Successful Lap. Sleeve Gastrectomy for Morbid Obesity in a 63 Y.O. Male

Chief Complaints

A 63-year-old male patient with a body mass index (BMI) of 40.3 presented to the Surgical Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of swelling in the umbilical region and bilateral inguinal regions for the past two years, where the inguinal swelling was reducible, but the umbilical swelling was irreducible. He was also morbidly obese and had associated symptoms impacting daily activities. 

The patient was a known case of hypertension, for which he was on medication, and obstructive sleep apnea, previously managed with BiPAP support. He also had a history of bronchial asthma and was on regular inhalation therapy. No history of diabetes, coronary artery disease, or prior abdominal surgeries was reported. 

On clinical evaluation, the patient was conscious, coherent, oriented, and hemodynamically stable. Systemic examination findings were within normal limits, with normal respiratory and cardiovascular parameters. Abdominal examination revealed findings consistent with an umbilical swelling (irreducible) and bilateral inguinal swellings (reducible), while the abdomen remained soft and non-tender overall.

Upon admission to PACE Hospitals, following the clinical assessment, the Surgical Gastroenterology team conducted a comprehensive clinical evaluation based on his complaints of umbilical and bilateral inguinal swellings along with a history of morbid obesity. A detailed medical history, physical examination, and preoperative assessment were performed to evaluate overall fitness for surgery and identify associated comorbid conditions. 

Baseline investigations, including complete blood picture, renal function tests, liver function tests, serum electrolytes, coagulation profile, viral screening, chest X-ray, and cardiac evaluation (2D Echo), were carried out and were largely within acceptable limits for surgical intervention. 

Based on the confirmed diagnosis, the patient was advised to undergo Weight loss surgery and Hernia repair Treatment in Hyderabad, India, under the expert care of the Surgical Gastroenterology Department.

After a detailed consultation with Dr. CH Madhusudan, Senior Consultant Surgical Gastroenterologist and Liver Transplant Surgeon, along with the team, including Dr. Suresh Kumar S, Consultant Surgical Gastroenterologist, a comprehensive evaluation of the patient was undertaken with multidisciplinary inputs. Considering the patient’s history of morbid obesity (BMI 40.3 kg/m²), irreducible umbilical hernia, and bilateral inguinal hernias, along with comorbid conditions including hypertension, obstructive sleep apnea, and bronchial asthma, the clinical condition was reviewed in detail to determine the most appropriate management strategy.

Further assessment confirmed the presence of an umbilical hernia with a defect of approximately 3 × 3 cm and associated bilateral inguinal hernias in the setting of increased intra-abdominal pressure due to obesity. Laboratory and cardiac evaluations were within acceptable limits, and the patient was optimised for surgery.

Based on the multidisciplinary evaluation, it was determined that laparoscopic sleeve gastrectomy combined with laparoscopic IPOM plus repair was identified as the most appropriate treatment to achieve weight reduction, repair hernia defects, prevent recurrence, and reduce the risk of complications such as obstruction or strangulation, while offering the benefits of a minimally invasive approach. 

The patient and his family members were counselled in detail regarding the diagnosis, planned surgical procedure, associated risks, benefits, and expected postoperative recovery. Informed consent was obtained prior to proceeding with the surgery.

Following the decision, the patient was scheduled to undergo a Laparoscopic IPOM Plus Repair Surgery with Laparoscopic Sleeve Gastrectomy in Hyderabad at PACE Hospitals under the expert care of the Surgical Gastroenterology Department.

The procedure involved the following steps:

• Exploration and Hernia Assessment: Intraoperative findings revealed an umbilical hernia with a 3 × 3 cm defect with omentum adherent to the sac. Adhesiolysis was performed, and the omentum was carefully separated and reduced. 

• Gastric Mobilisation: The stomach was mobilised by dividing the gastrocolic and gastrosplenic ligaments along with other attachments to prepare for sleeve creation. 

• Sleeve Gastrectomy: The stomach was stapled starting approximately 6 cm from the pylorus, and the gastric sleeve was created using multiple stapler firings. The resected portion was removed. 

• Umbilical Hernia Repair: The hernia defect was cleared, excess tissue was excised, and the defect was closed using sutures. 

• Mesh Reinforcement (IPOM Plus Repair): A 15 × 15 cm mesh was placed and fixed using absorbable tackers to strengthen the abdominal wall and reduce recurrence risk. 

• Drain Placement and Closure: Surgical drains were placed, and port sites were closed after ensuring complete hemostasis.

The procedure was uneventful, and the patient was closely monitored during the postoperative period. He remained hemodynamically stable and was managed with intravenous therapy for infection control, pain management, gastric protection, and supportive care to ensure adequate recovery. Early mobilisation was initiated on the first postoperative day along with respiratory support as advised. On the second postoperative day, a contrast imaging study confirmed no evidence of leak, following which the patient was started on a liquid diet. By the third postoperative day, surgical drains were removed, and wound care was performed. The patient showed gradual clinical improvement and tolerated diet progression well, indicating a satisfactory postoperative recovery.

The patient was discharged in a hemodynamically stable condition following satisfactory postoperative recovery. At discharge, he was prescribed therapy for infection prevention, gastric acid suppression, pain control, and to prevent venous thromboembolism, along with nutritional supplementation to support recovery. 

The patient was advised regarding postoperative wound care, including maintaining hygiene at the surgical site and monitoring for any signs of infection. He was instructed to follow a liquid diet for one week, followed by a gradual diet progression as per dietician guidance, along with adequate hydration to support recovery and nutritional balance. Additionally, the patient was advised to adhere to prescribed medications, avoid strenuous activities, and attend regular follow-up visits for clinical evaluation and further management. 

The patient was informed to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as fever, severe abdominal pain, persistent vomiting, breathlessness, or chest pain.

The patient was advised to follow up with the Surgical Gastroenterologist in Hyderabad, at PACE Hospitals, after 5 days for postoperative evaluation. He was also counselled regarding the importance of regular follow-up, dietary compliance, and monitoring for recovery progress. 

This case highlights the successful management of a male patient with morbid obesity complicated by an irreducible umbilical hernia and bilateral inguinal hernias. Following comprehensive clinical evaluation and multidisciplinary decision-making, the patient underwent laparoscopic sleeve gastrectomy combined with laparoscopic IPOM plus repair, addressing both obesity and abdominal wall defects in a single setting.

The procedure was completed successfully without complications, and the patient demonstrated stable postoperative recovery with good clinical improvement. He was discharged in a hemodynamically stable condition with appropriate medications, dietary advice, and follow-up recommendations. This combined minimally invasive approach ensured effective surgical management, reduced the risk of hernia recurrence, and contributed to improved overall health outcomes and quality of life.