Abdominal Wall Hernia After Metabolic and Bariatric Surgery: A Narrative Review

Abdominal wall hernias, including incisional and trocar site hernias (TSHs), represent a significant clinical challenge in the field of metabolic and bariatric surgery (MBS). Morbid obesity is a potent risk factor for fascial defects due to chronically elevated intra-abdominal pressure and impaired wound healing mechanisms. This narrative review explores the incidence, risk factors, and management strategies for hernias in the bariatric population. Evidence indicates that ventral hernias are prevalent in 8% to 20% of MBS candidates. Furthermore, TSH incidence is substantially higher in bariatric patients-reaching up to 34% to 40% in prospective studies-compared to general laparoscopic cohorts, where rates typically range from 0.1% to 1.5%. Management involves a strategic balance between concurrent and staged repair; while concurrent repair of small defects is safe, it is associated with a higher mesh infection rate (3.6%) compared to staged approaches (1.9%). However, the use of synthetic mesh remains essential to reduce recurrence rates from 25.7% to 1.1%. Prevention hinges on safe primary access techniques, such as Palmer's point or optical trocars, and meticulous fascial closure of larger ports, especially at specimen extraction sites where hernia rates can reach 22.4%. Meticulous management of modifiable comorbidities like diabetes and smoking is also vital to minimize 30-day wound morbidity. In conclusion, a high index of suspicion for TSH and a tailored approach to hernia repair are necessary to optimize long-term surgical outcomes in bariatric patients.