Incisional hernia in the abdomen is due to weakness of the wall of the surgical scar and leads to protrusion of the intestine.
"A surgeon can do more for the community by operating on hernia cases and seeing that his recurrence rate is low than he can by operating on cases of malignant disease"
Sir Cecil Wakely- President: Royal College of Surgeons (Eng) 1948
Incisional hernias can range in size from very small to large and complex and appear as a bulge at or near the area of a previous surgical scar. Nearly any prior abdominal operation can develop an incisional hernia, however they most frequently occur along incisions running down from the breastbone to the pubic area.
These hernias may occur after large surgeries such as intestinal or vascular (large arteries, and veins) surgery, or after smaller surgeries such as an appendectomy or an even through the small scar of a laparoscopy wound.
Surgical correction of Incisional hernias is usually recommended, as they carry a potential risk of becoming strangulated at the opening in the abdominal wall and having their blood supply cut off. If this happens it becomes a medical and surgical emergency.
It is especially advised that these hernias be repaired via a TENSION FREE repair method. If the defect is very small, it may be closed with strong non-absorbable sutures. If the hernia defect is larger, it should be closed with a piece of synthetic mesh as incisional hernias have a high rate of recurrence if repaired under tension.
Incisional Hernias - Incidence
Incisional hernias are more likely to occur in people who have had multiple abdominal operations, those who have chronic cough or if they are over-weight or pregnant.
This occurs after 2-10% of all abdominal surgeries, although some people are more at risk. The rate of incisional hernia occurrence can be as high as 13% with some abdominal surgeries.
Men, women, and children of all ages and ethnic backgrounds may develop an incisional hernia after an abdominal surgery. They occur more commonly among adults than among children.
After surgical repair, incisional hernias have a high rate of recurring or returning. It is almost as high as 20-45%.
The incidence is also higher if there is wound infection immediately after surgery.
In the past, material that was used to close the abdominal incision was of the absorbable nature and the rate of such hernias was higher. However, now synthetic, non-absorbable suture material is used and the rate has come down. Incisional Hernias - Causes
Incisional hernias are caused due to stretching of scar tissue that forms after surgery and occurs due to constant pressure of abdominal contents on the scar.
Not all abdominal surgeries will lead to incisional hernia, but any full thickness abdominal incision can leave a weakness and make that area prone to hernia. Usually a proper closure and adequate post-operative measure avoids the problem. However, sometimes despite the best care, a person may develop the hernia and at other times it can be predicted depending on the patient’s general condition and the type of surgery performed.
Normally there are three layers covering the abdominal contents. These include a thin inner sheet called the peritoneum, a thick middle layer of muscles and the third outer layer – the outer skin. An incisional hernia forms usually due to weakness of the thick layers of muscles. There are various factors that can lead to the weakness or hernia formation and these factors generally can be broadly looked at as –
Or Technical factors
Mechanical factors increase the intra-abdominal pressure after an operation and causes the hernia. Common causes include-
Chronic cough- Coughing and vomiting are associated with a brief but significant increase in intra-abdominal pressure. This, again, leads to too much tension on the incision and possible breakdown of the incision.
Lifting heavy weights- Obviously, if a patient lifts something too heavy immediately after the operation, he or she can also tear the incision and cause a hernia.
Postoperative ileus- This occurs when the abdomen becomes distended because the intestines are not working properly after an operation. The swelling of the intestines increases the pressure in the abdomen and places tension on the incision. The tension then leads to defective healing.
Straining to move bowels after surgery– Constipation is another culprit for hernia formation. During the post-operative period and for a few months afterwards one should avoid straining while moving the bowels.
Patient-related factors Patient factors are diseases or illnesses that impair wound healing. The three principle examples are infection, malnutrition and diabetes.
An infection of the surgical incision impairs wound healing. In part, this may be because sutures and tissues are destroyed by the infection.
Malnutrition leads to poor wound healing because the nutrients necessary for good healing are present in insufficient quantities or are completely absent. Malnutrition may be a generalized condition in which proteins and energy are deficient, or a specific condition, such as lack of a specific vitamin. Scurvy, which results from vitamin C deficiency, is an example of a deficiency in one key nutrient that leads to poor wound healing.
