A PROSPECTIVE RANDOMIZED STUDY OF SUBFASCIAL VERSUS PREFASCIAL POLYPROPYLENE MESH REINFORCEMENT OF MIDLINE WOUND CLOSURE AFTER VERTICAL BANDED GASTROPLASTY IN MORBID OBESE PATIENTS

Background: Incisional hernia is a common problem following a midline vertical incision in all patients undergoing 
open bariatric procedures. 
Patients and methods: The present study was conducted on 30 morbid obese patients who underwent vertical banded 
gastroplasty (VBG) operation through upper midline incision. The patients were randomly divided into three groups. Group I: Patients for whom the midline abdominal incisions were reinforced by subfascial preperitoneal polypropylene mesh before closure of the linea alba. Group II: The midline abdominal incisions were reinforced by prefascial subcutaneous polypropylene mesh after closure of the linea alba. Group III: The linea alba was closed en-mass with continuos polypropylene No 1 sutures (standard closure). 
Results: The mean age was 30.4 years. Twenty-four patients were females (80%) and six were males (20%). The mean body mass index was 45.4kg/m2. The commonest associated medical conditions were, osteoarthritis detected in 18 patients (60 %), hypertension in 17 patients (56.7%), type II diabetes mellitus in 15 patients (50%). Most of the patients presented with more than one associated medical condition as, osteoarthritis & hypertension. The mean time of incision closure was 36 minutes in group I, 31 minutes in group II and 15.4minutes in group III. Early postoperative wound complications were, superficial wound infection in one patient of group I(10%), in 3 patients of group II(30%) and in one patient of group III(10%) . Partial wound disruption in 2 patients of group II(20 %) and in one patient of group III(10%). Subcutaneous seroma in one patient of group I(10%), 3 patients of group II(30%) and one patient of group III (10%). During the period of follow up (mean of 22 months), chronic pain at the scar site was reported in 2 patients of group I(20%), 3 patients of group II(30%) and one patient of group III(10%). Incisional hernia reported in 3 patients of group III(30%). 
Conclusion: The subfascial placement of the mesh has many advantages over prefascial position, as, the possibility of bowel obstruction or fistula formation is not present, likewise, the risks of seroma and wound infection were minimized. The subfascial technique also does not initiate adhesions between the subcutaneous tissue and rectus sheath with subsequent difficult dissection during late dermolipectomy if needed. Subfascial placement of the mesh is a very simple technique and is recommended as an ideal method for closure of the midline abdominal incisions in morbid obese patients.