The classical sign of incisional hernia is the appearance of bulges and protrusions at or near the site of the surgical incision. They appear as palpable lumps/masses or visible protrusions of internal elements, such as internal tissues, intestine, other organs. The emergence of these signs is usually accompanied by pain, fever and a high abdominal pressure. The bulges and protrusions might occur virtually from any abdominal operation, from large abdominal procedures like intestinal or vascular surgeries to small incisions like appendix removals, but appear to be particularly frequent from incisions lying along the straight vertical line going from the xiphoid process of the sternum to the pubis.

Other frequent signs include foul-smelling drainage, redness and/or red streaks, which usually indicate the presence of infections, and bowel obstruction as the result of intestine strangulation. These are usually associated with symptoms related to compromised organs, such as digestive disorders and jaundice due to liver protrusion.

• Fever

  Medicines: NSAIDs, such as ibuprofen, help decrease swelling, pain, and fever. This medicine is available with or without a doctor's order. NSAIDs can cause stomach bleeding or kidney problems in certain people. [drugs.com]

  The emergence of these signs is usually accompanied by pain, fever and a high abdominal pressure. [symptoma.com]

  So on history my patient said she initially had sharp poky persistent pain localized to the RIF then had fever 3 days prior to admission and 2 episodes of clear watery vomitus and diarrhea 1 day prior. [slideshare.net]

  Fever. Bulging lump of mass which is appeared on the scar is a symptom of incisional hernia. Bowel obstruction due to strangulation of the human intestines is a symptom of incisional hernia. [epainassist.com]

• Anemia

  We report an interesting case of transmural mesh migration into the small bowel presenting with chronic microcytic anemia and abdominal pain 5 years after laparoscopic incisional hernia repair with a composite polypropylene/ePTFE mesh. [ncbi.nlm.nih.gov]

  Older age, male gender, chronic pulmonary disease, coughing, ascites, jaundice, anemia, emergency surgery, wound infection, obesity, steroid use, hypoalbuminemia, hypertension, perioperative shock are also important risk factors. [websurg.com]

  Very important is also the presence of concomitant diseases, like anemia, diabetes mellitus and connective tissue disorders. Wound dealing might also be influenced by poor nutritional statuses, ill health, and environmental factors. [symptoma.com]

• Weight Gain

  Strenuous activity, substantial weight gain, or pregnancy can cause excessive stress on the healing abdominal tissue and should be avoided during this healing window. [mountsinai.org]

• Chronic Cough

  They may also be caused by increased intra-abdominal pressure due to a chronic cough (as in COPD), constipation, urinary obstruction (as in BPH), pregnancy, or ascites. They can also result from poor surgical technique. [en.wikipedia.org]

  […] or sneezing The factors that increase your risk of developing a hernia include: a personal or family history of hernias being overweight or obese a chronic cough chronic constipation smoking, which can trigger a chronic cough Conditions such as cystic [healthline.com]

  Persistently raised intra-abdominal pressure (e.g., due to ascites, pregnancy, intra-abdominal tumors, chronic cough, etc.) increases the risk of developing an abdominal hernia. [amboss.com]

  The greater the forces on the sutures, such as due to chronic coughing, heavy lifting soon after surgery, and patient heaviness, the more likely the sutures will pull through normal tissue. Dr. [drdumanian.com]

  For chronic constipation, the amount of fiber in one’s diet should be increased. [dovemed.com]

• Sneezing

  Forceful activities, such as coughing, sneezing or lifting heavy weights, may also lead to this type of hernia. [shouldice.com]

  Coughing or sneezing. Inappropriate surgical techniques or stitching is a major cause of incisional hernia. [epainassist.com]

  The hernia may not be noticeable unless the patient is involved in an activity that increases abdominal pressure, such as coughing, sneezing, pushing to have a bowel movement, or lifting a heavy object. [surgery.about.com]

  Anything that causes an increase in pressure in the abdomen can cause a hernia, including: Lifting heavy objects without stabilizing the abdominal muscles Diarrhea or constipation Persistent coughing or sneezing In addition, obesity, poor nutrition, and [webmd.com]

