Incisional Hernia and Its Treatment

An incisional hernia is a bulge in the abdomen that forms when tissues or organs protrude at the site of a surgical scar. It can occur when the surgical incision weakens the abdominal muscles, which normally protect, support, and hold in the abdominal organs. An incisional hernia is a common complication associated with abdominal surgery.

A surgical incision in the abdomen can allow the abdominal lining or abdominal organs to push through the stomach wall directly under the skin. It can be painful or tender to the touch. Surgical repair is the only curative treatment for an incisional hernia. However, nonoperative management may be an option if the hernia is small and asymptomatic.

Incisional Hernia Causes and Risk Factors

Sometimes, muscles that have been cut during abdominal surgery might not fully heal, and a gap can open up as the muscles move during your regular physical activities.

The incision is weakest, and most prone to a hernia, while it is still healing. Incisional hernias are most likely to develop three to six months after surgery, but they can develop or enlarge months or years after surgery.

After a while, the structures underneath may escape through the muscle gap and start to poke through the opening, to the point where they can be felt under the skin. In severe cases, portions of organs may move through the hole, but this is much less common.

Incisional hernias range in size from small to very large, depending on factors such as the size of the surgical incision, how well your muscles heal, and how long you've had the hernia.

A history of multiple abdominal surgeries may increase the risk of an incisional hernia. Gaining significant weight after abdominal surgery, anemia, hypoproteinemia, malnutrition, diabetes, immunosuppression, old age, and male gender are risk factors for incisional hernia.

Diagnosis

Incisional hernias may seem to appear and disappear. This is described as a reducible hernia. The hernia might only be noticeable during activities that increase abdominal pressure, such as coughing, sneezing, pushing to have a bowel movement, or lifting a heavy object.

Your doctor can diagnose your hernia with a physical examination, and it doesn't usually require diagnostic testing. Your healthcare provider may request that you cough or bear down so they can see the hernia during your physical examination.

If the hernia is large enough to allow more than the lining of the abdominal cavity to bulge through, testing may be required to determine which organs are affected.

Strangulated Incisional Hernia

A hernia that gets stuck in the "out" position is referred to as an incarcerated hernia. This can quickly become an emergency if it becomes a strangulated hernia, in which blood, food, or stool can't flow through the intestines.

A strangulated hernia can cause necrosis (death) of the tissue that is bulging through the hernia. This could be so severe that you would need to have a portion of your intestines surgically removed, and it can be life-threatening.

A strangulated hernia may have a deep red or purple color of the bulging tissue. It may be accompanied by severe pain, but is not always painful. Nausea, vomiting, diarrhea, and abdominal swelling may also be present.

This is analogous to tying a string so tight around your finger that your finger swells, preventing you from getting the string off.

Incisional Hernia Treatment

An incisional hernia may need surgical repair to prevent it from getting larger, and to prevent incarceration or strangulation.

A truss is a nonsurgical option. This is a garment that is similar to a weight belt or girdle that applies constant pressure to a hernia. A truss treats the symptoms of a hernia and not the actual hernia. The only curative treatment is surgical repair.

An incisional hernia may require surgery if:

• It continues to enlarge over time
• It is very large
• It is cosmetically unappealing
• The bulge remains even when you are relaxed or lying down
• The hernia causes pain

Your doctor might recommend surgery if you are at risk of complications. In some of these cases, the decision of whether to have surgery is up to you. You may want to have surgery if you're feeling uncomfortable or are concerned about how the hernia looks, for example.

Incisional Hernia Repair Surgery

Incisional hernia repair surgery is typically done on an inpatient basis and requires general anesthesia. Incisional hernia repairs can be performed laparoscopically or with an open repair, depending on factors such as the size of the hernia and the presence of excess skin. The surgery is often performed using the laparoscopic method, using small incisions rather than a large open incision.

Surgery is performed by a general surgeon or a colon-rectal specialist.

During the procedure incisions are made on either side of the hernia. A laparoscope is inserted into one incision, and the other incision is used for the insertion of additional surgical instruments. The surgeon isolates the hernia sac (the portion of the abdominal lining that is pushing through the muscle) and returns it to its proper position. If the defect in the muscle is small, it may be sutured closed to prevent the hernia from returning.

For large defects, suturing might not be adequate. In this case, the hernia is closed and a mesh graft will be used to cover the hole. The mesh is permanent and prevents the hernia from returning. Once the mesh is in place or the muscle has been sewn, the laparoscope is removed. The skin incision is closed. The incision is typically closed with dissolvable sutures. Medical glue or adhesive strips (Steri-Strips) may also be used.

If only a suture method is used with larger muscle defects (approximately the size of a quarter or larger), there is an increased chance of reoccurrence. The use of mesh for larger hernia repairs is the standard of treatment, but it may not be appropriate for people who have a history of rejecting surgical implants or who have a condition that prevents the use of mesh.

Recovery

Most people who have hernia repair surgery are able to return to their normal activity within about three weeks after surgery. The abdomen will be tender, especially for the first week after surgery.

While healing, the incision should be protected during any activity that increases abdominal pressure by applying firm but gentle pressure on the incision line.

Activities during which the incision should be protected include:

• Rising from a seated position
• Sneezing
• Coughing
• Bearing down during a bowel movement (contact your surgeon if you are constipated after surgery, a stool softener may be prescribed)
• Vomiting

You should not lift heavy objects when you are healing.

Call your doctor if you have severe pain, increasing pain, fever, or if you see any pus or redness around the incision.