Obesity Increases the Odds of Acquiring and Incarcerating Noninguinal Abdominal Wall Hernias

BRIANA LAU, M.D., HANJOO KIM, M.S., PHILIP I. HAIGH, M.D., M.SC., TALAR TEJIRIAN, M.D.

From the Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
The current data available describing the relationship of obesity and abdominal wall hernias is sparse. The objective of this study was to investigate the current prevalence of noninguinal abdominal wall hernias and their correlation with body mass index (BMI) and other demographic risk factors. Patients with umbilical, incisional, ventral, epigastric, or Spigelian hernias with or without incarceration were identified using the regional database for 14 hospitals over a 3-year period. Patients were stratified based on their BMI. Univariate and multivariate analyses were performed to distinguish other significant risk factors associated with the hernias. Of 2,807,414 patients, 26,268 (0.9%) had one of the specified diagnoses. Average age of the patients was 52 years and 61 per cent were male. The majority of patients had nonincarcerated umbilical hernias (74%). Average BMI was 32 kg/m2. Compared with patients with a normal BMI, the odds of having a hernia increased with BMI: BMI of 25 to 29.9 kg/m2 odds ratio (OR) 1.63, BMI of 30 to 39.9 kg/m2 OR 2.62, BMI 40 to 49.9 kg/m2 OR 3.91, BMI 50 to 59.9 kg/m2 OR 4.85, and BMI greater than 60 kg/m2 OR 5.17 (P \ 0.0001). Age older than 50 years was associated with a higher risk for having a hernia (OR, 2.12; 95% [CI], 2.07 to 2.17), whereas female gender was associated with a lower risk (OR, 0.53; 95% CI, 0.52 to 0.55). Those with incarcerated hernias had a higher average BMI (32 kg/m2 vs 35 kg/m2; P \ 0.0001). Overall, BMI greater than 40 kg/m2 showed an increased chance of incarceration, and a BMI greater than 60 kg/m2 had the highest chance of incarceration, OR 12.7 (P \ 0.0001). Age older than 50 years and female gender were also associated with a higher risk of incarceration (OR, 1.28; 95% CI, 1.02 to 1.59 and OR, 1.80; CI, 1.45 to 2.24). Increasing BMI and increasing age are associated with a higher prevalence and an increased risk of incarceration of noninguinal abdominal wall hernias.

with 33.8 per cent of the U.S. population being obese and 68 per cent O being either overweight or obese according to 2007 to
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2008 National Health and Nutrition Examination Survey data.1 Obesity is commonly associated with diabetes mellitus, cardiovascular disease, nonalcoholic fatty liver disease, and sleep apnea,2 but few current studies have investigated the relationship between obesity and ventral hernias. Interestingly, a study examined U.S. patients with inguinal hernias and found there to be an inverse correlation between body mass index (BMI) and inguinal hernia formation.3 Similar data analyzing Swedish men over a 34-year period showed that obesity conferred a 43 per cent reduced risk for having an
Presented at the 23rd Annual Scientific Meeting of the Southern California Chapter of the American College of Surgeons in Santa Barbara, CA, January 2022, 2012. Address correspondence and reprint requests to Talar Tejirian, M.D., 4760 Sunset Boulevard, 3rd Floor, Los Angeles, CA 90027. E-mail: Talara.x.Tejirian@kp.org.

inguinal hernia compared with those with normal weight.4 However, little is known about the current prevalence of ventral hernias and their relationship with obesity. Few studies have shown an increased rate of occurrence of incisional hernias with obesity57 and increased recurrence after repair of incisional hernias,8, 9 but these studies had small sample sizes and did not include other abdominal wall hernias. This study seeks to examine the current prevalence of all noninguinal abdominal wall hernias and their correlation with obesity and other risk factors.
Methods

This is a retrospective review of adult patients older than 18 years with noninguinal abdominal wall hernias within the Kaiser Permanente Southern California regional database, comprising information from 14 hospitals, from January 2007 through December 2010. International Classification of Diseases, 9th Revision codes were used to identify patients with a diagnosis

