What is Incisional Hernia?
An incisional hernia is a type of hernia that occurs at the location of a past surgical cut in the abdominal wall. It falls under the category of ventral (front body wall) hernias. The most common place for these hernias to occur is in the center of the abdomen. It might be a complete hernia, with all the typical parts including the gap, sac, and displaced tissue. Alternatively, it may just be a weak spot in the wall with a small sac and an occasional bulge. This is a common issue surgeons often handle. Doctors frequently examine patients with incisional hernias because they can lead to discomfort. The usual symptom of this condition is a protrusion that can be felt more prominently when coughing. Individuals with incisional hernias also risk experiencing complications. These could include the hernia becoming trapped (incarcerated), blockage (if the displaced tissue is intestine), or reduced blood supply (strangulation). This discussion covers how to identify and manage incisional hernias.
What Causes Incisional Hernia?
Incisional hernias can happen after any surgery that involves a cut in the abdomen, and they may also occur after a traumatic injury to the abdominal wall. The hernia happens when the abdominal wall does not properly close after the surgery. Even with new advancements in surgical techniques, about 15% to 20% of all surgeries involving a cut in the abdomen may still result in an incisional hernia.
Although there is ongoing research on the best ways to prevent incisional hernias, surgeons still frequently encounter this issue. Factors that contribute to the failure of the abdominal wall to close properly can be grouped into patient-related factors, disease-related factors, and technical factors.
Patient-related factors include conditions that affect the body’s ability to heal the wound and to build strong tissue to support the abdominal wall. Conditions like diabetes, kidney failure, obesity, smoking, and malnutrition or long-term use of medications like steroids and immune system suppressants can increase the chances of someone developing an incisional hernia. Excessive obesity is a common risk factor.
Disease-related factors include the location of the cut, timing and urgency of the procedure, complications, and the specific disease that necessitated the procedure. Emergency surgeries, cuts made down the middle of the abdomen, infections, and surgeries for acute abdominal conditions are more likely to result in an incisional hernia. Developing an infection in the wound after surgery is a commonly associated risk factor.
The technical factors include the surgeon’s technique and the materials used to close the cut. If the technique is poor, it may result in a wound that does not heal properly, leading to an incisional hernia. When the edges of the cut in the fascia (a band of connective tissue below the skin) are not brought together properly with sutures of suitable strength and length, the chances of an incisional hernia occurring increase.
Despite advancements in techniques for closing the abdominal wall, the rate of incisional hernia after surgery involving an abdominal cut remains high – between 15% to 20%. Researchers continue to search for the best techniques to prevent incisional hernias.
Risk Factors and Frequency for Incisional Hernia
Each year, millions of abdominal surgeries are carried out across the globe, including in the USA. Unfortunately, a considerable number of these surgeries, about 20%, lead to complications in the healing of the wound. Over time, these complications can turn into an incisional hernia. At first, the hernia might not be noticeable. However, as time goes on, it tends to get worse and a bulge may become apparent. Anyone, regardless of age, gender, or ethnicity, can develop this condition.
Signs and Symptoms of Incisional Hernia
An incisional hernia is a condition where there’s a bulge on the belly where a previous surgical incision was made. Sometimes the bulge becomes more noticeable when there’s more pressure inside the abdomen, such as when coughing, sneezing, lifting heavy objects. Signs of an incisional hernia may vary. Some people may not notice any symptoms, while others may feel discomfort, pain, or show signs of complications such as a blocked or strangulated intestine. These symptoms often limit physical activities to prevent the hernia from getting worse.
During a physical check-up, doctors usually check the abdomen by touch. In most cases, the contents of the hernia can be felt. Sometimes, the edges of the hernia can be felt, giving an idea of its size. The doctor can then discuss the best surgical treatment options with the patient. If needed, imaging tests like computed tomography (CT) scans can be used. These scans are especially useful in early stages, in overweight patients, or in complex cases. They can confirm the diagnosis and help plan the surgical treatment.
In some cases, small incisional hernias are discovered during another abdominal surgery. If the surgeon operates at the same site where the previous scar is, or uses a laparoscopic method, they may see defects in the muscle layer of the abdomen with fat trapped inside.
Testing for Incisional Hernia
Most of the time, doctors can diagnose an incisional hernia (a type of hernia that occurs through a previously made incision in the abdominal wall) through a medical history review and a physical exam. However, sometimes, the hernia may be too small to detect or might be hidden in patients with obesity. In such cases, additional testing with imaging might be needed.
