Incisional Hernias

Question 1

What are incisional hernias?

Answer 1

Hernias arising after incompletely healed surgical wound
Rare in thoracic and limb wounds
Less than 10% of mid line laparotomy suffer herniation to some degree

Question 2

Risk factors

Answer 2

• Wound infection
• Steroid use
• Malnutrition at the time of original surgery
• Heavy labor increases risk of incisional hernias and are becoming significant
• slightly less common after muscle splitting/ transverse incision compared to midline laparotomy
• the peak time of presentation is up to 5 years after surgery

Question 3

Clinical presentation

Answer 3

• the hernia occurs through the tissue in which the incision was made

Typically, the sac is made up of peritoneum, eventrated (protruded) and subcutaneous scar tissue

May vary from a few cm to a near complete defect in the anterior abdominal wall

The risk of strangulation is maximal in small to medium size defects

Large/very large defects: the viscera are often permanently herniated, and for a long period, the remaining lateral abdominal wall tissue chronically retracts and there may be insufficient room for all the viscera within the revised abdominal cavity when the tissues are re-approximated

Question 4

Treatment

What do you ask yourself?

Answer 4

What is the risk of complications/strangulation?
Is it likely that the contents of the hernia be reduced fully?
Is the patient able to undergo the anesthesia necessary for the surgery required?
Is there a risk to respiratory function if a very large incisional hernia is reduced and repaired?

Question 5

Treatment of different sized defects

Answer 5

Small: simple sutured repair

Medium: overlapping (mayo) sutured repair +/- reinforcing “onlay” mesh

Large: interposition mesh (inlay?) (prosthetic/porcine collagen)

For unfit/ those refusing surgery: a custom made support corset is often useful