Diabetes Mellitus also impairs wound healing and is associated with a higher incidence of hernia formation than the general population. Diabetes affects wound healing by impairing the function of white cells, predisposing the patient to infection and limiting the ability of new blood vessels to grow into the healing area.
Chronic illness of any type also affects wound healing through problems with nutrition and a general increase in inflammation.
The principle technical factor that leads to an Incisional hernia is too much tension on the incision when it is closed. This can lead to:
Tearing- Tension sutures can tear through the tissue when added stress is placed on it, such as during coughing or lifting.
Decreased blood supply- Excessive tissue tension can also reduce blood flow to the tissue around the suture itself. This leads to breakdown of the tissue and the suture pulls through.
Other technical factors unrelated to tissue tension may also play a role. For example the sutures may have been placed in weak tissue, the wrong layer of tissue may have been sutured, the suture may have broken or the suture may not have been strong enough for the tension it is later subjected to. Incisional Hernias - Symptoms
The two most common symptoms of Incisional hernias are discomfort and a bulge. The bulge of an incisional hernia is located in the incision itself.
Typically, there are no symptoms on awakening but with prolonged periods of standing, sitting, or lifting the symptoms appear and often intensify.
Incisional hernias are usually associated with:
A burning sensation,
A pressure or fullness
An ache or constant pain at the site of the hernia
An awareness that something is present in the incision that should not be there
Reducible hernia- The bulge may be always present but typically goes away when the patient lies down. The reason is that the pressure that pushes tissue into the hernia when the patients stand is eliminated when the patient lies down because the tissue goes back into the abdomen. People can often push in the bulge (reduce the hernia), by applying gentle, steady pressure over the lump.
Incarcerated hernia- If the lump does not go away, the tissue is stuck. This is known as an incarcerated hernia and is almost always associated with unrelenting discomfort. This requires early surgical attention.
Bowel Obstruction- An incarcerated hernia can lead to bowel obstruction, which causes pain, abdominal distention and vomiting. This is a surgical emergency and if left alone can put the life of the patient at risk.
Strangulated hernia- If the neck of the hernia is narrow - there is always the risk of strangulation of the hernia. In this situation the blood supply to the intestine or the structure in the hernial sac is cut off and this leads to gangrene. This can be catastrophic and fatal if not treated immediately by surgery. Incisional Hernias - Diagnosis
Incisional hernia is a clinical diagnosis and tests are seldom required to further substantiate the diagnosis.
Reviewing the patient's symptoms and medical history are important in establishing the diagnosis of incisional hernia.
Detailed case records, of prior surgeries, is required with emphasis on postoperative period.
The surgeon should establish the amount of pain or discomfort the patient is experiencing and if it has grown in size since it was first noticed.
The hernial area is touched (palpated) to feel for any abnormal lump and if it increases in size when the patient coughs or strains or when they bend.
If in doubt about the diagnosis - radiological tests such as an ultrasound examination or in a complex case a computed tomography (CT) may be performed. This will tell the surgeon the extent of the hernia and the contents in the bulge. Incisional Hernias - Before Surgery
Preoperative work up helps to assess a patient’s ability to withstand the stress of anesthesia.
Preoperative measures for the surgical procedure are:
Many months before the surgery, the patient's doctor may advise for weight loss to help reduce the risks of surgery and to improve the surgical results.
In diabetics the control of sugar is advocated.
In smokers – cessation of smoking for over a month or more before surgery is recommended.
If on any blood thinning tablets like aspirin – it should be stopped for 3 to 5 days before surgery. Some of the newer medications like clopidrel need to be stopped for a week before surgery.
However do check with surgeon first before stopping any tablets.
Close to the time of the scheduled surgery, the patient will have standard preoperative blood and urine tests, an electrocardiogram, and a chest x ray to make sure that heart and lungs and major organ systems are functioning well.
Starting the night before surgery, patients must not eat or drink anything.
The lower chest, abdomen, groin and genital area may be shaved and prepared for the surgery.
The night before surgery a bath maybe advisable. While bathing thorough cleaning of the abdominal and genital area with soap and water a few times can help in lowering the bacterial count and lessen the chances of any infection from surgery.
