Incisional Hernia and Its Treatment

An incisional hernia is a bulge in the abdomen that forms when tissues or organs protrude through the abdominal wall. It can occur when the surgical incision weakens the abdominal muscles, which normally protect, support, and hold the abdominal organs. An incisional hernia is a common complication associated with abdominal surgery.

Some hernias are painful while others are asymptomatic. Strangulated hernias might be extremely painful, and require immediate medical attention. They are rare, occurring in fewer than 5% of all hernias.

If you have a hernia, there may be ways to manage it medically. However, the only absolute cure is surgery to repair the abdominal wall.

What Are the Symptoms of an Incisional Hernia?

An incisional hernia can cause a bulge on the abdomen where the hernia is located. It can become more pronounced when the patient coughs. It can also cause discomfort or pain during activities that cause stress on the area, like coughing, sneezing, lifting heavy objects, or having a bowel movement.

People with an incisional hernia might also have gastrointestinal symptoms like constipation, bloating, nausea, and vomiting.

In rare cases, a section of the bowel can poke through the incisional hernia, called a strangulated hernia. This is a medical emergency. Symptoms are extreme pain, discoloration and burning of the hernia, fever, nausea, and vomiting.

What Are the Causes of an Incisional Hernia?

Sometimes, muscles cut during abdominal surgery might not fully heal, and a gap can open up as the muscles move during your regular physical activities.

The incision is the weakest and most prone to a hernia while still healing. Incisional hernias are most likely to develop three to six months after surgery but can develop or enlarge months or years after surgery.

After a while, the structures underneath may escape through the muscle gap and poke through the opening to the point where they can be felt under the skin. In severe cases, portions of organs may move through the hole, but this is much less common.

Incisional hernias range in size from small to very large, depending on the surgical incision size, how well your muscles heal, and how long you've had the hernia.

Risk Factors

Risk factors for an incisional hernia include:

• A history of multiple abdominal surgeries
• Gaining significant weight after abdominal surgery
• Anemia
• Hypoproteinemia
• Malnutrition
• Diabetes
• Immunosuppression
• Advanced age
• Male gender

What Is a Strangulated Incisional Hernia?

A hernia that gets stuck in the "out" position is called an incarcerated hernia. This can quickly become an emergency if it becomes a strangulated hernia, where blood, food, or stool can't flow through the intestines.

A strangulated hernia can cause necrosis (death) of the bulging tissue through the hernia. This could be so severe that you would need to remove a portion of your intestines surgically, and it can be life-threatening.

A strangulated hernia may have a deep red or purple color of the bulging tissue. It may be accompanied by severe pain, but it is not always painful. Nausea, vomiting, diarrhea, and abdominal swelling may also be present.

This is analogous to tying a string so tight around your finger that your finger swells, preventing you from getting the string off.

How Are Incisional Hernias Diagnosed?

Incisional hernias may seem to appear and disappear. This is described as a reducible hernia. The hernia might only be noticeable during activities that increase abdominal pressure, such as coughing, sneezing, bearing down during a bowel movement, or lifting a heavy object.

Your doctor can diagnose your hernia with a physical examination, which doesn't usually require diagnostic testing. Your healthcare provider may request that you cough or bear down so they can see the hernia during your physical examination.

If the hernia is large enough to allow more than the lining of the abdominal cavity to bulge through, testing may be required to determine which organs are affected.

How Are Incisional Hernias Treated?

An incisional hernia may need surgical repair to prevent it from getting larger and to prevent incarceration or strangulation.

A truss is a nonsurgical option. This is a garment that is similar to a weight belt or girdle that applies constant pressure to a hernia. A truss treats the symptoms of a hernia and not the actual hernia. The only curative treatment is surgical repair.

An incisional hernia may require surgery if:

• It continues to enlarge over time.
• It is very large.
• It is cosmetically unappealing.
• The bulge remains even when you are relaxed or lying down.
• The hernia causes pain.

