Incisional h ernias occur along the scar of a previous abdominal operation. All factors that disrupt wound healing after abdominal surgery can lead to incisional hernias.
Risk factors for an incisional hernia are
- Severe obesity
- smoking
- Metabolic disorders of the connective tissue
- Several previous abdominal operations
- Difficulties with surgical closure of the abdominal wall
- Bleeding after the operation
- Wound infection
Anemia and diabetes can also interfere with wound healing. These patients therefore have an increased risk of an incisional hernia.
With an abdominal wall hernia, contents from the abdominal cavity leak out through a weak point.
In an abdominal wall hernia, contents leak out of the abdominal cavity through a weak point. In incisional hernias, the weak point is a previous surgical scar © blueringmedia | AdobeStock
An incisional hernia may or may not cause symptoms.
Initially, the incisional hernia is noticeable as a pulling sensation in the scar. Later, a swelling and protrusion can usually be seen, which can be easily pushed back into the abdominal cavity. However, it can become larger when standing up.
Pain occurs in particular
- when coughing
- during the urge to defecate
- during physical and sporting activity
The incisional hernia can remain visible even when lying down and without straining.
It becomes dangerous if the intestine that has passed through is trapped in the hernial orifice. This causes severe pain. The protrusion can no longer be pushed back. This situation can lead to a life-threatening intestinal obstruction.
The intestinal section may no longer receive sufficient blood and oxygen. The affected area is at risk of dying off. Bacteria enter the abdominal cavity and the vascular system. There is an acute danger to life. Sudden, colicky abdominal pain with fever, nausea and vomiting may occur.
In acute cases, you should go to hospital immediately. An incisional hernia operation is usually performed quickly. Even in non-acute situations, you should not delay the operation.
The doctor will make a suspected diagnosis based on the protrusion of the scar and other symptoms. He will feel the scar and check whether and how easily the hernia sac can be pushed back into the abdominal cavity. If the hernia cannot be pushed back, there is a risk that it is trapped. Immediate incisional hernia surgery is then necessary.
Depending on the size of the incisional hernia and the weight of the patient, additional examinations may be necessary in individual cases. They are used to diagnose and assess the severity of the incisional hernia.
Additional examination methods are
This allows doctors to recognize the different layers of the abdominal wall and any gaps. Further instrumental examinations are not normally necessary.
Surgery is also necessary in the following situations
- persistent complaints
- social withdrawal
- Reduced quality of life
- impending or permanent inability to work
There should be a gap of at least three (preferably six) months between the operation and the previous surgical procedure.
After the examination, the doctor will advise the patient on treatment options and the next steps.
Surgery can be performed under local anesthesia for a small incisional hernia. A larger incisional hernia with the opening of the abdominal cavity is performed under general anesthesia. An anesthetist will inform you about the procedure and the risks of anesthesia before the operation.
In the case of an incisional hernia operation under general anesthesia, you will have to stay in hospital for five to ten days, depending on the course of the operation.
The day before the operation, the patient will be given a mild laxative and thrombosis prophylaxis. On the day of the incisional hernia operation, you will be given a sedative.
Depending on the type of original abdominal surgery and the size of the hernia, the doctors close the hernia using
The standard procedure is open incisional hernia closure with plastic mesh reinforcement.
- Open incisional hernia surgery
In open incisional hernia surgery, doctors expose the hernia sac through an incision. The surgeon pushes the contents of the hernia sac back into the abdominal cavity.
The hernial orifice is closed:
- by directly suturing the fascia (supporting fibrous layer of the abdominal wall)
- by doubling the fascia
- by stabilizing the hernial orifice closure with artificial materials
In fascial doubling, surgeons suture the edges of the abdominal wall layers (fascia) in an overlapping (doubled) fashion, which allows for greater stability. This procedure is also known as Mayo incisional hernia surgery.