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of umbilical hernia (551.1, 552.1, 553.1), incisional hernia (551.21, 552.21, 553.21), ventral hernia (551.2, 552.2, 553.2), epigastric hernia or Spigelian hernia (551.29, 552.29, 553.29), with or without incarceration or strangulation. The data incorporates both inpatient and outpatient records. Hernias of unspecified or other sites (553.8, 553.9) were excluded. BMI, calculated using weight in kilograms divided by the square of height in meters, was used a proxy for human body fat. Patients were then stratified by standard BMI categories (Table 1). The odds of having an incarcerated hernia was calculated against nonincarcerated hernias within the same BMI group. We also analyzed the risk of a hernia based on gender, age, and ethnicity. Data were analyzed using univariate and multivariate analysis with SAS Version 9.2 (SAS Institute, Cary, NC).
Results

Of the 2,807,414 patients in the database, 26,268 had a diagnosis of a noninguinal abdominal wall hernia for
TABLE 1. Body Mass Index (BMI) Categories BMI (kg/m2) <19 2024.9 2529.9 3039.9 4049.9 5059.9 60+ Category Underweight Normal weight Overweight Obesity Morbid obesity Super morbid obesity Super, supermorbid obesity

FIG. 1.

Distribution of diagnoses.

an overall prevalence of 0.9 per cent. The average age of the patients was 52 years, and 60 per cent were male. The average BMI of patients with a hernia was 32 kg/m2, whereas the average BMI of all the patients in the database was 28 kg/m2. There was no significant difference in average BMI between the genders in patients with a hernia. The majority of the patents were white (57%), followed by black (8.13%), then Asian/ Pacific Islander (2.21%), and multiple/other/unknown. The breakdown of the hernia diagnoses were as follows: 74.3 per cent were nonincarcerated umbilical, 22.26 per cent were nonincarcerated incisional, with the remaining being nonincarcerated ventral or Spigelian. Only 1.12 per cent were strangulated/incarcerated (Fig. 1). The odds of having a hernia diagnosis directly correlated with each increase in BMI group. Compared with the lowest BMI group, the odds were more than double for overweight patients and the highest univariate odds ratio was 8.2 for the super, supermorbidly obese (BMI greater than 60 kg/m2). The multivariate analysis also showed a stepwise increase of hernia occurrence with an odds ratio of 5.17 for the super, supermorbidly obese (Table 2). The odds of having a hernia with respect to patients ethnicity is outlined in Table 3. The mean BMI for patients with an incarcerated hernia was significantly higher than those without incarceration (35 kg/m2 vs 32 kg/m2, P < 0.001). The risk of having an incarcerated hernia also significantly increased with BMI with odds ratio (OR) of 2.26 for the morbidly obese, 2.46 for the super morbidly obese, and 10.04 for the super, supermorbidly obese. Multivariate analysis showed a significant OR of 2.08 for the morbidly obese and 12.07 for the super, supermorbidly obese (Table 4). When analyzed by gender, the odds of incurring a hernia was nearly half as likely for females than males (univariate OR, 0.53; confidence interval [CI], 0.52 to 0.55; P < 0.0001; multivariate OR, 0.52; CI, 0.51 to 0.55; P < 0.0001) and about twice as likely for patients older than 50 years old (OR, 2.12; CI, 2.07 to 2.17; P < 0.0001 and OR, 1.69; CI, 1.64 to 1.74; P < 0.0001) by multivariate analysis. The risk of incarceration was nearly twice as likely for females (univariate OR, 1.80; CI, 1.45 to 2.24;

TABLE 2. Odds of Hernia Diagnosis by BMI Group BMI Group (kg/m2) 019 2024 2529 3039 4049 5059 60+ Hernia (no.) 371 3,154 7,908 11,643 2,638 477 77 Non-hernia (no.) 119,941 733,593 968,594 825,961 136,821 19,463 3,041 Univariate Analysis % 0.31 0.43 0.82 1.41 1.93 2.45 2.53 OR 1.11 1.63 2.62 3.91 4.85 5.17 CI Reference 0.991.26 1.451.83 2.332.93 3.474.42 4.155.68 3.866.91 P Value N/A NS <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 OR 1.39 2.64 4.56 6.23 7.92 8.19 Multivariate Analysis CI Reference 1.251.55 2.382.93 4.115.05 5.596.95 6.919.08 6.3910.49 P Value N/A <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001

BMI, body mass index; OR, odds ratio; CI, confidence interval; N/A, not applicable; NS, nonsignificant.