An enema maybe administered to the patient prior to performing the surgery. Sometimes a laxative maybe given instead of an enema to clear the bowels prior to surgery.
Once in the hospital, a tube may be placed into a vein in the arm (intravenous line) to deliver fluid and medication during surgery.
The patient will be given a preoperative injection of antibiotics before the procedure. A sedative may be given to relax the patient.
On the evening before the operation a light easily digestible meal is advised. Incisional Hernias - Surgery
Incisional hernias need to be surgically corrected to prevent complications such as strangulation.
Incisional Hernias should be repaired surgically at a convenient time after they are discovered. Unfortunately, there is no other treatment other than surgery that has significant success.
Surgical Options are:
Open Surgical Repair
Laparoscopic Surgical Repair
In most cases, the open approach is the best and safest way to repair an incisional hernia. However, there are situations in which patients may benefit from the laparoscopic approach. Incisional hernias is not like inguinal hernias where advantages are present for most patients with the laparoscopic approach.
At present many surgeons do prefer to repair the hernia using the laparoscope. However this will depend on the complexity of the hernia and adhesions of the structure within the abdomen to the hernia. Occasionally the surgeon may start with the laparoscopic approach and later convert to the open method if the inside of the abdomen looks complex.
The arrival of daVanci Robotic system (Intutive systems) for laparoscopy has recently added a new dimension to the repair of incisional hernias laparoscopically and many surgeons are gaining expertise and are able to tackle the most complex cases laparoscopically. Incisional Hernias - Synthetic mesh
Using a synthetic mesh to repair an incisional hernia reduces tension at the surgical wound and prevents recurrence.
Synthetic mesh allows defects of any size to be repaired without tension with a low recurrence rate.
Synthetic mesh is a weave, usually of a synthetic material called polypropylene, which looks like the mosquito-net or wired-screens on the window and doors. The mesh is used to patch an area. The idea is that if the cut ends of the surgical defect are sewn back together, tension may be present at the repair site. In addition, the pressures that led to the hernia in the first place are still present. And together, the tension on the repair and the pressures that caused the hernia can cause the hernia to recur.
The use of the synthetic mesh provides a tension free repair and provides the added support to the weak wall of the abdomen.
Mesh and infection
Any foreign material placed in the body is a potential source for infection. Due precautions need to be exercised before and during surgery to prevent infections.
In the current era where almost everything used in operation theatre is disposable the incidence of infection is low. However if does happen the mesh may need to be removed. Sometimes the mesh may erode through the skin or into the intestine. Incisional Hernias - Open Surgical Repair
Open Surgical repair is the preferred surgical technique for Incisional hernias.
Different types of anesthesia can be provided for the hernia repair. These include local anesthesia, spinal or epidural anesthesia or general anesthesia.
During the surgery
The patient lies on the operating table, either flat on the back or on the side, depending on the location of the hernia.
General anesthesia is usually given, though some patients may have local or regional anesthesia, depending on the location of the hernia and complexity of the repair.
A catheter may be inserted into the bladder to remove urine and decompress the bladder.
If the hernia is near the stomach, a gastric (nose or mouth to stomach) tube may be inserted to decompress the stomach.
The abdomen and groin are prepared with an antibacterial solution.
An incision is made about the length of the lump that is present.
The tissue layers are divided until the weakness in the abdominal wall is identified.
The contents of the hernia are pushed back into the abdomen.
The tissue around the defect is dissected to find good, strong, healthy tissue, known as fascia. The fascia is the gristly layer that provides the strength to your abdominal wall.
The defect is then closed, either by suturing together the good strong tissue on either side of the hole or by applying a synthetic mesh across it to patch the hole.
Following the repair, the layers of tissue are brought back together with sutures.
The skin is closed with stainless steel staples, dissolvable sutures or non-dissolvable sutures. Occasionally, a small amount of skin is also removed to leave a better cosmetic result. Incisional Hernias - Laparoscopic Surgical Repair
Laparoscopic Surgery is used to treat Reducible Incisional hernias. The more complicated hernias may require direct visualization to plan the surgery.
Steps of Surgery
This procedure is performed under General Anesthesia.
After administering anesthesia the abdomen and groin are prepared with an antibacterial solution.
