Incisional Hernias
Lawrence H. Knott, Jr., MD, FACS

Incisional hernias are those that occur in the abdominal wall where a prior surgical procedure was done. The abdominal wall is composed of several layers including skin, fatty tissue, muscle and fascia, and peritoneum. A breakdown of the muscle or fascial layer allows abdominal organs, usually intestines, to bulge or herniate through this opening.

Hernias may occur about 10% of the time following abdominal surgeries. They may be evident quite soon after surgery or may not be apparent until two or more years have elapsed. They manifest themselves as a bulge in the area of the old incision.

Many factors contribute to the development of incisional hernias. These include infection in the incision, obesity, steroid usage, hematoma or fluid accumulation, and breathing problems associated with increased coughing. Other factors may include previous use of incisions, crossing of older incisions, and excessive tension on the wound at the time of wound closure. Nutritional deficiencies and the presence of malignancy may interfere with normal wound healing as well. Chemotherapy and/or radiation likewise may retard wound healing.

Once the bulge appears, it will generally increase in size. The bulge may or may not cause pain or discomfort initially. It will flatten out when you push against it or lie down (a reducible hernia) early in the course. Later, you may not be able to flatten the bulge with pressure or lying down (nonreducible or incarcerated hernia). Finally, if the intestine trapped in the hernia loses its blood supply, the hernia is said to be strangulated (a surgical emergency).

Through the years, many methods of repair have been undertaken. Unfortunately, as many as 25-50% of the repairs failed leading to a recurrent incisional hernia. Repairs initially attempted to pull the disrupted fascial or muscular layers together, often under tension, and recurrences were quite common. Recognizing the limitations of primary repair, surgeons began using a variety of prosthetic (artificial) materials to try and reconstruct the abdominal wall. One of the major drawbacks of prosthetic or mesh artificial materials was the necessity to avoid contact of the abdominal cavity contents with the materials used. Complications of bowel obstruction, erosion, and fistulization occurred with intestinal contact with the initial mesh materials utilized. More recently, advances in mesh design have allowed contact with intestines without the above-mentioned mechanical complications occurring.

Conventional surgical repair with mesh material often requires large incisions, wide areas of dissection, and the use of drains. There is often a lengthy hospital stay and a significant delay in return to normal activities. Failures may still occur with larger or recurrent hernias in 20-25% of the cases.

Currently, laparoscopic repair of incisional hernias has become possible. Results appear quite promising with lower recurrence rates compared with conventional open surgical repair. The mesh is placed into the abdominal cavity through small incisions well away from the area of the hernia. It is affixed to the abdominal wall tissues with tacks or sutures or both placed laparoscopically. Hospital stay appears to be shortened, and a faster resumption of normal activities is reported.

In summary, if an incisional hernia is diagnosed, repair usually will be recommended to stop the hernia’s progression and avoid serious complications. Possibilities include primary repair without prosthetic materials for small hernias. Larger or recurrent hernias may be repaired with mesh materials either utilizing conventional surgical techniques or the laparoscopic approach. Your surgeon can discuss the options with you based on each individual situation.