• Respiratory Distress

  distress Normal results Good outcomes are expected with incisional hernia repair, particularly with the laparoscopic method. [surgeryencyclopedia.com]

• Abdominal Pain

  We report an interesting case of transmural mesh migration into the small bowel presenting with chronic microcytic anemia and abdominal pain 5 years after laparoscopic incisional hernia repair with a composite polypropylene/ePTFE mesh. [ncbi.nlm.nih.gov]

• Abdominal Distension

  Many factors are associated with incisional herniation: old age, male sex, obesity, bowel surgery, type of suture, chest infection, abdominal distension, and, most important, wound infection. [ncbi.nlm.nih.gov]

  distension and wound infection. [casesjournal.biomedcentral.com]

  An incarcerated hernia can also obstruct your bowel thereby causing abdominal distension. These are emergency situations and require immediate medical attention. [southwestaustinsurgical.com]

• Diarrhea

  So on history my patient said she initially had sharp poky persistent pain localized to the RIF then had fever 3 days prior to admission and 2 episodes of clear watery vomitus and diarrhea 1 day prior. [slideshare.net]

  Anything that causes an increase in pressure in the abdomen can cause a hernia, including: Lifting heavy objects without stabilizing the abdominal muscles Diarrhea or constipation Persistent coughing or sneezing In addition, obesity, poor nutrition, and [webmd.com]

  Such symptoms may include nausea, vomiting, diarrhea or constipation. The development of severe gastrointestinal symptoms may indicate that the hernia has become strangulated—a potentially life-threatening condition if left untreated. [livestrong.com]

  Nausea, vomiting, diarrhea, and abdominal swelling may also be present. Think of it as the hernia equivalent of typing a string around your finger until it turns purple and hurts and then you cannot get the string off. [surgery.about.com]

• Tachycardia

  Diagnosis is made on a clinical basis with the identification of the combination of hypotension, tachycardia, oliguria, and increased bladder pressures. [ajronline.org]

• Jaundice

  Older age, male gender, chronic pulmonary disease, coughing, ascites, jaundice, anemia, emergency surgery, wound infection, obesity, steroid use, hypoalbuminemia, hypertension, perioperative shock are also important risk factors. [websurg.com]

  These are usually associated with symptoms related to compromised organs, such as digestive disorders and jaundice due to liver protrusion. [symptoma.com]

  Pain Infection Visible protrusion (see internal segment poking out of surgical wound) Aching Swelling Other symptoms can include digestive disorders & jaundice because of protrusion of the liver. [epainassist.com]

  Post-operative transfusion Chemotherapy Radiotherapy Abdominal aortic aneurysm surgery Patient-related History Age Male sex Previous incisional hernia surgery Emergency surgery Smoking Comorbidities Obesity Chronic pulmonary disease Type 2 diabetes mellitus Jaundice [www1.racgp.org.au]

  Pt. appears to be in pain (pt. rates it 6/10) Vitals: Temp: 37.9 BP: 112/82 PR: 89 RR: 20 HEENT: Nil(s)- pallor, jaundice, cyanosis. [slideshare.net]

• Purpura

  On the 3rd day following surgery to repair an incisional hernia, a 67-year-old male patient with Werlhof's disease (idiopathic thrombocytopenic purpura) was diagnosed with a histologically confirmed pyoderma gangraenosum (PG), a rare complication of wound [ncbi.nlm.nih.gov]

• Muscle Weakness

  An incisional hernia, or ventral hernia, is caused by muscle weakness at the site of a previous surgical wound. They can occur following nearly any type of abdominal procedure, including caesarian section births and appendectomies. [floridasurgicalspecialists.com]

  Sometimes the muscle weakness is present at birth; more often, it occurs later in life. [webmd.com]

  Hernias are caused by a combination of muscle weakness and strain. Depending on its cause, a hernia can develop quickly or over a long period of time. [healthline.com]

