Delayed elective ventral hernia repair may increase risk in patients with obesity

Access to elective ventral hernia repair is often limited for patients with obesity due to presumed higher risks of recurrence and complications. We hypothesize that higher BMI alone does not increase the risk of recurrence, and that delayed access may lead to worse outcomes.

A retrospective cohort of 11,979 index ventral hernia repairs performed by 200 surgeons across 30 facilities (2017-2025) within a single system. The primary endpoint was reoperation for recurrence; secondary patient-centered outcomes included urgent presentation, length of stay (LOS), and 30-day readmission. Mixed-effects multivariable survival models were used to estimate hazard ratios (HRs).

Compared to BMI 20-25 kg/m², BMI > 25 kg/m² was associated with a higher reoperation hazard (HR 2.50, p < 0.001); however, incremental risk hazard attenuated beyond BMI 25 kg/m². Median follow-up was 3.6 years, with 546 reoperations occurring (50% within 417 days). For index procedures, surgical approaches were 63% open, 19% laparoscopic, and 17% robotic, with conversion-to-open rates of 11.3% (laparoscopic) and 5.0% (robotic) (p < 0.001). Independent predictors of a higher reoperation hazard included emergency admission (HR 2.03, p = 0.04), elective inpatient procedures (HR 2.18, p < 0.001), inpatient procedures (HR 1.75, p = 0.03) versus outpatient procedures, and bowel resection (HR 1.80, p = 0.017). Protective factors included umbilical hernia (HR 0.63, p < 0.001) and mesh use (HR 0.70, p = 0.027). There was no difference in recurrence between robotic and laparoscopic approaches. BMI ≥ 35 kg/m² predicted urgent presentation (OR 1.45 ± 0.11, p < 0.001) but was not associated with longer LOS or increased readmission.

Beyond a BMI of 25 kg/m², increasing BMI was not associated with progressively higher recurrence risk. Adverse outcomes in patients with obesity appear more strongly related to delayed access and unplanned presentation than to BMI alone.