Incisional Hernia

A hernia is a bulge that develops when the internal organs of the abdominal cavity are pushed out through a weakened spot in the abdominal wall.

An incisional hernia is the bulge that develops from a previous abdominal surgical scar that causes weakness in the abdominal area. Incisional hernias can occur with a few types of abdominal surgeries. The scars left from surgeries of the heart and intestine, appendectomy (removal of appendix) and laparoscopy (minimally invasive surgery) are prone to incisional hernia. Poor healing of the surgical incisions or pressure on the scars may cause a bulge to develop months or years after the surgery.

Several factors are responsible for developing an incisional hernia after surgery. These include:

• Being overweight
• Elderly
• Pregnancy
• Fluid retention
• Wound infection or bleeding after a surgery
• More than one surgery on the same incisional site
• Nutritional deficiency
• Previously treated with steroids or chemotherapy
• Lung problems
• Chronic cough
• Lifting heavy objects
• Intestinal swelling after an intestinal surgery
• Straining during constipation

An incisional hernia may also develop when tension is created while applying sutures to the wounds after surgery. The pressure on the abdominal wall increases in overweight patients thereby increasing the risk of hernia after any abdominal or groin surgery.

Signs & Symptoms

The first symptom of an incisional hernia is pain near the scar formed from a prior surgery. The site may or may not show a bulge. Symptoms may be more noticeable when the size of the bulge increases. Some other symptoms include:

• Pressure and fullness in the abdomen
• Pain and discomfort while bending or lifting
• Swelling near the incisional site which disappears after lying down (reducible hernia)
• Feeling of something being present in the incisional site
• Burning sensation

Inability to push back the hernia when you lie down may be due to a trapped hernia (incarcerated hernia) which can cause severe discomfort. Trapped hernias pose a risk for strangulation, where the blood supply to the herniated part is cut off, causing tissue death (necrosis). An incarcerated hernia can also obstruct your bowel thereby causing abdominal distension. These are emergency situations and require immediate medical attention. You may have a strangulated or incarcerated hernia if you experience the following symptoms:

• Nausea and vomiting
• Unable to pass bowel motions or gas
• Severe abdominal pain
• Non-reducible hernia / bulge

Screening & Diagnosis

The first step in the diagnosis of an incisional hernia is the review of symptoms and medical history. Your doctor will enquire about your prior surgeries, post-operative period and intensity of the pain.

A physical examination will be conducted where your doctor will examine the bulge and ask you to strain or cough to check for the prominence of the bulge at the incisional site.

Imaging tests such as ultrasound or computed tomography (CT) scan may be ordered to confirm a hernia and rule out tumours. The size of the hernia in the images can help your doctor decide the appropriate therapy for treating it.

Treatment Options

Surgery is indicated in the following conditions:

• Very large hernia which enlarges over time
• Bulge that does not reduce even when you lie down
• Painful hernia

Your doctor may recommend either open surgery or laparoscopic surgery based on the severity of the situation and what is most beneficial for you. Open surgery is the traditional approach for treating incisional hernias. In open surgery, your surgeon will make a single cut at the site of the bulge, remove the fat and scar tissue and push the internal organs back inside the abdominal cavity. In a laparoscopic surgery, several small incisions will be made on the abdominal wall to insert a laparoscope (flexible tube with a lighted device and a camera attached to it) and other special instruments. The bulge will then be pushed back into your abdomen.

The hernia is then repaired by one of two methods. An incisional hernia that is smaller than 3 centimetres may be repaired with just suturing the defect. However, larger hernias require a repair with a mesh patch to support the abdominal wall.

Recurrent incisional hernia repair may be prevented by following a few measures:

• Regular exercise to strengthen the abdominal muscles
• Avoid constipation and fluid retention to reduce abdominal pressure
• Lift heavy objects safely without straining