Incisional hernia repair
Definition
Incisional hernia repair is a surgical procedure performed to correct an incisional hernia. An incisional hernia, also called a ventral hernia, is a bulge or protrusion that occurs near or directly along a prior abdominal surgical incision. The surgical repair procedure is also known as incisional or ventral herniorrhaphy.
Purpose
Incisional hernia repair is performed to correct a weakened area that has developed in the scarred muscle tissue around a prior abdominal surgical incision, occurring as a result of tension (pulling in opposite directions) created when the incision was closed with sutures, or by any other condition that increases abdominal pressure or interferes with proper healing.
Demographics
Because incisional hernias can occur at the site of any type of abdominal surgery previously performed on a wide range of individuals, there is no outstanding profile of an individual most likely to have an incisional hernia. Men, women, and children of all ages and ethnic backgrounds may develop an incisional hernia after abdominal surgery. Incisional hernia occurs more commonly among adults than among children.
Description
An incisional hernia can develop in the scar tissue around any surgery performed in the abdominal area, from the breastbone down to the groin. Depending upon the location of the hernia, internal organs may press through the weakened abdominal wall. The rate of incisional hernia occurrence can be as high as 13%
with some abdominal surgeries. These hernias may occur after large surgeries such as intestinal or vascular (heart, arteries, and veins) surgery, or after smaller surgeries such as an appendectomy or a laparoscopy , which typically requires a small incision at the navel. Incisional hernias themselves can be very small or large and complex, involving growth along the scar tissue of a large incision. They may develop months after the surgery or years after, usually because of inadequate healing or excessive pressure on an abdominal wall scar. The factors that increase the risk of incisional hernia are conditions that increase strain on the abdominal wall, such as obesity, advanced age, malnutrition, poor metabolism (digestion and assimilation of essential nutrients), pregnancy, dialysis, excess fluid retention, and either infection or hematoma (bleeding under the skin) after a prior surgery.
Tension created when sutures are used to close a surgical wound may also be responsible for developing an incisional hernia. Tension is known to influence poor healing conditions because of related swelling and wound separation. Tension and abdominal pressure are greater in people who are overweight, creating greater risk of developing incisional hernias following any abdominal surgery, including surgery for a prior inguinal (groin) hernia. People who have been treated with steroids or chemotherapy are also at greater risk for developing incisional hernias because of the affect these drugs have on the healing process.
The first symptom a person may have with an incisional hernia is pain, with or without a bulge in the abdomen at or near the site of the original surgery. Incisional hernias can increase in size and gradually produce more noticeable symptoms. Incisional hernias may or may not require surgical treatment.
The effectiveness of surgical repair of an incisional hernia depends in part on reducing or eliminating tension at the surgical wound. The tension-free method used by many medical centers and preferred by surgeons who specialize in hernia repair involves the permanent placement of surgical (prosthetic) steel or polypropylene mesh patches well beyond the edges of the weakened area of the abdominal wall. The mesh is sewn to the area, bridging the hole or weakened area beneath it. As the area heals, the mesh becomes firmly integrated into the inner abdominal wall membrane (peritoneum) that protects the organs of the abdomen. This method creates little or no tension and has a lower rate of hernia recurrence, as well as a faster recovery with less pain. Incisional hernias recur more frequently when staples are used rather than sutures to secure mesh to the abdominal wall. Autogenous tissue (skin from the patient's own body) has also been used for this type of repair.
Two surgical approaches are used to treat incisional hernias: either a laporoscopic incisional herniorrhaphy, which uses small incisions and a tube-like instrument with a camera attached to its tip; or a conventional open repair procedure, which accesses the hernia through a larger abdominal incision. Open procedures are necessary if the intestines have become trapped in the hernia (incarceration) or the trapped intestine has become twisted and its blood supply cut off (strangulation). Extremely obese patients may also require an open procedure because deeper layers of fatty tissue will have to be removed from the abdominal wall. Mesh may be used with both types of surgical access.
Minimally invasive laporoscopic surgery has been shown to have advantages over conventional open procedures, including:
- reduced hospital stays
- reduced postoperative pain
- reduced wound complications
- reduced recovery time
Surgical procedure
In both open and laparoscopic procedures, the patient lies on the operating table, either flat on the back or on the side, depending on the location of the hernia. General anesthesia is usually given, though some patients may have local or regional anesthesia, depending on the location of the hernia and complexity of the repair. A catheter may be inserted into the bladder to remove urine and decompress the bladder. If the hernia is near the stomach, a gastric (nose or mouth to stomach) tube may be inserted to decompress the stomach.
In an open procedure, an incision is made just large enough to remove fat and scar tissue from the abdominal wall near the hernia. The outside edges of the weakened hernial area are defined and excess tissue removed from within the area. Mesh is then applied so that it overlaps the weakened area by several inches (centimeters) in all directions. Non-absorbable sutures (the kind that must be removed by the doctor) are placed into the full thickness of the abdominal wall. The sutures are tied down and knotted.