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TABLE 3. Multivariate Analysis Odds by Ethnicity, Indexed to White Univariate Analysis Ethnicity Black Asian/Pacific Islander Others OR 0.70 0.22 0.68 CI 0.670.74 0.200.24 0.650.72 P Value <0.0001 <0.0001 <0.0001 OR 0.68 0.28 0.69 Multivariate Analysis CI 0.650.71 0.260.31 0.650.73 P Value <0.0001 <0.0001 <0.0001

OR, odds ratio; CI, confidence interval. TABLE 4. Risk of Incarceration by BMI BMI Group (kg/m2) 019 2024 2529 3039 4049 5059 60+ Univariate Analysis Inc (n) 1 36 78 128 67 13 8 Non-inc (n) 370 3,118 7,830 11,515 2,571 464 69 % 0.27 1.15 1.00 1.11 2.61 2.80 11.59 OR 0.23 1 0.86 0.96 2.26 2.43 10.04 CI 0.031.71 Reference 0.581.28 0.661.40 1.503.40 1.284.61 4.5022.40 P Value NS N/A NS NS <0.0001 <0.01 <0.0001 OR 0.28 1 0.98 0.98 2.08 1.83 12.07 Multivariate Analysis CI 0.042.06 Reference 0.621.56 0.631.53 1.293.37 0.794.23 4.9829.25 P Value NS N/A NS NS <0.01 NS <0.0001

BMI, body mass index; Inc, incarcerated; OR, odds ratio; CI, confidence interval; NS, nonsignificant; N/A, not applicable.

P < 0.0001; multivariate OR, 1.50; 1.141.98; P < 0.005). Risk of incarceration was only slightly more for patients older than age 50 years (univariate OR, 1.28; CI, 1.02 to 1.59; P < 0.05; multivariate OR, 1.39; 1.05 to 1.83; P < 0.05).
Discussion

Our results show that the risk of having a noninguinal abdominal wall hernia significantly increases with advancing age, male gender, white ethnicity, and increasing BMI. Furthermore, the risk of incarceration with a ventral hernia increases and becomes significant with BMI greater than 40 kg/m2, advancing age, and female gender. The pathogenesis of hernia formation is still being investigated but is likely multifactorial. Many studies show a relationship between the intrinsic strength and makeup of the tissues and the wall tension. The strength of tissues is based on a genetic component and collagen makeup and stressors such as infections. The wall tension, on the other hand, is directly related to intra-abdominal pressure and radius of the abdominal wall.10 Obesity has been linked to increased intraabdominal pressure11 and perhaps this increased force leads to weakened tissues and expansion of the hernia defect. Similarly, the intra-abdominal pressure increases the difficulty in reduction of the hernia contents leading to a higher rate of incarceration. The implications of a higher BMI on laparoscopic operative intervention have been studied, and obesity has been shown to increase the time and complexity of the operation12 without a difference in outcomes.13 There is also an increased risk of hernia recurrence after repair with

increasing obesity,59, 14 although studies do not show that weight loss decreases this risk of recurrence after a repair.15 The association of increased age with ventral hernia formation is supported by the fact that aging tissues are weaker, and it has been suggested, especially by data for inguinal hernias, that older patients have decreased abdominal muscle mass and therefore decreased abdominal wall resistance.4 Although this study is highly powered, it is limited by the retrospective nature because it relies heavily on the diagnostic coding. In addition, the BMI does not take into account the distribution of weight, which may alter the intra-abdominal pressure, like in a patient with central obesity.
Conclusion

This study confirms that noninguinal abdominal wall hernias are more common in obese patients and also shows a higher prevalence of hernias in whites, males, and patients older than age 50 years. The risk of incarceration increases with higher BMI, age older than 50 years, and female patients. Additional research studying the underlying cause of these relationships can be helpful. This information can be useful in counseling patients with and without hernias. Obese patients at risk for developing hernias should be counseled on the importance of weight loss.
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