What is an 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.
A number of factors are responsible for developing an incisional hernia after surgery. These include:
- Being overweight
- 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 bowels or gas
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 or enlarged lymph glands. The size of the hernia in the images can help your doctor decide the appropriate therapy for treating it. If necessary, your doctor may order a Herniagram, a test to confirm the presence of a hernia. A radio-opaque liquid is injected into the bulged hole which can be viewed on X-ray images.
Laboratory tests such as blood tests and stool tests may be ordered to check for infection, inflammation, bleeding and irregular bowels.
Your doctor may suggest a hernia belt (truss) which compresses the bulge back into its proper place and reduces it. Surgery is not necessary for treating a small incisional hernia. However, a large painful hernia that is growing in size requires surgical repair. 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 considered the best approach for treating incisional hernias. In an 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 centimeters may be repaired with just suturing the cut. However, larger hernias require a tension-free repair with a mesh patch to support the abdominal wall. These procedures will be performed under general, local or regional anaesthesia.
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