Great Debates: Do BMI Cut-offs for Surgical Candidacy Do More Harm than Good in Patients With Ventral Hernia

Obesity is a well-established risk factor for perioperative morbidity and recurrence in patients undergoing ventral hernia repair (VHR). To mitigate poor outcomes, body mass index (BMI) is increasingly used as a preoperative optimization metric, with some surgeons only offering elective VHR to patients of a predetermined BMI threshold (cutoff). While substantial evidence supports improved outcomes for lower BMI patients, the options for VHR are extremely nuanced with multiple techniques, mesh, and even surgical approach (open, laparoscopic, and robotic). Consequently, using BMI as a binary decision-making tool remains controversial. This narrative summarizes the existing literature on BMI thresholds and outcomes following VHR. We examine the relationship between BMI and postoperative complications, recurrence, and quality of life for open and minimally invasive VHR. We also review evidence regarding BMI-based deferral strategies, emergency repair risk, and health disparities and discuss the role of preoperative optimization within a broader risk assessment framework.