In the less-invasive laparoscopic procedure, two or three small incisions will be made to access the hernia site—the laparoscope is inserted in one incision and surgical instruments in the others to remove tissue and place the mesh in the same fashion as in an open procedure. Significantly less abdominal wall tissue is removed in laparoscopic repair. The surgeon views the entire procedure on a video monitor to guide the placement and suturing of mesh.
Diagnosis/Preparation
Diagnosis
Reviewing the patient's symptoms and medical history are the first steps in diagnosing an incisional hernia. All prior surgeries will be discussed. The doctor will ask how much pain the patient is experiencing, when it was first noticed, and how it has progressed. The doctor will palpate (touch) the area, looking for any abnormal bulging or mass, and may ask the patient to cough or strain in order to see and feel the hernia more easily. To confirm the presence of the hernia, an ultrasound examination or other scan such as computed tomography (CT) may be performed. Scans will allow the doctor to visualize the hernia and to make sure that the bulge is not another type of abdominal mass such as a tumor or enlarged lymph gland. The doctor will be able to determine the size of the defect and whether or not surgery is an appropriate way to treat it. A referral to a surgeon will be made if the doctor believes that medical treatment will not effectively correct the incisional hernia.
Preparation
Many months before the surgery, the patient's doctor may advise weight loss to help reduce the risks of surgery and to improve the surgical results. Control of diabetes and smoking cessation are also recommended for a better surgical result. Close to the time of the scheduled surgery, the patient will have standard preoperative blood and urine tests, an electrocardiogram, and a chest x ray to make sure that heart and lungs and major organ systems are functioning well. A week or so before surgery, medications may be discontinued, especially aspirin or anticoagulant (blood-thinning) drugs. Starting the night before surgery, patients must not eat or drink anything. Once in the hospital, a tube may be placed into a vein in the arm (intravenous line) to deliver fluid and medication during surgery. The patient will be given a preoperative injection of antibiotics before the procedure. A sedative may be given to relax the patient.
Aftercare
Immediately after surgery, the patient will be observed in a recovery area for several hours, for monitoring of body temperature, pulse, blood pressure, and heart function, as well as observation of the surgical wound for undue bleeding or swelling. Patients will usually be discharged on the day of the surgery; only more complex hernias such as those with incarcerated or strangulated intestines will require overnight hospitalization. Some patients may have prolonged suture-site pain, which may be treated with pain medication or anti-inflammatory drugs. Antibiotics may be prescribed to help prevent postoperative infection.
Once the patient is home, the hernia repair site must be kept clean, and any sign of swelling or redness reported to the surgeon. Patients should also report a fever or any abdominal pain. Outer sutures may have to be removed by the surgeon in a follow-up visit about a week after surgery. Activities may be limited to non-strenuous movement for up to two weeks, depending on the type of surgery performed. To allow proper healing of muscle tissue, hernia repair patients should avoid heavy lifting for at least six to eight weeks after surgery, or longer as advised.
Risks
Long-term complications seldom occur after incisional hernia repair. Short-term risks are greater with obese patients or those who have had multiple earlier operations or the prior placement of mesh patches. The risk of complications has been shown to be about 13%. The risk of recurrence and repeat surgery is as high as 52%, particularly with open procedures or those using staples rather than sutures for wound closure. Some of the factors that cause incisional hernias to occur in the first place, such as obesity and nutritional disorders, will persist in certain patients and encourage the development of a second incisional hernia and repeat surgery. Each subsequent time, the surgery will become more difficult and the risk of complications greater. Postoperative infection is higher with open procedures than with laparoscopic procedures.
Postoperative complications may include:
- fluid buildup at the site of mesh placement, sometimes requiring aspiration (draining off)
- postoperative bleeding, though seldom enough to require repeat surgery
- prolonged suture pain, treated with pain medication or anti-inflammatory drugs
- intestinal injury
- nerve injury
- fever, usually related to surgical wound infection
- intra-abdominal (within the abdominal wall) abscess
- urinary retention
- respiratory distress
Normal results
Good outcomes are expected with incisional hernia repair, particularly with the laparoscopic method. Patients will usually go home the day of surgery and can expect a one- to two-week recovery period at home, and then a return to normal activities. The American College of Surgeons reports that recurrence rates after the first repair of an incisional hernia range from 25–52%. Recurrence is more frequent when conventional surgical wound closure with standard sutures (stitches) is used. Recurrence after open procedures has been shown to be less likely when mesh is used, although complications, especially infection, have been shown to increase because of the larger abdominal incisions. Laparoscopy with mesh has shown rates of recurrence as low as 3.4%, with fewer complications as well.
Morbidity and mortality rates
Deaths are not reported resulting directly from the performance of herniorrhaphy for incisional hernia.
Alternatives
The alternatives to first-time and recurrent incisional hernia repair begin with preventive measures such as:
- Losing weight; maintaining suitable weight for age and height.
- Strengthening abdominal muscles through regular moderate exercise such as walking, tai chi, yoga, or stretching exercises and gentle aerobics.
- Reducing abdominal pressure by avoiding constipation and the buildup of excess body fluids, achieved by adopting a high-fiber, low-salt diet.
