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Pak J Med Sci September - October 2022 Vol. 38 No. 7 www.pjms.org.pk 1776
INTRODUCTION
The umbilicus is one of the potential weak areas
of the abdomen. Umbilical hernia is a common dis-
ease and it represents 10% of all abdominal wall
hernias.1 Obesity is an important health challenge in
the world.2,3 and it is one of the major causes of in-
creased intra-abdominal pressure which may result
in developing an umbilical hernia.4
Obese patients are prone to developing abdomi-
nal wall hernias with/without all potential compli-
cations. A number of studies have found an associa-
tion between operative difculty in obese patients5
and post-operative complications.6 Recent stud-
ies have identied the impact of body mass index
(BMI) on open and laparoscopic hernia surgery.7
Although, abdominal obesity is more important
measure of central abdominal fat and is a better pre-
dictor of morbidity,8 but no study has explored the
effect of abdominal obesity on the outcome of hernia
surgery. Abdominal obesity is the accumulation of
visceral fat resulting in an increase in waist size and
it is an indication of adverse metabolic outcomes in-
dependent of body mass index. The absolute waist
circumference (>102 centimeters in men and >88
centimeters in women) are used as parameters of
abdominal obesity.9
1. Dr. Abdulrahman Saleh Al-Mulhim, FRCSI, FICS, FACS.
Professor of Surgery,
2. Dr. Abdul Qadeer Memon, FCPS, FICS.
Assistant Professor of Surgery
1,2: Department of Surgery,
King Faisal University College of Medicine,
Al-Ahsa 31982, Kingdom of Saudi Arabia.
Correspondence
Dr. Abdul Qadeer Memon, FCPS, FICS.
Assistant Professor of Surgery
King Faisal University College of Medicine,
Hofuf, P.O. Box. 400, Al-Hassa 31982
Kingdom of Saudi Arabia.
Email: drqadeermemon@yahoo.com
* Received for Publication: April 10, 2022
* 1st Revision Received: June 27, 2022
* 2nd Revision Received: August 17, 2022
* Final Revision Accepted: August 30, 2022
Original Article
Laparoscopic Umbilical Hernia repair in
male patients with abdominal obesity
Abdulrahman Saleh Al-Mulhim1, Abdul Qadeer Memon2
ABSTRACT
Objective: Obesity is a global health problem, and obese patients are subject to developing abdominal
wall hernias. There are few prospective studies comparing the laparoscopic method of umbilical hernia
mesh repair between abdominal obesity patients and normal abdominal waist patients. The aim of this
study was to evaluate the short-term outcomes (operative time, early complications and hospital stay) in
the patients having laparoscopic hernia repair with abdominal obesity.
Methods: This prospective cohort study was conducted at King Fahad Hospital Hofuf, Kingdom of Saudi
Arabia from June 2014 to June 2021. Fifty four (54) adult male patients with umbilical hernia were included
in this study. The patients were divided into two groups: Group-A: Patients with abdominal obesity (n=26),
and Group-B: Patients without abdominal obesity (n=28). All the patients underwent laparoscopic repair
of umbilical hernia. The patients with abdominal obesity were dened as those having an abdominal girth
more than 102 centimeters.
Results: No signicant differences were observed as related to age, co-morbidity and risk factors between
the two groups. The statistically signicant difference between the two groups observed was related to the
mean operative time and the mean hospital stay.
Conclusion: Laparoscopic umbilical hernia repair can be safely performed in abdominal obesity in male
patients without an additional risk of complications.
KEYWORDS: Umbilical hernia, Obesity, Laparoscopic repair.
doi: https://doi.org/10.12669/pjms.38.7.6470
How to cite this:
Al-Mulhim AS, Memon AQ. Laparoscopic Umbilical Hernia repair in male patients with abdominal obesity. Pak J Med Sci.
2022;38(7):1776-1779. doi: https://doi.org/10.12669/pjms.38.7.6470
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abdulrahman Saleh Al-Mulhim et al.