The abdomen is inflated with a harmless gas (carbon dioxide) to allow the doctor to view the internal structures.
Three to four small keyhole incisions are used for an incisional hernia repair: two are 5 mm in length and one or two maybe 12 mm in length.
A laparoscope is a thin, telescope-like instrument, which helps to visualize the operating field, if inserted.
A camera, which is attached to the laparoscope, captures and produces a continuous image that is magnified and projected onto a television screen.
Using the laparoscopic surgical tools, the tissues and vessels are divided until the weakness in the abdominal wall is identified.
The tissue around the defect is dissected to find good, strong, healthy tissue, known as fascia. The fascia is the gristly layer that provides the strength to the abdominal wall.
The defect is then closed, either by suturing together the good strong tissue on either side of the hole or by applying a synthetic mesh across it to patch the hole.
The small abdominal incisions are closed with stitches or with surgical tape. The small abdominal incisions heal faster and within a few months, the incision is barely visible.
Benefits of laparoscopic hernia surgery:
Three to four tiny scars rather than one larger incision
Reduced postoperative pain
Faster return to work
Shorter recovery time and earlier resumption of daily activities (a recovery time of days instead of weeks) Incisional Hernias - Post Operative
After surgery the patient will be observed in a postoperative ward and then shifted to the ward after his condition is stabilized.
Immediately after surgery, the patient will be observed in a recovery area for one to several hours depending on the time duration of the surgery. This is to monitor body temperature, pulse, blood pressure, and heart function.
There maybe a small drain from inside the wound to collect secretions for a day or more.
The surgical wound will be observed for undue bleeding or swelling.
The patient may then be transferred to a regular room.
Laparoscopically done cases will usually be discharged on the day of the surgery but more complex hernias such as those with incarcerated or strangulated intestines will require overnight hospitalization.
Open surgical cases may stay for 4 to 5 days or longer.
Some patients may have prolonged suture-site pain, which may be treated with pain medication or anti-inflammatory drugs.
Antibiotics may be prescribed to help prevent postoperative infection. Incisional Hernias - Home care instructions
It is important to follow home care instructions after surgery to avoid complications.
You can eat a regular diet without any restrictions after surgery. This, of course, will be limited by other illnesses you have, such as diabetes, heart disease or hypertension.
On the first day, eat small, light, meals and liquids. Progress to a normal diet as tolerated.
Nausea and vomiting from anesthesia are not uncommon for 24 hours. If you feel nauseous, take clear liquids only. Contact your doctor if nausea and vomiting persist for greater than 36 hours.
Do not take any alcoholic drinks for at least 24 hours and while you are taking narcotic painkillers with codeine.
You can do whatever you are comfortable doing, except heavy lifting, after you are discharged.
For 24 to 48 hours after surgery you may resist movement due to pain. Although you should get rest during this time, it is equally important to get up and walk.
Do not drive while you are taking narcotic pain medicines and while your incisions hurt. This may reduce your ability to move quickly.
Your thought processes may take 24 to 48 hours to return to normal because of anesthesia. Do not make any important business or personal decisions during this time.
It is okay to go up and down stairs, and it is encouraged.
You can return to work when you feel comfortable you can perform your job safely and at the level you and your employer expect. Usually this is a minimum of one week. If your job involves heavy lifting you should stay out of work for 2-4 weeks.
Most people find they fatigue easily during the second and even the third week, so don’t overload your schedule.
Do not return to exercise or strenuous activity until you are seen for a follow-up appointment.
Pain and Discomfort
It is normal to have pain after the operation. How much pain a person experiences usually depends on the individual and not on the operation. Pain normally is located over the incision. Narcotics and painkillers are prescribed for relief from pain.
Keeping ice on the area of surgery for 24 to 48 hours will minimize postoperative swelling and reduce pain. There is no benefit to using ice after the first 48 hours.
Care of the Incision
Surgical incisions are covered with a gauze pad. It is not uncommon for the pad to become saturated with blood during the first 24 hours. Do not become alarmed; just change the bandages as needed.
You can take a shower 24-36 hours after surgery. Be sure to gently dry your incisions and replace the bandage.
After 2-3 days, it is not necessary to keep your incisions covered but it will usually make you more comfortable to do so as you increase your activity.
