Hernia Repair in Severe Obesity Shows Low Short-Term Risk but Higher-Than-Expected Recurrence

Minimally invasive ventral hernia repair in patients with class III obesity carries reassuringly low short-term morbidity, but a new single-center study reports a mid-term radiologic recurrence rate of 17.3 percent that the authors say should not be characterized as low. The retrospective cohort, conducted at Montefiore Medical Center in the Bronx and published in the Journal of Abdominal Wall Surgery, followed 52 consecutive adults with a body mass index of at least 40 kilograms per square meter who underwent predominantly laparoscopic or robotic hernia repair between January 2012 and December 2024. Every patient had at least one postoperative computed tomography scan, allowing the team to detect hernia failures that physical examination alone would likely have missed.

The question the study addresses is one of the most contested in abdominal wall surgery. Obesity is a well-established driver of hernia formation and recurrence, because excess body mass raises intra-abdominal pressure, strains the abdominal wall, and impairs wound healing. Many surgeons defer elective repair above a BMI threshold, commonly 35 kilograms per square meter, despite the absence of universally accepted guidance for patients with class II or III obesity. That deferral strategy aims to reduce perioperative risk, but it can delay care in symptomatic patients, and prior research suggests that patients who are turned away often fail to return for elective repair and instead present emergently, when complication rates are nearly doubled.

Minimally invasive techniques have changed this calculus. Compared with open repair, laparoscopic and robotic approaches are associated with fewer wound complications, less postoperative pain, and shorter hospital stays. The Montefiore team used a deliberately heterogeneous mix of techniques reflecting routine academic practice: intraperitoneal onlay mesh with defect closure was the predominant operation, performed in 27 of 52 patients, followed by primary closure without mesh, intraperitoneal onlay mesh without closure, robotic enhanced-view totally extraperitoneal repair, and a small number of other approaches. Laparoscopy was used in 43 patients and robotic assistance in 9. Mesh was placed in 41 patients, with a median mesh-to-defect area ratio of 12.1, and four procedures required conversion to open or planned hybrid operations.

The cohort itself was high-risk by any measure. Mean preoperative BMI was 45.0 kilograms per square meter, 80.8 percent of patients were female, and most were American Society of Anesthesiologists class III. Diabetes was present in 46.2 percent, chronic obstructive pulmonary disease in 19.2 percent, and more than a quarter had prior bariatric surgery. Recurrent incisional hernia was the most common classification, accounting for 40.4 percent of cases, with incisional hernias making up another 30.8 percent and primary hernias 28.8 percent. Rectus diastasis, a widening of the midline abdominal muscles, was documented in 92.9 percent of patients with available imaging data.

On the primary endpoint, radiologic hernia recurrence occurred in 9 of 52 patients, or 17.3 percent, with a 95 percent confidence interval of 9.4 to 29.7 percent, at a median imaging follow-up of 793 days. The median interval from repair to the CT scan documenting recurrence was 1208 days, meaning clinically meaningful failures continued to accrue well beyond the first postoperative year. Short-term outcomes were far more favorable: the 30-day complication rate was 11.5 percent, comprising four seromas, one surgical site infection, and one abdominal wall abscess. When the analysis was broadened to include any radiologic recurrence, hernia or diastasis, the rate rose to 37.3 percent of evaluable patients, and clinical recurrence was documented in half of the 20 patients with physical examination follow-up.

The most striking pattern was a stepwise concentration of recurrence by hernia phenotype. Not a single primary hernia recurred, zero of 15, while recurrence occurred in 2 of 16 incisional hernias, 12.5 percent, and 7 of 21 recurrent incisional hernias, 33.3 percent, a difference that reached statistical significance. When primary hernias were excluded, the recurrence rate climbed to 24.3 percent. The authors frame this gradient through the vicious cycle model of ventral hernia repair, in which each successive operation leaves the abdominal wall more scarred, less vascularized, and structurally weaker, so that every subsequent repair attempt carries a progressively higher risk of failure. Under this framework, recurrent incisional hernia is not simply a more severe variant of incisional hernia but a distinct risk state shaped by the cumulative physiological toll of prior surgery, independent of BMI.