Your doctor might recommend surgery if you are at risk of complications. In some cases, deciding whether to have surgery is up to you. For example, you may want to have surgery if you're feeling uncomfortable or are concerned about how the hernia looks.

Incisional Hernia Repair Surgery

Incisional hernia repair surgery is typically done on an inpatient basis and requires general anesthesia. Incisional hernia repairs can be performed laparoscopically or with an open repair, depending on factors such as hernia size and excess skin. The surgery is often performed using the laparoscopic method, using small incisions rather than a large open incision.

A general surgeon or a colorectal specialist performs surgery.

Laparoscopic Repair

During the procedure, incisions are made on either side of the hernia. A laparoscope is inserted into one incision, and the other incision is used for the insertion of additional surgical instruments. The surgeon isolates the hernia sac (the portion of the abdominal lining pushing through the muscle) and returns it to its proper position. If the defect in the muscle is minor, it may be sutured closed to prevent the hernia from returning.

For large defects, suturing might not be adequate. In this case, the hernia is closed, and a mesh graft will cover the hole. The mesh is permanent and prevents the hernia from returning. The laparoscope is removed once the mesh is in place or the muscle has been sewn. The skin incision is closed. The incision is typically closed with dissolvable sutures. Medical glue or adhesive strips (Steri-Strips) may also be used.

If only a suture method is used with more significant muscle defects (approximately the size of a quarter or larger), there is an increased chance of reoccurrence. The use of mesh for larger hernia repairs is the standard of treatment, but it may not be appropriate for people who have a history of rejecting surgical implants or who have a condition that prevents the use of mesh.

Open Hernia Repair

Surgeons might do an open hernia repair instead of a laparoscopic repair. Some factors that the surgeon will weigh include:

• Size of the hernia
• Location of the hernia
• Patient health and co-morbidities
• Previous operations

Open surgeries have a larger incision, which increases the likelihood of wound healing complications. Recovery typically takes a little longer in open surgery than in laparoscopic surgery.

What’s the Recovery Process Like?

Most people with hernia repair surgery can return to normal activity within about three weeks after surgery. The abdomen will be tender, especially for the first week after surgery.

While healing, the incision should be protected during any activity that increases abdominal pressure by applying firm but gentle pressure on the incision line.

Activities during which the incision should be protected include:

• Rising from a seated position
• Sneezing
• Coughing
• Bearing down during a bowel movement (contact your surgeon if you are constipated after surgery, a stool softener may be prescribed)

You should not lift heavy objects when you are healing.

Call a healthcare professional if you have severe pain, increasing pain, fever, or if you see any pus or redness around the incision.

Potential Complications

Every surgical procedure has potential complications. However, a healthcare provider will weigh possible complications against the procedure's benefits to decide whether surgical intervention is advisable.

Potential complications of incisional hernia surgery include:

• Anesthesia complications: Anesthesia is generally safe, but possible complications include sore throat, nausea, vomiting, and tooth damage. More severe complications include low blood pressure, high body temperature, and, very rarely, death.
• Mesh complications: The mesh used to help reinforce the abdominal wall can sometimes have complications like infection, erosion, or migration. It can also form a fistula, where the mesh erodes the intestines.
• Wound healing: Any surgical procedure carries a risk of poor wound healing, which may require antibiotics or other interventions. Surgery also leaves scars.
• Infection: Surgery carries a risk of infection. However, sterile techniques help minimize this risk.
• Reoccurrence of the hernia: A hernia repair might not be successful, or the hernia could come back. This happens more often when surgical mesh is not used.

If you are concerned you might be experiencing a complication from a surgical incisional hernia repair, see a healthcare provider for help.

Summary

Surgical scars can cause tissue to bulge through the abdominal wall, causing an incisional hernia. If a hernia is not treated, it can become strangulated, which has very serious consequences. The treatment for this is a surgical repair, either laparoscopic or open. The procedure is usually well-tolerated, and recovery takes about three weeks for most people.