If you do not see metal clips or sutures, the sutures are in the skin itself and will dissolve. This occurs 3-4 weeks after surgery and may be associated with a little drainage from the incision.
It is common for patients to notice some black and blue or maroon discoloration around the incision. This represents a small amount of blood and is normal. It should not alarm you. It is also common for this to only become apparent 2-3 days after surgery as blood in the tissues moves to the surface.
Contact the doctor if your incision is red, hot and tender; you may have an infection.
You have been given antibiotics in the operating room prior to surgery. Unless discussed with you, you do not need them after surgery.
You may also notice black and blue discoloration near your incision. This is not cause for alarm, even if it occurs a few days after the surgery. It will usually resolve in 7 to 10 days.
It is normal for the incisions and the hernia site to be hard and swollen following surgery. This is called a healing ridge and represents wound healing. It is not a hernia and will go away in eight to twelve weeks.
Do not tan your incision for one year after surgery, as it will darken your scar.
Some people believe Vitamin A and Vitamin E applied to the incision helps wound healing.
Following your surgery you may notice alterations in your bowel habits.
Diarrhea can occur from the surgery itself or from the antibiotics you received.
Constipation is very common and results from the narcotic pain medicine you are taking.
If you or your family were not informed of anything unusual after surgery, rest assured that everything is fine and went according to plan.
Contact your doctor if you experience:
Persistent light headedness
Chills and/or fever greater than 101°F
Pus or infection at the incisions
Inability to pass urine
Any worrisome condition Incisional Hernias - Risks & Complications
The risks and complications include those related to general anesthesia and those related to the surgery.
Risks of general anesthesia include nausea, vomiting, urinary retention, cut lips, chipped teeth, sore throat and headache. More serious complications include heart attacks, stroke and pneumonia.
Postoperative complications may include:
Fluid buildup at the site of mesh placement, sometimes requiring aspiration (draining off)
Postoperative bleeding, though seldom enough to require repeat surgery
Prolonged suture pain, treated with pain medication or anti-inflammatory drugs
Injury to intra abdominal organs like the intestines, liver etc.
Fever, usually related to surgical wound infection
Intra-abdominal (within the abdominal wall) abscess
Blood clots can form in the legs due to inactivity after surgery
Blood clots can get dislodged from the legs and can get embedded in the lungs leading to respiratory distress Incisional Hernias - Recurrent hernia
A recurrent hernia is one that occurs at the site of a previous hernia repair.
The risk of recurrence is greater with obese patients or those who have had multiple earlier operations or the prior placement of mesh patches.
Some of the factors that cause incisional hernias to occur in the first place, such as obesity and nutritional disorders, will persist in certain patients and encourage the development of a second incisional hernia and repeat surgery.
The risk of complications has been shown to be about 13%.
Each subsequent time, the surgery will become more difficult and the risk of complications greater.
Postoperative infection is higher with open procedures than with laparoscopic procedures.
To prevent recurrence of hernia a few precautions maybe advised–
Using an abdominal corset in the early post-operative period
Treating any chronic cough before treating hernia,
Avoid straining during bowel movement or passing urine. Incisional Hernias - Prognosis
The prognosis for Incisional hernia surgery and its success is good if done early.
Good outcomes are expected with incisional hernia repair, particularly with the laparoscopic method.
Patients will usually go home the day of surgery and can expect a one- to two-week recovery period at home, and then a return to normal activities.
The American College of Surgeons reports that recurrence rates after the first repair of an incisional hernia range from 25–52%.
Recurrence is more frequent when conventional surgical wound closure with standard sutures (stitches) is used.
Recurrence after open procedures has been shown to be less likely when mesh is used, although complications, especially infection, have been shown to increase because of the larger abdominal incisions.
Laparoscopy repair of incisional hernia (repair with mesh) has shown rates of recurrence as low as 3.4%, with fewer complications as well.
Deaths are not reported resulting directly from the performance of Herniorrhaphy for incisional hernia. Incisional Hernias - Lifestyle Changes
Lifestyle Changes which, reduce undue abdominal pressure, can help prevent Incisional hernias.
The alternatives to first-time and recurrent incisional hernia repair begin with preventive measures such as:
Losing weight; maintaining suitable weight for age and height.
