Overview
Definition:
Herniation of wrap, also known as incisional or ventral hernia, refers to the protrusion of intra-abdominal contents through a defect in the abdominal wall at the site of a previous surgical incision
This is a common complication following abdominal surgery
It can arise from various factors including wound infection, dehiscence, poor surgical technique, and patient-specific risk factors.
Epidemiology:
The incidence of incisional hernias varies widely, ranging from 2% to 20% or more, depending on the type of incision, surgical technique, and patient factors
Factors like obesity, smoking, diabetes, and wound infection significantly increase the risk
Older age and prolonged postoperative ventilation are also associated with higher rates.
Clinical Significance:
Incisional hernias pose significant clinical challenges
They can cause pain, discomfort, and cosmetic deformity
More critically, they are prone to complications such as incarceration (trapping of contents) and strangulation (compromise of blood supply to the incarcerated contents), which are surgical emergencies requiring prompt intervention
Recurrence after repair is also a major concern, necessitating careful management and appropriate surgical techniques.
Clinical Presentation
Symptoms:
A visible or palpable bulge at the site of a prior surgical scar
Pain or discomfort, often exacerbated by straining, lifting, or standing
A dragging sensation
Nausea and vomiting if incarceration or obstruction occurs
Tenderness over the bulge if strangulation is suspected
A history of previous abdominal surgery is paramount.
Signs:
A protuberant bulge that may increase in size when the patient stands or strains
The bulge may be reducible (contents can be pushed back into the abdomen) or irreducible (incarcerated)
Signs of strangulation include severe pain, erythema over the bulge, systemic signs of sepsis (fever, tachycardia, hypotension), and absence of bowel sounds.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on patient history and physical examination findings
Imaging modalities like ultrasound or CT scan may be used to confirm the diagnosis, delineate the size and contents of the defect, and identify associated pathology, especially in complex or recurrent cases
There are no specific formal diagnostic criteria beyond clinical suspicion and confirmation.
Diagnostic Approach
History Taking:
Detailed history of previous abdominal surgeries, including type of incision, any complications (e.g., wound infection, dehiscence), and previous hernia repairs
Onset and progression of symptoms
Nature and severity of pain
Associated gastrointestinal symptoms
Patient's risk factors for hernia development (obesity, smoking, chronic cough, immunosuppression, diabetes).
Physical Examination:
Inspection for visible bulges, especially in erect posture or Valsalva maneuver
Palpation to assess size, reducibility, and tenderness of the bulge
Auscultation for bowel sounds over the bulge
Careful examination of the entire abdominal wall to rule out other hernias.
Investigations:
Ultrasound is useful for initial assessment, particularly in obese patients or to differentiate from other soft tissue masses
CT scan is more definitive, assessing the fascial defect, contents, and identifying any incarcerated bowel
It is also useful for planning complex or redo repairs
Laboratory investigations are typically not required for uncomplicated hernias but are essential in suspected incarceration/strangulation to assess for infection and electrolyte imbalances.
Differential Diagnosis:
Other causes of abdominal wall masses: lipomas, hematomas, desmoid tumors, sarcomas, abscesses
Postoperative seromas
Rectus sheath hematoma
Endometriosis
Incisional abscess
Epidermal inclusion cysts.
Management
Initial Management:
For uncomplicated hernias, management involves elective surgical repair
For incarcerated or strangulated hernias, immediate surgical intervention is required
Patients should be made NPO (nil per os), given IV fluids, and broad-spectrum antibiotics
Pain management is crucial
Reduction of incarcerated contents may be attempted cautiously if no signs of strangulation are present, but this should not delay definitive surgical intervention.
Medical Management:
There is no medical management for a hernia itself
Medical management is supportive and involves pain control and management of co-morbidities that increase surgical risk
In cases of bowel obstruction due to incarceration, nasogastric decompression and fluid resuscitation are essential preoperatively.
Surgical Management:
Surgical repair is the definitive treatment
Options include: Primary repair (suturing the fascial edges), Mesh repair (using synthetic or biological mesh to bridge the defect), and Laparoscopic repair (minimally invasive approach)
The choice depends on hernia size, location, patient factors, and surgeon preference
Redo surgery for recurrent hernias requires careful planning and often involves mesh reinforcement
Techniques like component separation may be used for large or complex defects.
Supportive Care:
Postoperative care includes adequate pain control, early mobilization, and prevention of respiratory complications
For patients with risk factors, interventions like smoking cessation and weight management should be strongly encouraged
Nutritional support is important, especially in malnourished patients or those with prolonged recovery.
Complications
Early Complications:
Wound infection
Hematoma
Seroma
Fascial dehiscence
Mesh infection
Injury to intra-abdominal organs
Ileus
Urinary retention
Deep vein thrombosis (DVT) and pulmonary embolism (PE).
Late Complications:
Hernia recurrence
Chronic pain
Mesh-related complications (migration, erosion, chronic infection, fistula formation)
Adhesions
Bowel obstruction secondary to adhesions.
Prevention Strategies:
Meticulous surgical technique with proper wound closure in layers
Use of absorbable or non-absorbable sutures appropriate for fascial closure
Avoidance of excessive tension on sutures
Prophylactic antibiotics
Management of modifiable risk factors (smoking cessation, diabetes control, weight reduction)
Careful handling of tissues
Appropriate use of mesh for large defects or in high-risk patients
Consideration of minimally invasive techniques where appropriate.
Prognosis
Factors Affecting Prognosis:
The prognosis depends on the complexity of the hernia, the presence of incarceration or strangulation, the chosen surgical technique, and the patient's co-morbidities
Recurrence rates are higher with primary repairs and in obese or smokers
Successful repair of uncomplicated hernias generally has good outcomes.
Outcomes:
For uncomplicated hernias, successful surgical repair leads to relief of symptoms and improved quality of life
Recurrence rates can be as low as 1-5% with modern mesh techniques in experienced hands, but can be significantly higher with primary repairs or in recurrent cases
Strangulated hernias carry a higher morbidity and mortality, especially if bowel resection is required.
Follow Up:
Follow-up is essential to monitor for recurrence and potential complications
Initial follow-up is typically at 2-4 weeks post-operatively, with further checks as needed
Patients should be educated on signs of recurrence or complications and advised to seek medical attention promptly
Long-term follow-up may be recommended for complex repairs or in high-risk individuals.
Key Points
Exam Focus:
Differentiate between reducible, incarcerated, and strangulated hernias
Understand indications for mesh versus primary repair
Recognize immediate management for strangulated hernia
Know common causes of recurrence
Laparoscopic versus open repair principles.
Clinical Pearls:
Always consider incisional hernia in patients with prior abdominal surgery presenting with a bulge
Do not delay surgery for strangulated hernias
reduction attempts should be brief and not postpone definitive care
Preoperative optimization of co-morbidities significantly impacts outcomes
Meticulous closure of the fascia is key to preventing primary hernias.
Common Mistakes:
Attempting primary repair for very large defects, leading to high recurrence
Underestimating the risk of strangulation in incarcerated hernias
Inadequate management of patient risk factors (obesity, smoking)
Failure to consider mesh reinforcement in appropriate cases
Delayed diagnosis of strangulation leading to bowel loss.