  Usually the area of muscle weakness is reinforced with a synthetic or biologic mesh to provide additional support to reduce the likelihood of recurrence. Laparoscopic Ventral Hernia Repair Laparoscopic surgery is performed using general anesthesia. [transplant.surgery.ucsf.edu]

• Back Pain

  Truly massive incisional hernias, otherwise known as abdominal wall failure, may also cause core instability, back pain, respiratory compromise and difficulty evacuating due to an inability to increase intra-abdominal pressure. [www1.racgp.org.au]

It is very important to check the patient’s medical history for previous surgical procedures at the abdominal area and complications in the postoperative periods. After this, the surgeon should establish the amount of pain and discomfort experienced by the patient and see if there are signs of hernia size increment by touching the surface of the abdomen. A typical sign to observe is the increase of the hernia size when the patient couches, makes an effort, or bends downwards.

Radiological tests, such as ultrasound examination and computed tomography, can be very useful for the diagnosis of IH, especially when still in doubt after performing the aforementioned physical examinations, or to know the extent of the hernia and the contents of bulges and protrusions.

• Pneumoperitoneum

  Pre-operative progressive pneumoperitoneum is a technique which has been used in such cases. [ncbi.nlm.nih.gov]

There are two major surgical methodologies to treat incisional hernia, the open repair and the laparoscopic repair. The open repair is the classical surgical procedure, during which is made an incision which is large enough to allow the removal of the tissue in excess. After tissue removal, a mesh is applied to overlap the weakened area by several centimeters in all directions. Since the open repair usually requires large sized incisions, the occurrence of complications is quite frequent, especially infections on the points where sutures and meshes are applied. Furthermore, the large sized incisions required by this methodology frequently cause significant postoperative pain.

Laparoscopic repair is a reasonable alternative to open repair, and represents a new surgical methodology for surgeons and physicians [25] [26] [27]. In this procedure two or three small incisions are made at the site of the hernia. One of these is used to insert the laparoscope, while the others are used to insert the instruments necessary to perform the procedure itself. The tissue in excess is removed and a mesh is placed underneath the abdominal muscles. Laparoscopic repair is much less invasive, technically feasible and allows to remove much less abdominal wall tissue.

The prognosis of incisional hernia is good, especially when laparoscopy is used as surgical method. The period of recovery is usually of one or two weeks, and the patient can immediately go home soon after the surgery. According to the American College of Surgeons, recurrence rates generally vary from 25% to 52%, with peaks when the surgical operation is performed using conventional surgical wound closures and standard stitches. Complications, instead, especially infections, are more frequent with larger abdominal incisions. Laparoscopy repair appears to have the lowest recurrence rates, as low as 3.4%, and the lowest frequency of complications.

An incisional hernia emerges when there is a point of weakness in the muscle of the abdomen, that allows the formation of a hole through the muscle itself. This hole then permits the internal abdomen tissues to protrude outside and form the hernia. The hernia might occur due to a weakness of the surgical wound caused by hematomas, seromas or infections, or be the final outcome of an increased intraabdominal pressure due to various conditions such as pregnancy, chronic cough or urinary obstruction. Otherwise, the point of weakness is simply the final result of poor surgical techniques. The protrusion contains the peritoneum as superficial layer, which forms a saclike internal structure lining the protruding organs within [1].

In the mildest cases, incisional hernia appears as a small protrusion, where only the peritoneum protrudes through the abdominal hole. In the most severe cases, instead, entire portions of the internal abdominal organs, especially the intestine, move through the hole, determining the formation of unsightly and painful hernias which enormously enlarge the abdominal diameter.

No precise estimations can be done about the incidence and prevalence of IH, since the epidemiological data coming from the developing countries, where there is the majority of the human population, are limited. Anyway, according to several studies conducted in USA, 10% of the population should develop some kind of hernia during life [2]. 10% of these turn out to be cases of incisional or ventral hernia, which occur in the aftermath of 2-10% of all abdominal operations.

The IH pathophysiology is influenced by at least two elements: the surgical technique and the patient-related factors.

