An incisional
hernia occurs
in an area of weakness caused by an incompletely-healed surgical wound. Since
median incisions in the abdomen are
frequent for abdominal
exploratory surgery, ventral incisional hernias are termed ventral
hernias.
These can be among the most frustrating and difficult hernias to treat.
Clinically, incisional hernias present as a bulge or protrusion at or near the
area of a surgical incision. Virtually any prior abdominal operation can develop
an incisional hernia at the scar area (provided adequate healing does
not occur), from large abdominal procedures (intestinal surgery, vascular
surgery), to small incisions (appendix removal, or abdominal
exploratory surgery). While these hernias can occur at any incision, they tend
to occur more commonly along a straight line from the xiphoid process of the sternum straight
down to the pubic
bone, and are more complex in these regions. Hernias in this area have a high
rate of recurrence if repaired via a simple suture technique
under tension. For this reason, it is especially advised that these be repaired
via a tension free repair method using mesh.
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Incisional hernia: Abdominal surgery causes a flaw in the abdominal wall. This
flaw can create an area of weakness in which a hernia may develop. This occurs
after 2%-10% of
all abdominal surgeries, although some people are more at risk. Even after
surgical repair, incisional hernias may return.
Men, women, and children
of all ages and ethnic backgrounds may develop an incisional hernia after
abdominal surgery. Incisional hernia occurs more commonly among adults than
among children.
1. Many patients do not have any symptoms
2. Difficulty in bending
3. Cosmetic deformity
4. Persistent abdominal pain
5. Discomfort in abdomen
6. Occasional episodes of subacute intestinal obstruction
7. Incarceration
8. Strangulation
9. Unusually it may rupture
10. Dermatitis due to friction of bulge on clothes
The first symptom a person may have with an incisional hernia is pain, with or without a bulge in the abdomen at or near the site of the original surgery. Incisional hernias can increase in size and gradually produce more noticeable symptoms.
The factors that increase the risk of incisional hernia are conditions that
increase strain on the abdominal wall, such as obesity, advanced age,
malnutrition, poor metabolism (digestion and assimilation of essential
nutrients), pregnancy, dialysis, excess fluid retention, and either infection or
hematoma after a prior surgery.
Tension created when sutures are used to close a surgical wound may also be
responsible for developing an incisional hernia. Tension is known to influence
poor healing conditions because of related swelling and wound separation.
Tension and abdominal pressure are greater in people who are overweight,
creating greater risk of developing incisional hernias following any abdominal
surgery, including surgery for a prior inguinal (groin) hernia. People who have
been treated with steroids or chemotherapy are also at greater risk for
developing incisional hernias because of the affect these drugs have on the
healing process.
1. Sepsis is the main cause which occurs in post operative status giving rise to incisional hernia within first year of surgery.
2. Drainage tubes placement
3. Repeated surgeries within 6 months
4. Inflammatory bowel disease.
5. Early wound dehiscence.
6. Laparoscopic Surgery-Port sites
7. Following specific surgeries on abdomen and pelvis cause incisional hernia in excess number of Patients:
Ø Hysterectomy
Ø Cholecystectomy and Biliary tract surgery
Ø Appendectomy
Ø Colorectal surgery
Ø Gastric operations
Ø Cesarean Surgery
8. Midline incisions taken are at high risk developing hernia.
9. Lower midline incision have high risk of developing hernia.
Reviewing the
patient's symptoms and medical history are the first steps in diagnosing an
incisional hernia. All prior surgeries will be discussed. The doctor will ask
how much pain the patient is experiencing, when it was first noticed, and how it
has progressed. The doctor will palpate the area, looking for any abnormal
bulging or mass, and may ask the patient to cough or strain in order to see and
feel the hernia more easily. To confirm the presence of the hernia, an
ultrasound examination or other scan such as computed tomography (CT) may be
performed. Scans will allow to visualize the hernia and to make sure that the
bulge is not another type of abdominal mass such as a tumor or enlarged lymph
gland. The doctor will be able to determine the size of the defect and whether
or not surgery is an appropriate way to treat it.
Many months before the surgery, the
patient's doctor may advise weight loss to help reduce the risks of surgery and
to improve the surgical results. Control of diabetes and smoking cessation are
also recommended for a better surgical result.
Patients having discomfort,pain,recurrent colic,occasional episodes of subacute episodes of subacute intestinal obstruction,irreducible hernias,narrow neck defects.
Incisional hernias are repaired most of the times due to above said indications. However in patients with extreme obesity the repair should be undertaken after weight control according to height and age.
Procedure: Two types of procedure are practiced :
1. Open prosthetic incisional hernia Repair
2. Laparoscopic Incisional hernia repair.
Defect of hernia
Choice of mesh: The choice of mesh is guided by , the characteristics of the patient and hernia defect(s) and ultimately the surgeon’s preference. The mesh should be sized to provide an overlap of at least 4 to 5 cm around the circumference of the defect. Large central defects should be repaired with wider overlap to allow fixation to normal abdominal wall to avoid eventration of the mesh. Small, Swiss cheese–type defects may require a lesser margin. The potential for prosthetic mesh contraction should always be considered when sizing the mesh. Depending on the type of mesh the degree of contraction may vary considerably.
Ø Onlay Mesh Repair: After closure of the peritoneum , the edges of the aponeurotic defects are approximated and closed with non absorbable sutures. The onlay mesh is taken and assured that the edges of the mesh cover 5 cms over the defect area on all sides.
• Inlay mesh repair: Intraperitoneal-hernia sac is excised and fascial margin is identified around the hernia defect. Either polypropylene or ePTFE is sutured circumferentially to fascial edge. Polypropylene would be used when omentum can be placed between intestine and mesh;ePTFE should be used when there is no omentum available.
In general, the procedure for laparoscopic incisional hernia repair (LIHR)
consists of four steps: appropriate port placement, adhesiolysis,
intraperitoneal measurement of the hernia size, and anchoring of the mesh. The
first trocar should be placed away from scars and sites of previous surgery to
prevent intraoperative bowel injury as well as to enable easy access to
adhesiolysis.
