<Incisional Hernia>

What is an Incisional hernia?

An incisional hernia is a type of hernia caused by an incompletely-healed or weakened postoperative abdominal wound. Incisional hernias may occur in up to 30 percent of the patients who have had surgeries in the abdomen. At the thin and weakened wound of the abdominal wall, the internal organs (e.g. bowel or omentum) push against the abdominal wall and form a soft bulge below the skin.

Signs and symptoms

Majority of the incisional hernia patients have symptoms, e.g. (1) a soft and protruding swelling near the abdominal surgery wound, (2) pain or discomfort especially during coughing, exercise, lifting heavy objects, passing urine or during bowel opening. The symptoms often get worse throughout the day, or after standing or walking, and may improve when lying down. An incisional hernia usually presents as a bulging area at or near the previous surgical wound. It may become larger when bearing down and may reduce in size partially or completely when lying down.

Risk Factors

Incisional hernias are usually caused by the weakening of surgical wounds, such as wound hematoma, wound seroma, wound infection, poor surgical technique, and all causes of increased intra-abdominal pressure.

Risk factors for increased intra-abdominal pressure include:

  • Smoking
  • Chronic obstructive pulmonary disease (COPD)
  • Obesity
  • Pregnancy
  • Peritoneal dialysis
  • Chronic liver disease
  • Benign prostatic hypertrophy
  • Weight lifting

Complications

Most incisional hernias enlarge over time if not repaired surgically. Incisional hernias can cause pain, swelling, bowel obstruction, or even bowel strangulation. An incarcerated (irreducible) hernia occurs if the contents of the hernia become trapped and cannot return to the abdomen. It can obstruct the bowel, leading to severe pain, nausea, vomiting, and inability to pass gas or defecate.

A strangulated hernia is a dangerous stage of an incarcerated hernia where the blood flow to the hernia content, mostly small bowel and omentum, is cut off. Strangulation can lead to the death of the affected small bowel tissue, causing bowel rupture and peritonitis or even death. A strangulated hernia is a potentially life-threatening situation and requires immediate surgery.

Signs and symptoms of a strangulated hernia include:

  • Nausea
  • Vomiting
  • Fever
  • Painful abdominal swelling
  • Inability to pass gas or defecate
  • Severe abdominal pain
  • Tenderness upon touching the abdominal swelling
  • Red, purple, or dark discoloration of the hernia
  • Failure to reduce the hernia

Please go to the Accident and Emergency Department if you suspect you have a strangulated hernia.

Diagnosis

Incisional hernias can often be diagnosed clinically, based on signs, symptoms and physical examination. Medical imaging, e.g. ultrasound scan, CT scan, or MRI scan, is usually needed to confirm the diagnosis, identify the anatomy of the hernia and find out if there will be any unknown factors leading to incisional hernia formation.

Indication of surgery

All hernias are generally considered as an indication for surgical repair because of the risk of pressure symptoms, bowel obstruction, or bowel strangulation. Elective surgery is preferred as emergency surgery for incarceration and strangulation may carry higher risk.

Surgery

Traditional open repair of incisional hernias using stitches only had a recurrence rate of up to 50%. Nowadays, using artificial mesh to fix the hernia is the standard treatment, as artificial mesh repair can reduce the recurrence risk to less than a few percent in ten years after surgery.

Surgical repair of incisional hernias with artificial mesh may be done by:

  1. Traditional open surgery
  2. Small-incision open surgery
  3. (Minimal invasive) laparoscopic surgery

Traditional open surgery usually requires a longer skin incision (an incision that is slightly longer than the incisional hernia) to fix the mesh and repair the hernia.

Small-incision open surgery uses a smaller incision (~3cm - 5cm) to fix the mesh and repair the hernia.

Laparoscopic surgery generally requires three to four small 0.5cm - 1cm incisions to pass the instruments into the abdominal cavity, and to place and fix the mesh in place.

Elective small-incision surgery or laparoscopic surgery causes less pain and reduces the downtime of the patients. Most patients undergoing elective surgical repair do very well and may be able to go home one or two days after surgery. The outcome of elective surgery is generally very good, and the risk of complications is low.

Oral analgesics and long-acting local anesthetics are often used to reduce postoperative wound pain to a minimum. Absorbable subcutaneous stitches are often used to close the hernia wounds, eliminating the need to remove any skin stitches. Patients are usually required to keep the wound dry for 2 weeks. After 3 weeks, all wound dressings can be removed. Patients can usually return to office work 1 to 2 weeks after surgery. Most patients can start to exercise 4 to 6 weeks after surgery.

If emergency traditional open surgery is needed, the wound required to return the hernia content and fix the mesh will be larger (~15-20cm) and will cause more pain postoperatively. If there is gut infarction or perforation, laparotomy and bowel surgery will be required to fix the problem. Emergency surgery carries a higher risk of bowel complications, greater morbidity, and mortality rates. Patients undergoing emergency surgery are expected to stay in the hospital for about 1 to 2 weeks.

FAQs

Q: After my abdominal surgery, I have a raised and soft lump near my abdominal surgical scar. It disappears when I lie down. Am I suffering from an incisional hernia?
A: It is very likely you are having postoperative abdominal incisional hernia. If you suspect it, please consult your doctor for advice.
Q: Can I leave my abdominal incisional hernia untreated?
A: Yes. You may choose not to treat your abdominal incisional hernia. But you may feel pain or discomfort every time you stand or walk. As the condition worsens over time, you may face more serious complications such as intestinal ischemia, intestinal perforation, peritonitis, and even death. It is indeed unwise to leave it untreated. Using the latest methods to treat abdominal incisional hernia, most patients feel no pain or minor pain after surgery. Most patients can return to their favorite activities within 6 - 8 weeks. What worries you? Please do not hesitate and consult your doctor for advice.
Q: Is artificial mesh repair surgery for abdominal incisional hernia safe?

A: The latest artificial mesh repair surgeries for incisional hernia are very safe. The operation takes about 1-2 hours, the postoperative pain is low, and the recurrence rate is low. Please consult your doctor for advice.