Surgical techniques

Suture materials appear to have a certain effect on the IH incidence. According to several meta-analysis studies, the lowest values of incidence can be observed with the use of monofilamentous, nonresonable or long-term reasonable suture materials [3] [4] [5]. In any case, this advantage has to be balanced against the presence of a permanent mechanical tissue irritation, which determines a higher incidence of fistula formation and higher rates of postoperative wound pain. Suture tension too can influence IH incidence, as it might disturb wound healing and stable scar formation.

Patient-related factors

There are several patient-related factors which have a direct or indirect influence over wound healing and IH incidence. Infections and seromas, which frequently occur after medical procedures, represent important risk factors [6] [7] [8], as they increase cytokine and protease production, thus reducing fibroblasts and wound stability [9].

Aging becomes a significant risk factor after the age of 45, since it delays wound healing through changes in fibroblasts and collagen formation [10] [11]. On the other hand, the influence of gender is not clear, as some studies appear to suggest a higher frequency in males than females [12] [13] [14] [15], while others underline no significant difference between the two [16]. Very important is also the presence of concomitant diseases, like anemia [17], diabetes mellitus [18] and connective tissue disorders [19] [20] [21] [22].

Wound dealing might also be influenced by poor nutritional statuses, ill health, and environmental factors. Among these there are smoking, which favors hernia recurrence and formation, and several drugs, as some of them might be able to influence wound healing stages [23] [24]. Many of these medications are pharmaceuticals with widespread use, like ACE inhibitors, corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDs), and chemotherapeutic agents.

The prevention mainly depends on three major factors. The first one in undoubtedly the type of surgical techniques used by the surgeon, which should be carefully chosen to minimize further complications in the subsequent postoperative phase. The second is the patient’s compliance in following the discharge instructions, which are studied to avoid surgical wound contamination and help surgical wound healing. In this regard, physicians strongly advise the use of special gels developed to promote wound healing.
The third factor influencing prevention is the behavior of the patient himself, who should avoid all those activities that put pressure on the abdominal incision. In particular, these include measures like avoiding overexertion, treating constipation to avert straining, avoiding sexual activities during wound healing and reducing or eliminating smoke.

An incisional hernia (IH) appears along the vertical incisions of previous abdominal surgeries, after some months or even years from the procedure. Therefore, most of the time the condition occurs as a post-surgical complication which appears in subjects who usually are very overweight, in advanced ages, have made use of steroid medications, or have experienced lung complications after the surgical procedure. Very frequent are also cases forming after post-surgical wound infections or when the same incision has been used more than once in multiple operations.

Incisional hernia is often large in size and painful, requiring immediate medical attention. Not all the cases appear along incisions of former surgical procedures, because some might develop due to other types of trauma or congenital problems.

Incisional hernia is a kind of hernia in the abdominal region that occurs along the incision of a previous surgical procedure after some months or years. It emerges when there is a point of weakness in the muscle of the abdomen, that allows the formation of a hole through the muscle itself. This hole then permits the internal abdomen tissues to protrude outside and form the hernia.

The pathophysiology is influenced by two elements, the surgical technique and the patient-related factors. The prognosis is very good, especially when laparoscopy is used as surgical method. The classical sign is the appearance of bulges and protrusions at or near the site of the surgical incision, which appear as palpable lumps/masses of internal elements, like internal tissues, intestine, fatty contents or organs. The emergence of these signs is usually accompanied by pain, fever and a high abdominal pressure.

There are two major surgical methodologies to treat IH, the open repair and the laparoscopic repair. The open repair is the classical surgical procedure, during which an incision is made which is large enough to allow the removal of the tissue in excess. Laparoscopic repair is a reasonable alternative to open repair, in which two or three small incisions are made at the site of the hernia. One of these is used to insert the laparoscope, while the others are used to insert the instruments necessary to perform the procedure itself. The tissue in excess is removed and a mesh is placed underneath the abdominal muscles.

The prevention of incisional hernia mainly depends on three major factors. The first one in undoubtedly the type of surgical techniques used by the surgeon, the second is the patient’s compliance in following the discharge instructions, while the third is the behavior of the patient himself, who should avoid all those activities that put pressure on the abdominal incision.

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