Perhaps the most unexpected finding concerned postoperative weight. Patients who developed recurrence lost significantly more weight than those who did not, a mean of 15.6 percent of total body weight versus 4.6 percent, and all nine patients with recurrence lost weight during follow-up, while 44.2 percent of patients without recurrence maintained or gained weight. The most recent BMI was lower in the recurrence group, 36.0 versus 42.6 kilograms per square meter. The authors offer a plausible mechanical explanation: substantial weight reduction alters abdominal wall mechanics and reduces tension across the repair, potentially destabilizing the mesh-tissue interface, and prior work has shown that weight change significantly impacts intra-abdominal and hernia volumes. But they are careful to note that three alternative interpretations cannot be excluded. Reverse causation is possible, since patients with subclinical recurrence may experience altered abdominal wall integrity, caloric intake, or activity that drives weight change rather than the reverse. Ascertainment bias is also possible, because patients who lose weight may be more likely to undergo repeated imaging, increasing the probability of detecting otherwise occult recurrence. And the use of most recent weight rather than a standardized timepoint may inflate between-group differences if recurrence status correlates with the duration or intensity of clinical observation.

Technical variables told a quieter story. Neither operative technique, mesh fixation method, closure suture type, posterior sheath closure, nor the mesh-to-defect area ratio demonstrated a statistically significant association with recurrence, and no patient who underwent concomitant diastasis repair developed a hernia recurrence, though only five such repairs were performed. The authors stress that these null findings should not be read as evidence that technical factors do not influence durability; with only nine events, the study was underpowered to detect such associations, and a signal for male sex, at 44.4 percent versus 14.0 percent of the recurrence and non-recurrence groups, approached but did not reach significance. All nine recurrences occurred in patients who underwent laparoscopic repair, and none among the nine robotic cases, a descriptive observation the team presents without formal inference.

The authors situate their recurrence estimate against a literature that has generally been more reassuring. An ACS-NSQIP analysis found that only a BMI of 50 or higher was independently associated with complications after minimally invasive ventral hernia repair, and a systematic review and meta-analysis of 11 studies and 3,199 patients found no significant differences in recurrence, seroma, or surgical site infection rates among patients with BMI above 40 undergoing minimally invasive repair. The higher rate observed here is likely attributable to several cohort-specific factors: prolonged and non-standardized imaging follow-up, with some patients scanned beyond three years; a high proportion of incisional and recurrent incisional hernias, 71.2 percent of the cohort; and the use of radiologic rather than clinical recurrence as the primary endpoint, which is expected to capture asymptomatic and subclinical failures. Population-based data with complete follow-up show that reoperation for recurrence after elective incisional hernia repair continues to accrue throughout five years of observation, so the 17.3 percent figure is best regarded as a lower bound on what longer, protocol-driven surveillance would reveal.

The study’s limitations are substantial and the authors are unusually candid about them. With 52 patients and nine events, all comparisons are unadjusted and exploratory, and confounding by unmeasured variables cannot be excluded. Restricting inclusion to patients with postoperative imaging may have introduced selection bias, since clinicians may have preferentially ordered CT scans in symptomatic patients, potentially inflating the observed recurrence rate. All procedures were performed by attending surgeons within a single high-volume division of minimally invasive and bariatric surgery, whose expertise in operating on patients with severe obesity likely exceeds that of general surgeons in most practice settings, so the low short-term morbidity may reflect concentrated subspecialty expertise rather than the safety of the approach at this BMI threshold more broadly. The team calls for prospective multicenter studies with protocol-driven imaging at prespecified intervals, standardized weight timepoints, and dedicated evaluation of abdominal wall biomechanics, including the apparent signal associated with concomitant diastasis repair. Until such data exist, the findings are hypothesis-generating: repair in class III obesity appears feasible with low perioperative risk, but mid-term durability, particularly in patients whose abdominal walls have already been scarred by prior surgery, remains an open question that BMI thresholds alone cannot answer.

Subject of Research: Surgery

Article Title: Radiologic recurrence after minimally invasive ventral hernia repair in patients with class III obesity: a single-center retrospective cohort study

Article References: Ahmed, A., Khalid, F., Sadeghi, A., Rodriguez Valladares, M., Flores, M., Loja Pauta, V., Alas-Pineda, C., & Mandujano, C. C. (2026). Radiologic recurrence after minimally invasive ventral hernia repair in patients with class III obesity: a single-center retrospective cohort study. Journal of Abdominal Wall Surgery, 5, Article 17051. https://doi.org/10.3389/jaws.2026.17051

Image Credits: AI Generated

DOI: 10.3389/jaws.2026.17051

Keywords: hernia recurrence, minimally invasive surgery, obesity, ventral hernia repair, weight loss, Radiologic, recurrence, minimally, invasive, ventral, hernia, repair