Rethinking Hernia Repair in Morbidly Obese Emergency Surgery Patients

When Standard Approaches Fall Short, Two Underused Techniques Offer a Lifeline

Apr 12, 2025

Managing hernias in morbidly obese patients is difficult even in elective settings. But in the emergency context—often complicated by incarceration, contamination, or comorbid infection—surgeons are left with few reliable options. In such cases, traditional strategies like prehabilitation, delayed repair, or the use of synthetic mesh are either impractical or outright contraindicated.

At the 2024 American College of Surgeons Clinical Congress, Dr. Olliver Núñez Cantú, a general surgeon at Centro Médico ABC in Mexico City, presented two surgical alternatives for abdominal wall reconstruction in this uniquely complex setting: the reinforced tension line (RTL) suture1 and the Da-Silva, Malmo peritoneal flap2. Both techniques, though underutilized, offer practical and effective solutions when surgeons are faced with emergent repair in patients who cannot wait and for whom mesh is unsafe.

The Challenge: Emergencies in Morbidly Obese Patients with Contaminated Fields

The classic tenets of abdominal wall hernia repair—elective timing, preoperative optimization, and mesh reinforcement—frequently collapse in the emergency setting. Particularly in obese patients, hernias present late, contaminated, or with concurrent infection, precluding mesh and making primary closure both difficult and prone to recurrence.

“This is a real challenge; most of the time, prehabilitation is not possible in these patients. While ideal, it is often impossible to complete standardized repairs due to contamination at the hernia site.”—Dr. Núñez Cantú

Dr. Núñez Cantú illustrated these scenarios through three representative cases:

An incarcerated umbilical hernia present for over 24 hours, raising concerns for contamination.
A colonic fistula complicated by obstruction and infection at the previous scar site.
A large abdominal wall defect in a patient with acute cholecystitis and an irreducible defect, where reapproximating the midline was likely unfeasible.

Each scenario reflects a clinical minefield—where neither mesh nor delayed reconstruction is possible.

Technique One: The Reinforced Tension Line (RTL) Suture

Originally described by Hollinsky in 2007, the RTL suture technique relies on biomechanical principles that distribute mechanical stress across multiple tissue layers, minimizing tension at the suture line and improving structural integrity in contaminated fields where mesh is contraindicated.

“These two strategies are very good for these conditions when we are not able to have prehabilitation in the operating room, in the emergency setting.” Dr. Núñez Cantú

The technique involves placing two continuous polypropylene suture lines: the first approximates the hernia defect, anchored on either side to distribute tension; the second reinforces the repair by securing tissue layers external to the initial suture, further diffusing stress.

“The basic principle is to create two running lines using polypropylene sutures that encompass the hernia defect, secured on either side, which serves as an anchor point.” Dr. Núñez Cantú

The RTL method has demonstrated strength in both open and laparoscopic contexts. Notably, it showed reduced incisional hernia rates in recent comparative studies—even outperforming the widely accepted 4:1 suture closure ratio in elective laparotomies.

Technique Two: The Da-Silva, Malmo Peritoneal Flap

The second approach presented—less familiar to most surgeons—is the Da-Silva, Malmo peritoneal flap. In cases where mesh can’t be used due to contamination, or even in elective cases requiring tension-free closure, this technique repurposes the hernia sac into a reconstructive element.

“This is a modified peritoneal flap. We use the hernia sac; we separate the sac from the skin and open the sac in the middle.” Dr. Núñez Cantú

In practice, the flap is bisected and folded into the abdominal wall layers: one limb is placed posterior to the rectus abdominis, while the other is sutured anteriorly, reestablishing continuity and strength without foreign material. In uncontaminated fields, mesh can be added for reinforcement, but the flap functions independently when necessary.

Perspectives from the Broader Surgical Community

Dr. Ivanesa Pardo, chief of minimally invasive and bariatric surgery at MedStar Washington Hospital Center, commented on the value of the presentation.

“The talk was eye-opening,” she said. “I was not familiar with the RTL or Da-Silva, Malmo techniques before. RTL in particular has strong theoretical and early clinical backing.”

She pointed to a study from British Journal of Surgery showing RTL’s superiority over standard closure methods in preventing incisional hernias.

“One especially intriguing study compared the rate of incisional hernias following laparotomy using 4:1 suture closure versus RTL and found a lower rate in RTL patients.” Dr. Pardo

However, she noted that while the Da-Silva, Malmo flap is creative and potentially useful, its practicality in U.S. practice is limited.

“In theory, it sounds like a great technique to have under your belt for a complex patient, and of course as a surgeon you want to have as many tools as possible,” she said. “But we typically don’t have to do a complex abdominal reconstruction in the middle of the night—we have the option to temporize with a non-permanent mesh and come back later.”

Reclaiming Techniques for the Non-Elective Arena

While mesh-based repair remains the gold standard in elective hernia surgery, real-world practice often demands alternatives. The reinforced tension line suture and the Da-Silva, Malmo peritoneal flap offer two durable, biologically compatible methods for dealing with contaminated or high-risk hernia repairs in obese patients requiring urgent intervention. These are not new techniques—but their reintroduction into emergency surgery warrants broader awareness and training.

For the acute care surgeon confronting hostile anatomy in the middle of the night, expanding the toolbox beyond standard mesh techniques could mean the difference between temporary closure and long-term success.

The Informed Incision

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