Incisional hernia

Incisional hernias are seen frequently after open procedures of the abdomen. Laparoscopic operations carry a lower risk of developing incisional hernias but they do occur. 

In incisional hernia the layers of the abdominal wall separate under the pressure from within the abdomen. The causes are poor surgical technique in closing the incision at the time of the first operation, weak thinned out abdominal wall structures, overweight, early start of physical exercise and/or work before the incision had healed properly etc.

The first sign is a bulge at the scar that increases in size especially with physical activity. An opening in the abdominal wall can be palpated and sometimes internal organs like bowel loops can be felt underneath the skin. This is where it gets dangerous, because a bowel loop can slip into the opening of the abdominal wall and get stuck there. The result is that the bowel swells and is stuck even tighter. Now the passage through the bowel is impaired and bowel obstruction begins. If this goes on further, the patient will start vomiting and the blood supply to the incarcerated bowel loop is diminished and finally stopped and the loop of bowel dies (necrosis). The patient is severely ill now and needs an operation immediately to save his live. The necrotic loop of bowel will have to be removed and sometimes these patients lose a significant amount of bowel in this process.

I have described the course of incarceration in more detail here, because it applies to all forms of hernias we deal with, whether it is incisional, inguinal, femoral, and umbilical and so on.

Of course operative treatment should come in long before the hernia reaches this dangerous point. Any hernia, no matter how small should be subject to surgery as soon as it is diagnosed. I always compare a hernia with a hole in a sock. It never closes by itself and gets bigger with use.

There are several surgical approaches to incisional hernias: The literature describes onlay- and sublay-techniques, direct suture of the defect and fascial transposition plasties. There is even a laparoscopic approach but its use is very limited because of the presence of adhesions following the primary operation and the extremely high cost of the materials necessary for the procedure.

I personally prefer a combination of a transposition plasty with an onlay repair using a Prolene mesh. This procedure is safe and efficient in my hands; it reconstructs the sometimes severely distorted shape of the body and has virtually no or very few complications. Hospital stay is 4-8 days and the patients have to restrain from heavy physical exercise (or work) for approximately 6 weeks.