In the case of a larger incisional hernia, doctors reinforce the suture with non-dissolvable plastic mesh or a combination of plastic mesh and the body's own material
- Closed incisional hernia surgery
In closed surgery, the hernial orifice is accessed through the abdominal wall via laparoscopy. The surgeon makes small incisions through which he inserts a small light source and tiny instruments.
The image from the camera can be seen live and enlarged on a monitor in the operating room. The surgeon uses the camera image to perform the operation inside the body.
Using special instruments, the surgeon closes the hernial orifice and also inserts a plastic mesh into the abdominal wall.
Laparoscopic incisional hernia surgery is a gentle surgical procedure.
The advantages:
- Less pain after incisional hernia surgery
- lower wound infection rate and
- faster physical recovery of the patient
In the case of a small incisional hernia (hernial orifice < 2 cm), the hernia is closed by suturing the edges of the hernia with a strong suture.
This operation is performed under general anesthesia and on an outpatient basis.
The advantages:
- Shortness of the procedure
- Low trauma
- Low complication rate
Due to the lack of reinforcement with a synthetic mesh, there is an increased risk of a repeat fracture. In addition, the patient must take it easy physically for several weeks.
Surgeons use open or minimally invasive plastic mesh for reinforcement. It is usually made of polypropylene, which is well tolerated.
The mesh must not come into contact with the intestinal loops, as otherwise there is a risk of adhesions. For this reason, polypropylene mesh with a layer that prevents adhesions has been available for some years.
The difference between the various methods of incisional hernia surgery with plastic mesh is the position of the mesh within the abdominal wall.
The most common procedures are
- Incisional hernia surgery using the sublay technique (below the abdominal muscles)
- Intraperitoneal onlay mesh (IPOM, position of the mesh between the intestine and peritoneum).
- Inlay technique (doctors insert the mesh into the hernia gap)
Detailed information on the procedures is provided below.
- Incisional hernia surgery: IPOM technique (intraperitoneal onlay mesh)
In this technique, doctors first fill the abdominal cavity with gas (pneumoperitoneum). The surgeon then loosens any adhesions (adhesiolysis).
A plastic mesh, which is fixed to the inside of the abdominal wall between the intestine and peritoneum, covers the hernia gap from the inside.
This incisional hernia operation is performed using keyhole surgery. As a result, wound infection rates and post-operative pain are low.
However, large hernias are not always suitable for this procedure.
The sublay mesh technique is an open surgical procedure for large incisional hernias that is only performed under general anesthesia. Doctors make a skin incision above the hernia sac. They then expose the hernia sac and remove it if necessary.
The surgeon loosens any adhesions in the abdominal cavity and pushes the contents of the hernia sac back into the abdominal cavity. They fix the plastic mesh underneath the abdominal muscles with a few sutures or a fibrin glue.
Incisional hernia surgery can lead to the following complications:
- Wound infections
- Seroma formation (accumulation of body fluids in cavities in the wound area)
- Hematomas (bruising)
When using a mesh, the infection rate is up to ten percent. Hematomas and seromas occur much more frequently with the use of a mesh than with direct closure of the incisional hernia.
The accumulation of fluid disappears after two to six weeks. In the case of large accumulations, doctors remove the fluid via a puncture.
Hardening may occur in the surgical area. Nerve injuries usually cause temporary (rarely permanent) numbness.
Occasionally, the patient complains of restricted movement and pain in the abdominal area.
Even with modern plastic meshes, there is a likelihood of a new hernia.
Normal eating is possible after incisional hernia surgery. A gradual build-up of food may be necessary.
The result of the incisional hernia operation is checked by the surgeons using ultrasound. Immediately after the operation, they will apply an elastic abdominal girdle to support healing. The patient should wear it day and night for a few weeks.
Ten to twelve days after the operation, the doctors will remove the stitches and you will be able to put more weight on your body. You should avoid heavy physical exertion (lifting over 20 kg) for three months .
No special aftercare is required.