Strengthening abdominal muscles through regular moderate exercise such as walking, tai chi, yoga, or stretching exercises and gentle aerobics.
Reducing abdominal pressure by avoiding constipation and the buildup of excess body fluids, achieved by adopting a high-fiber, low-salt diet.
Avoiding undue pressure- Learning to lift heavy objects in a safe, low-strain way using arm and leg muscles.
Controlling diabetes and poor metabolism with regular medical care and dietary changes as recommended.
Eating a healthy, balanced diet of whole foods, high in essential nutrients, including whole grains, fruits and vegetables, limited meat and dairy, and eliminating prepared and refined foods. Incisional Hernias - FAQs
Who treats an incisional hernia?
A general surgeon or a plastic surgeon treats Incisional hernia.
Who gets an incisional hernia?
Incisional Hernias can occur in anyone who has an incision, most commonly an incision through the abdominal wall. It represents a failure of the layer that gives strength to the abdominal wall (the fascia) to heal.
Can an Incisional hernia go away by itself?
No. Once a hernia has developed it will not go away. In fact it will get worse with time. The constant pressure on the area makes the hernia get bigger. This leads to more frequent, more intense and longer periods of discomfort.
Is it related to work?
It is likely that all Incisional hernias do not result from work, since many factors can lead to a hernia. However, it is impossible to say with certainly that the hernia is not from, work if you did not have one when you started your job. Furthermore, even if other factors were involved in the development of your hernia, lifting could have contributed. Therefore, all hernias are usually treated as worker’s compensation injuries.
Are there any tests I need to undergo to confirm I have an Incisional hernia?
No. Physical exam and history are the two best ways to diagnose an Incisional hernia. Fortunately, or unfortunately, there is no test, including a CT scan and MRI, that is better than your history and a physical examination. The reason it is unfortunate is that occasionally there are patients with a history that may indicate a hernia but none can be detected on physical exam. These patients may require a surgical exploration of the area to exclude a hernia, as a last resort.
What can I do before surgery to feel better?
Limiting your activity and any lifting may offer temporary relief. You should avoid exercise, especially any that places strain on the anterior abdominal wall muscles. A truss may also offer temporary relief but should not be used for a long time.
Do all surgeons perform both the laparoscopic and open approaches?
No. All surgeons perform the open approach but only some surgeons perform the laparoscopic approach.
Is there any treatment for an Incisional hernia other than surgery?
An abdominal corset maybe used to keep the hernia reduced during the daytime. For smaller hernia a truss maybe used. However this is only a temporary solution.
A truss is a belt with a large pad on it that applies pressure to the site of the hernia with the aim of keeping the bulge from popping out. Overall, a truss is not a good idea even though it may at times work. The truss does nothing to repair the hernia. It just minimizes symptoms by preventing significant herniation through the defect in the abdominal wall. As a result, the hernia will continue to get larger. In addition, there will be scar tissue formed that provides no strength to the area. Both of these factors, enlargement of the hernia and scarring, make the surgical repair of the hernia more difficult and later recurrence more likely. Therefore, a truss should only be used as a short-term measure until surgery can be performed. Incisional Hernias - Glossary
Abdominal wall - The layers of muscle and fatty tissue that surround the abdomen.
Anesthesia - A substance that prevents pain from being felt, given before an operation.
Complications - Secondary problems that can result from surgery.
Hernia - A weakness or rupture of the wall or cavity containing an organ, with the resulting protrusion of that organ or part of the organ though it.
Incision - A cut into the skin or abdominal wall.
Intra-abdominal - Inside the abdomen.
Non-reducible hernia - A hernia that cannot be flattened out by applying pressure or by lying down.
Recurrent hernia - A hernia that occurs at the same location as a previous hernia.
Reducible hernia - A hernia that can be flattened out either by applying pressure or by lying down.
Surgical Staples - U-shaped metal surgical fasteners.
Surgical Tacks - Metal surgical fasteners.
Sutures - Fine thread or other material used to surgically close a wound or join tissues.
Synthetic Mesh - A synthetic material resembling a flat, pliable thin screen, which is used to repair a hernia. Incisional Hernias - References http://www.njsurgery.com/html/Diseases/ hernias.shtml