Pak J Med Sci September - October 2022 Vol. 38 No. 7 www.pjms.org.pk 1777
Our objective was to evaluate the short-term out-
comes (operative time, early complications, and
hospital stay) of laparoscopic hernia repair in pa-
tients with abdominal obesity.
METHODS
This prospective cohort study was conducted at
King Fahad Hospital Hofuf, Saudi Arabia from June
2014 to June 2021. The approval was got from the Re-
search Ethics Committee of the King Faisal Univer-
sity College of Medicine (Ref No.: 2020-05-24, dated
August 31, 2020). Fifty-four adult male patients with
uncomplicated umbilical hernias were included in
this study. The demographic data and outcome of
the surgery of every patient were recorded in SPSS-
22. The data included were age, clinical presentation,
American Society of Anesthesiologists (ASA) score, co-
morbidity, size of the defect of umbilical hernia, anes-
thetic duration, operative time, intraoperative compli-
cations, post-operative complications, post-operative
pain, length of hospital stay, return to normal activity
and recurrences. The results were expressed as mean,
± standard deviation and the statistical signicance
difference as p-value < 0.01. WHO classication was
used for dening obesity (BMI=30kg/m2). The abso-
lute waist circumference (>102 centimeters) was used
for dening abdominal obesity.12,13 The waist circum-
ference was measured at a level midway between the
lowest rib and the iliac crest using the measuring tape.
Fifty four patients with umbilical hernias were
divided into two groups depending upon waist cir-
cumference i.e. the abdominal obesity as a risk fac-
tor of possible complications: Group-A: Patients with
abdominal obesity (n=26), and Group-B: Patients
without abdominal obesity (n=28). All the patients
underwent laparoscopic repair. The diagnosis of um-
bilical hernia was based on detailed clinical history,
physical examination, and the necessary radiologi-
cal investigations (ultrasound/computed scan). Base
line and specic investigations for pre-anesthesia as-
sessment were carried out. A preoperative abdomi-
nal CT-scan without contrast was routinely used in
all patients to determine the abdominal obesity.
Surgical procedure: The laparoscopic repair was per-
formed under general anesthesia using a technique as
originally reported for ventral hernias.10,11 The patients
were placed on operation table in a supine position
with both arms along the body, the surgeon at the left
of the patient and the screen opposite to the surgeon.
The pneumoperitoneum was made at 14 mmHg, es-
tablished by veress needle introduced at Palmer’s
point, which is a point 3cm below the left costal mar-
gin in the left mid-clavicular line. A 10mm, 30 optical
cameras through 10mm trocar and other two 5mm tro-
cars were placed as far away as possible from the her-
nia defect. The laparoscopic procedure was started by
inspection of whole abdominal cavity. The adhesions
surrounding the hernia defect, if found, were divided
and the hernia contents were reduced. The mesh was
measured with the abdomen deated (the pneumop-
eritoneum at 8mmHg), allowing at least 5cm overlap
beyond the borders of the fascial defect and applying
knot with prolene suture at the four corners of the
mesh. The mesh was hydrated by normal saline, rolled
with the lm inside and introduced into the abdomi-
nal cavity. A tiny stab skin incision was performed at
four cardinal points, to pull each prolene knot of the
mesh to stick it to the abdominal wall and x it with
absorbable tack by creating a double rounded ring. At
the end, the abdomen was deated under direct vision
and the fascial defect of 10mm trocar was closed. A
single dose of intravenous injection of broad-spectrum
antibiotic was administered at the induction of anes-
thesia, followed by two postoperative doses. Deep
vein thrombosis prophylaxis measures were taken in
all the patients. These included the injection Clexane
40mg subcutaneously before operation and continued
till the patients were discharged from the hospital, in-
termittent pneumatic compression device during the
operation and encouraging early mobilization when
the patients were fully awake.
The number of days of stay at the hospital was
counted as the number of nights the patients were in
the hospital postoperatively. Patients were allowed
to take oral meals postoperatively after recovering
from anesthesia. Patients were discharged when they
were symptomatically better and advised to perform
their routine daily activities. Post-operative pain and
severity of pain was assessed daily during hospital
stay using Visual Analogue pain Scale (VAS). The
patients were followed-up at one, three, six and 12
months intervals after operation and evaluated for
any complications and recurrences.