The most common method used to diagnose an incisional hernia is a computed tomography (CT) scan, which is a special type of X-ray taken from different angles to create a detailed view of your body. This method is not only useful for diagnosis, but it can also help plan the surgical treatment, especially in complex cases.
Other imaging techniques include ultrasound and magnetic resonance imaging (MRI). Ultrasound technology can help evaluate abdominal wall hernia by using high-frequency sound waves to create images of the inside of your body. MRI, on the other hand, uses a strong magnetic field and radio waves to generate detailed images of the inside of your body. However, MRI is less commonly used and whether it’s used or not depends on the hospital or clinic.
A comprehensive evaluation of an incisional hernia would include: confirming the diagnosis, measuring the size of the hernia opening, identifying what organs have moved into the hernia, and looking at the abdominal cavity to plan for surgery in complex hernias. A CT scan is often helpful in obtaining this information.
Treatment Options for Incisional Hernia
Treating an incisional hernia usually involves either surgical repair or non-surgical (conservative) treatment. The decision between these two options often depends on a few factors, such as if you are experiencing symptoms, the size of the hernia, potential complications, and your own personal preference. Small hernias that don’t cause any discomfort can usually be monitored without causing any major problems – in fact, the risk of complications in these cases can be as low as 2.6% per year according to some studies. However, larger or symptomatic hernias (hernias causing discomfort or other symptoms) should generally be surgically repaired if possible. This can help to prevent complications, relieve discomfort, and improve your quality of life.
There are several approaches to hernia repair surgery, including open surgery, laparoscopic surgery (using smaller incisions), and robotic surgery. The best technique for you will depend on your personal circumstances and the specific characteristics of your hernia. In most cases, a material called a “mesh” is used to help repair the hernia. This mesh acts as a kind of scaffold for your body’s own tissues to grow on, providing strength to the repair and helping to prevent the hernia from recurring. The mesh can be placed in different locations around the hernia, depending on the specific circumstances.
Different types of meshes are available for hernia repair. These are usually classified as permanent or absorbable (meaning they eventually dissolve), and synthetic or biological. Permanent, synthetic meshes are most commonly used. Absorbable meshes, which disappear over time, are typically used in situations where there might be contamination or infection. Biological meshes, which are made from tissues, may also be used in these situations, especially when a long-lasting solution is needed.
In general, if the hernia defect is 10 cm or smaller, the doctors will likely close the gap (fascial closure) and use mesh to support the repair. If closing the gap is not possible due to excessive tension, techniques such as component separation can be used. Do note that the specifics of surgical repair can be more complicated, and these details are discussed further with your doctor in other instances.
What else can Incisional Hernia be?
Some possible health issues that may present with similar symptoms include:
- Cancer
- Cyst
- Lipoma (a type of benign tumor)
- Wound infection
- Rectus diastasis (separation of the abdomen muscles)
What to expect with Incisional Hernia
The outlook for patients with incisional hernias — hernias that occur through an incision or scar from previous surgery — is somewhat uncertain. Even with the use of mesh and minimally invasive surgical techniques, these hernias often reoccur. Common issues include infection, pain, and the hernia coming back. If the patient can’t or doesn’t change the things that led to the hernia in the first place, the chance of the hernia recurring remains high.
There are also other serious complications associated with incisional hernias. These include bowel obstruction, where the normal flow of contents through the intestines is blocked; strangulation, where the blood supply to the hernia is cut off; and incarceration, where the hernia gets trapped and can’t be pushed back into the abdomen. These are serious conditions that require immediate medical attention.
Possible Complications When Diagnosed with Incisional Hernia
Incisional hernias tend to slowly grow larger over time. They may not cause any symptoms, or they might lead to a variety of symptoms. These hernias can result in some complications:
- Inmate hernia: This can be a chronic condition that doesn’t cause symptoms, often found in hernias with large defects, or it can be a sudden, likely symptomatic condition. It can be reduced or not, and it may be linked with other complications like blockage or no complication. In long-term inmate hernias, there can be adhesions or scar tissue that develops between the hernia and the sac. Small defect size can lead to a sudden onset of an inmate hernia.
- Obstruction: This is an immediate complication where the bowel gets blocked. If left untreated, it can lead to more severe complications like strangulation or rupture of the bowel.
- Strangulation: This can become a severe and immediate complication caused by an inmate hernia or obstruction. It demands immediate medical attention.
