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Incisional Hernia

Incisional hernia is a kind of hernia in the abdominal region that occurs along the incision of a previous surgical procedure.


Presentation

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.

Impaired Balance
  • Si Z, Bhardwaj R, Rosch R, Klosterhalfen B, Klinge U, Rhanjit B, Mertens PR (2002) Impaired balance of type I and type III procollagen mRNA in cultured fibroblasts of patients with incision hernia.[doi.org]
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]
  • A 46-year-old female presented four days following a laparoscopic surgery complaining of abdominal pain, nausea and lack of bowel movements. There was a palpable mass in the left lower quadrant under the 12mm trocar port incision.[ncbi.nlm.nih.gov]
  • A 63-year-old man was admitted to our department with continuous abdominal pain and irreducible minimal swelling in the right abdomen. His surgical history was significant for rectal cancer one year previously.[ncbi.nlm.nih.gov]
  • A multiparous woman with a known large incisional hernia presented at 33 weeks and 5 days gestational age with acute-onset, upper abdominal pain and nausea. The patient was diagnosed with small bowel obstruction secondary to an incarcerated hernia.[ncbi.nlm.nih.gov]
  • Seven months later, she presented miccional irritative symptoms and chronic lower abdominal pain. Leucocyturia and microhematuria were present, and computerized tomography showed 2 calcified nodules in the bladder wall.[ncbi.nlm.nih.gov]
Lower Abdominal Pain
  • Seven months later, she presented miccional irritative symptoms and chronic lower abdominal pain. Leucocyturia and microhematuria were present, and computerized tomography showed 2 calcified nodules in the bladder wall.[ncbi.nlm.nih.gov]
Chronic Abdominal Pain
  • Adhesions to mesh after ventral hernia mesh repair are detected by MRI but are not a cause of long term chronic abdominal pain. Gastroenterol Res Pract 2016; 2016:2631598 [Google Scholar] 15. Salati U, Mansour E, Torreggiani W.[ajronline.org]
Epigastric Mass
  • An objective examination showed an epigastric mass at the scar of the insertion site of a 5mm trocar during the cholecystectomy operation.[ncbi.nlm.nih.gov]
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]
Skin Lesion
  • Postoperative PG is always a differential diagnostic possibility in patients with sterile, progressive, painful, ulcerative skin lesions at or near the surgical wound.[ncbi.nlm.nih.gov]

Workup

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.

Microcytic 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]
Mycobacterium Chelonae
  • Mycobacterium chelonae is a rapidly growing mycobacterium that is found all over the environment, including sewage and tap water. They are important species associated with chronic non-healing wounds.[ncbi.nlm.nih.gov]

Treatment

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.

Prognosis

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.

Etiology

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.

Epidemiology

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.

Sex distribution
Age distribution

Pathophysiology

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.

Prevention

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.

Summary

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.

Patient Information

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.

References

Article

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  3. Hodgson NC, Malthaner RA, Ostbye T. The search for an ideal method of abdominal fascial closure: a meta-analysis. Ann Surg 2000; 231: 436–42.
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  11. Gottrup F. Healing of incisional wounds in stomach and duodenum. The influence of aging. Acta Chir Scand 1981; 147: 363–9.
  12. Hoer J, Lawong G, Klinge U, Schumpelick V. Factors influencing the development of incisional hernia. A retrospective study of 2,983 laparotomy patients over a period of 10 years. Chirurg 2002; 73: 474–80.
  13. Sorensen LT, Hemmingsen UB, Kirkeby LT, Kallehave F, Jorgensen LN. Smoking is a risk factor for incisional hernia. Arch Surg 2005; 140: 119–23.
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  17. Franchi M, Ghezzi F, Buttarelli M, Tateo S, Balestreri D, Bolis P. Incisional hernia in gynecologic oncology patients: a 10-year study. Obstet Gynecol 2001; 97(5 Pt 1): 696–700.
  18. Deak SB, Ricotta JJ, Mariani TJ, Deak ST, Zatina MA, Mackenzie JW et al. Abnormalities in the biosynthesis of type III procollagen in cultured skin fibroblasts from two patients with multiple aneurysms. Matrix 1992; 12: 92–100.
  19. Girotto JA, Malaisrie SC, Bulkely G, Manson PN. Recurrent ventral herniation in Ehlers-Danlos syndrome. Plast Reconstr Surg 2000; 106: 1520–6.
  20. Liem MS, van der GY, Beemer FA, van Vroonhoven TJ. Increased risk for inguinal hernia in patients with EhlersDanlos syndrome. Surgery 1997; 122: 114–5.
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  22. Uden A, Lindhagen T: Inguinal hernia in patients with congenital dislocation of the hip. A sign of general connective tissue disorder. Acta Orthop Scand 1988; 59: 667–8.
  23. Junge K, Klinge U, Klosterhalfen B, Rosch R, Stumpf M, Schumpelick V. Review of wound healing with reference to an unrepairable abdominal hernia. Eur J Surg 2002; 168: 67–73.
  24. Hein R, Mauch C, Hatamochi A, Krieg T. Influence of corticosteroids on chemotactic response and collagen metabolism of human skin fibroblasts. Biochem Pharmacol 1988; 37: 2723–9.
  25. Bingener J, Buck L, Richards M, Michalek J, Schwesinger W, Sirinek K. Long term Outcomes in Laparoscopic vs Open Ventral Hernia Repair. Arch Surg 2007 142 (6): 562–7.
  26. Nguyen SQ, Divino CM, Buch KE, Schnur J, Weber K, Katz LB, et al. Postoperative Pain After Laparoscopic Ventral Hernia Repair: a Prospective Comparison of Sutures Versus Tacks. Journal of Society of Laparoendoscopic Surgery 2008 12 (2): 113–6.
  27. LeBlanc KA. Incisional hernia repair: Laparoscopic techniques. World Journal of Surgery 2005 29 (8): 1073–9.

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Last updated: 2019-07-11 21:33