What Is An Incisional Hernia?
It is a hernia seen only after abdominal wall surgeries like a cesarean or an appendectomy. A hernia is a protrusion that occurs due to a gap in the muscles of the abdominal wall allowing the internal organs and tissue to push through the muscle layer. If this protrusion develops at the site of previous surgery, it is known as an incisional hernia.
What Causes An Incisional Hernia?
It is multifactorial; for easy understanding, the causes can be grouped into three types:
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Patient-Related Factors - In patients with underlying diseases like diabetes, kidney failure, etc., or if they are under medications like steroids and immunosuppressants, proper wound healing does not occur. This affects the strength of the new tissue that is supposed to support the abdominal wall, thereby increasing the chances of incisional hernia. Morbid obesity and smoking are often seen as associated risk factors.
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Disease-Related Factors - In a few patients, the incision site, the urgency of the procedure, and the reason for which the surgery is being done also predispose them to incisional hernia. For example, patients undergoing a cesarean with a midline incision have a higher incidence of incisional hernia.
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Technical Factors - Poor surgical technique often leads to wound dehiscence (reopening the cut). At the end of abdominal surgery, if the underlying layers are not approximated with an appropriate strength, the wound will not close. This increases the likelihood of an incisional hernia.
What Are the Symptoms of an Incisional Hernia?
Symptoms can range from no symptoms to a visible bulge alongside the suture site. The protrusion will flatten while lying down or pushed against it and can be confirmed with a positive cough test.
An increasing pain level can occur when lifting heavy objects or during a bowel movement/urination. In a few patients, severe abdominal pain is seen due to strangulation. The intestine bulges through the improperly healed abdominal wall; it starts to die due to strangulation and zero or reduced blood supply, which needs immediate care.
What Are the Investigations Done to Diagnose an Incisional Hernia?
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Physical Examination: Physical examination with abdominal palpation can help in the initial diagnosis.
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CT Scan: Computed tomography (CT) scanning helps to confirm the hernia and plan the surgical approach for repair.
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Dynamic Ultrasonography: Dynamic ultrasonography assessment for hernia (DASH) is an ultrasound technique used to evaluate incisional hernia.
How Is An Incisional Hernia Treated?
Small and asymptomatic hernias are observed for further growth; surgery is the only option for patients with pain and strangulation. The surgery aims to repair the hole or defect to prevent the bulging of the intestine into the abdominal wall. There are three major incisional hernia repair surgeries, they are:
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Open Hernia Repair - The cut made for the surgery that led to the incisional hernia is reopened, the intestine and the abdominal tissue is pushed inside, and a mesh is placed to reinforce this repair and prevent a recurrence. The mesh can be placed onlay (above the defect), inlay (in between the edges), or sublay (below the defect) of the abdominal wall. The meshes can be permanent or absorbable; synthetic ones are preferred over biological meshes. Once reinforced with the mesh, the skin is closed with dissolvable stitches.
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Laparoscopic Surgery (Keyhole Surgery) - Small incisions are made away from the location of the incisional hernia to reduce the chances of infection. A laparoscope (an illuminated tube with a camera at the tip) is inserted through one of the small incisions. The surgical mesh is inserted to support the abdominal wall, and the incisions are sutured.
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Robotic Hernia Repair - The entire procedure is similar to that of laparoscopy. Still, the surgeon performs it using robotic platforms (Xi or Si) while seated at a console in the operating room. Robotic hernia repair makes tiny incisions compared to open surgery with less pain.
The surgeon makes the final decision on the type of surgery to be performed after careful evaluation. It depends on the following factors:
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Age of the patient.
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Predisposing health conditions.
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Size of the hernia.
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The amount of skin graft needed for the repair.
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Presence of infection.
Besides repairing the hole, the surgery also revives the abdominal wall tone and shape by bringing the muscles back to their position.
What Care Should Be Taken Post-Surgery?
The surgery is done under general anesthesia; depending on the size and complexity of the hernia, the patient can leave on the same day or stay overnight. Any post-surgical bleeding, infection, or blood clots should be immediately notified to the clinician. Patients must wait for three to four weeks before resuming heavy physical activity.
What Are the Complications of Surgery?
The incisional hernia has a good prognosis; however, every surgery comes with risks; a few are specific to incisional hernia are the following:
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Incarceration - Incarceration refers to an irreducible hernia that cannot be pushed back into the abdomen due to free fluid in the hernia sac. Incarceration predisposes the hernia to obstruction, inflammation, and ischemia (restricted blood flow).
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Obstruction - The incarcerated hernia makes it difficult for the digesting materials to pass through the large intestine, causing an obstruction that becomes potentially deadly if left untreated.
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Strangulation - Incarceration and obstruction lead to strangulation, where a portion of the intestine protrudes and gets trapped. It is a serious complication and should be treated immediately.
Conclusion:
To conclude, incisional hernia repair needs a multi-disciplinary team, and the key to a successful operation is to prevent the problem in the first place. Some tips to minimize incisional hernias include using slow-absorbing monofilament sutures and maintaining a 4:1 ratio of suture to wound length. In addition, if the patient has predisposing conditions like obesity and smoking, making lifestyle changes reduces the chance of a recurring hernia.