RESULTS
Fifty four male adult patients with umbilical her-
nia underwent laparoscopic hernia repair. They were
divided into two groups: Group-A: Patients with ab-
dominal obesity (n=26), and Group-B: Patients without
abdominal obesity (n=28) (Table-I). The overall mean
age of the study sample was 39.4 ±3.2 years (range: 26-
53). In Group-A, it was 38.9 ±8.8 years (range: 27-53
years) and in Group-B it was 39.5 ±4 years (range: 26-
51 years). The mean waist circumference of Group-A
patients was 117 cm, and that of Group-B was 79 cm.
The mean BMI of Group-A was 36.3 and Group-B was
31.4. Group-A patients had more medical co-morbid-
ities than Group-B. The diabetes mellitus and hyper-
tension were present in 11.5%, and 3.8% in Group-A as
compared to 7.1%, and 3.6% in Group-B respectively.
There was no difference between the groups in terms
of the American Society of Anesthesiologists (ASA)
Pak J Med Sci September - October 2022 Vol. 38 No. 7 www.pjms.org.pk 1778
score. The mean symptomatic period of Group-A was
13 ± 1.1 months and the Group-B was 8 ±2.4 months.
The defect size ranged between 2.3 cm and 9.6 cm and
larger hernias were observed in Group-A as compared
to Group-B.
All the patients were operated laparoscopically
with a three-port approach. None were converted to
open surgery and no intra-abdominal drains were
placed. The mean operating time of Group-A was
75.4 minutes, while that of Group-B was 66.5 min-
utes. Hospital stay was two to ve days (mean 3.3
days) in the Group-A and 2 to 4 days (mean was 2.9
days) in the Group-B. The mean of the post-operative
pain (visual analogue scale) after six hours of the op-
eration was similar in both groups i.e., 4.6 and 4.5 in
Group-A and Group-B respectively, but Group-A pa-
tients experienced more pain (mean pain score six)
and movement limitations as compared to Group-B
(mean pain score 4.5) during overall hospital course.
During the follow-up period, there were no differ-
ences in pain and movements. The patients in both
the groups were able to return to their routine activi-
ties by the 2nd week of the operation.
Three (11.5%) patients developed postoperative se-
roma between the prosthetic mesh and the abdomi-
nal wall and one (3.8%) small hematoma in Group-
A, whereas two (7.1%) postoperative seroma and no
hematoma in Group-B. All these patients were man-
aged conservatively (Table-II).
Follow-up involved a physical assessment, ultra-
sound examination if needed at the outpatient clinic
after one week, followed by monthly assessment for
the rst six months, then every three months up to the
end of the study. The mean length of follow-up was
16±8 months (range: 12 – 30 months). No recurrence of
the umbilical hernia was observed in all the patients.
DISCUSSION
Generalized obesity and abdominal obesity i.e., in-
tra-abdominal fat accumulation is considered as ma-
jor health problem worldwide.8 Waist circumference
is now a standard for the diagnosis of metabolic syn-
drome (abdominal fat and its metabolic consequenc-
es) and the average waist circumference is increasing
globally.9,12
The complications observed in open repair of
umbilical hernia with mesh, enforces to adopt lap-
aroscopic technique and this approach is gaining
popularity all over the world. Since the rst report
of laparoscopic ventral hernia repair in 1993 by Le
Blanc K et al,10 this is the rst prospective study to
our knowledge that explores the outcome of laparo-
scopic umbilical hernia repair in patients with ab-
dominal obesity.
Table-I: Demographic data.
