 0.5-7.94; P = 0.45; I-2 = 0%), surgical site infection (OR 1.96; 95% CI 0.52-7.40; P = 0.32; I-2 = 0%), and overall complication (OR 0.80; 95% CI 0.37-1.74; P = 0.58; I-2 = 40%) rates were noted when comparing patients who underwent a preoperative weight loss intervention (prehabilitation or bariatric surgery) versus those who did not. In the subgroup analysis of patients who underwent bariatric surgery, we found no difference in hernia recurrence (OR 0.64; 95% CI 0.12-3.33; P = 0.59; I-2 = 41%) or overall complications (OR 1.14; 95% CI 0.36-3.64; P = 0.82; I-2 = 64%). In the subgroup analysis of patients who lost weight versus patients who did not, there was no significant difference in overall complication rates (OR 0.86; 95% CI 0.34-2.21; P = 0.76; I-2 = 55%). Conclusions: We found similar hernia recurrence, seroma, hematoma, and surgical site infection rates in patients who underwent preoperative optimization. These findings underline the need for prospective studies to define the optimal role of preoperative optimization and weight loss in obese patients undergoing ventral hernia repair.