Characteristic Group-A Group-B p-value
No. of Patients 26 28 > 0.01
Mean Age (rang) year 38.9 ±8.8 (27-53) 39.5 ±4 (26-51) > 0.01
Mean waist circumference (cm) 117 79 < 0.01
Mean BMI (rang) 36.3 (31.4 – 39.7) 31.4 (26.8 – 32.9) < 0.01
Co-morbidities
• Diabetes 11.5% 7.1% > 0.01
• Hypertension 3.8%) 3.6%
Mean symptomatic period 13 ±1.1 8 ±2.4 < 0.01
Mean defect size (cm) (rang) 5.6 (4.5 – 9.6) 4.2 (2.3 – 4.7 ) < 0.01
Table-II: Operative data.
Variable Group-A Group-B p-value
Mean Anesthetic time (minutes) 98.6 77.3 < 0.01
Mean Operating time (minutes) 75.4 66.5 < 0.01
Mean Post-operative pain score at 6 hours 4.6 4.5 > 0.01
Mean Post-operative pain at 24 hours (VAS) 6 4.5 > 0.01
Mean Hospital stay (range) days 3.3 (2 – 5) 2.9 (2 – 4) > 0.01
Mean Return to daily activities (days) 8 9 > 0.01
Mean Return to work (day) 21 19 > 0.01
Post-operative Complications:
• Seroma 3 2 > 0.01
• Hematoma 1 0 > 0.01
• Prolonged ileus 1 0 > 0.01
Laparoscopic Umbilical Hernia repair in abdominal obesity
Pak J Med Sci September - October 2022 Vol. 38 No. 7 www.pjms.org.pk 1779
Previous studies showed the negative impact of
obesity on surgical outcomes generally6,13,14 and they
described obesity as a risk factor for the development
of umbilical hernias as well as for recurrence and
complications after hernia repair.15 However, to our
knowledge, this is the one among very few studies
to examine the effect of abdominal obesity as dened
by abnormal waist circumference on the outcome of
patients undergoing laparoscopic umbilical hernia
repair. Many published series showed that the obese
patients in general are more likely to have longer sur-
gery duration as compared to the patients with normal
weight for a number of reasons.16 In this study, it is
observed that the mean BMI in the abdominal obesity
patients (Group-A) is more than Group-B (Table-I)
and they had a longer duration of operation as com-
pared to Group-B. We think that the increased dura-
tion of operative time is due to the following reasons.
Introducing the trocars is difcult due to the excess
adiposity and to overcome this problem, we used the
bladeless optical trocars. Secondly, the excess of intra-
abdominal fat in obese patients make mobilization of
the bowel and handling the mesh intra-peritoneally a
complicated task. To resolve this issue, more time was
spent to prevent any complication. This is consistent
with the results of many similar studies and the over-
all rate of complications was similar in both groups
in these studies.17 Moreover, the incidence of seroma
formation was low as compared to other studies18 and
no recurrence was observed.
The mean duration of post-operative ileus was 16.3
hours in Group-A patients, while it was 15.9 hours in
Group-B. One (3.8%) patient in the Group-A suffered
from prolonged ileus (36 hours), and this is consist-
ent with the results of many reports claiming pro-
longed ileus in 1 to 3% of laparoscopic ventral hernia
repairs.19-21 Group-A patients experienced more pain
(mean pain score 6) and movement limitations as
compared to Group-B (mean pain score 4.5) during
hospital course, but there were no differences during
the follow-up period. However, a prospective study
conducted in Pakistan showed better overall results
of laparoscopic para-umbilical hernia repair as com-
pared to the conventional open technique.22
Limitation: The limitation of the study is that it was
done in male patients only.
CONCLUSION
Though the laparoscopic umbilical hernia repair is
more challenging in patients with an abnormal waist
circumference, yet it is feasible. Patients with an ab-
dominal obesity have longer anesthetic and operative
time but have a similar complication prole as com-
pared to the patients without abdominal obesity.
Grant support & nancial disclosures: None.
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Authors’ Contribution:
Al-Mulhim AS: Analyzed, edited, reviewed and
finally approved the manuscript.
Memon AQ: Searched and collected the data, ana-
lyzed and wrote the manuscript, he is also respon-
sible for the accuracy of study.
Abdulrahman Saleh Al-Mulhim et al.