- Learning to lift heavy objects in a safe, low-strain way using arm and leg muscles.
- Controlling diabetes and poor metabolism with regular medical care and dietary changes as recommended.
- Eating a healthy, balanced diet of whole foods, high in essential nutrients, including whole grains, fruits and vegetables, limited meat and dairy, and eliminating prepared and refined foods.
See also Femoral hernia repair ; Inguinal hernia repair .
Resources
BOOKS
Maddern, Guy J. Hernia Repair: Open vs. Laparoscopic Approaches. London: Churchill Livingstone, 1997.
ORGANIZATIONS
American College of Surgeons (ACS), Office of Public Information. 633 North Saint Clair Street, Chicago, IL 60611-3211. (312) 202-5000. http://www.facs.org .
The National Digestive Diseases Information Clearinghouse (NIDDK). 2 Information Way, Bethesda, MD 20892-3570. http://www.niddk.nih.gov/health/digest/nddic.htm .
OTHER
"Focus on Men's Health: Hernia." January 2003. MedicineNet Home. http://www.medicinenet.com .
Incisional and Ventral Hernias (Patient Information). Central Montgomery Medical Center, Outpatient Surgery Department. 2100 N. Broad Street, Lansdale, PA 19446. (215) 368-1122.
L. Lee Culvert
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Incisional hernia repair is performed in a hospital operating room or a one-day surgical center by a general surgeon who may specialize in hernia repair procedures.
QUESTIONS TO ASK THE DOCTOR
- What procedure will be performed to correct my hernia?
- What is your experience with this procedure? How often do you perform this procedure?
- Why must I have the surgery?
- What are my options if I do not have the surgery?
- How can I expect to feel after surgery?
- What are the risks involved in having this surgery?
- How quickly will I recover? When can I return to school or work?
- What are my chances of having this type of hernia again?
- What can I do to avoid getting this type of hernia again?
Thanks, Danielle
Brian
Also, mesh was used in my last surgery and the site around my navel, were the mesh is, protrudes and you can tell exactly were the mesh is. I thought the mesh was supposed to be thin and undetectable???
Thank you
Since my aneurysm was at a 6, I was told, "we saved your life". As well they did, however, I thought the staples were barbaric and wondered if they could have closed another way. Six years ago I had Chemo for breast cancer and am free now. I am not overweight, eat a healthy diet, and have always been an active person. I think I am more terrified at the prospect of a recurring incisional hernia than any other thing I have been thru.
Please get back to me as fast as you can,
Thanks for your time.
Mrs Vera Orohwe
it for my sister she is 76 years old she had colon cancer 3 years ago now we find out that she has INCISIONAL HERNIA her Dr told her that she has the choice to be operated on or wait when it be came sirouse to the emergency to get operated on,please can somebody tell me how long it take for this kind operation time was in the operating room thank you again
Armand
I have had many previous surgeries. 2 Ventral and 2 Lateral. After losing a baby in 2000, my womb was ruptured and unbenown to the doctor, i was sent home. After 15 days i was rushed back into hospital to find all my insides had fused together, along with a serve infection. Hense the reason for the amounting surgeries. Since i have had a hysterectomy. Then a lump appeared along the side of the Ventral scar. My surgeon said he wasnt keen on giving me a mesh repair, but insisted he wanted to give me a repair using sutures. And also insisted if this didnt work, he would then perform reluctantly a mesh repair. Now 12 days after my surgery, after immense pain, not specifically where the wound is, but along my lateral scar, so much pain i couldnt cough, laugh, even move for a number of days. Which fortunately is just dying away now, Now I find a lump twice the size as my hernia originally was, and pertruding double the amount also, running the full length of my wound, running right across to the right side of my tummy. The lump is very hard indeed! And im wondering what this could be? and should i re-call my surgeon to get it checked out? Could it be the return of the hernia? Please someone help me as im really frightened :(
Can you suggest a good surgeon in Indianapolis, Indiana that could help me?
I am 65, overweight, out of shape, and very scared. From now till May I will be trying to lose weight and get in better shape and control my blood sugar better as I am a diabetic.
Thanks for whatever you can offer me.
Carol
Thanks
Lillian
I would like to know if after the sugery does the stomach size go down at all
The hernia is not that big and is on the uper part of stomach which pushes stomach out
It was 3 weeks before I could leave my house because I could not stand up, walk without a pillow supporting my belly (and then I was able to get a binder which helped immensely). Getting out of bed to use the bathroom took almost 1 hour one morning; good thing I didn't have to urgently go.
and I know its not. I'm a beleiver of GOD and I know He is the Higher Power, see GOD gave doctors knowledge but what good is that knowledge if the doctor has no faith in GOD?
Now I'm 57 years old and my health systoms are as follows: C.O.P.D.,sarcoidosis,heart problems, arthiritis,highg blood pressure, P.A.D, I have problems and I still have no fear, I'm sick, If I was well for a week I would be gratiful. I have no life with my 12 grandchildren, I can't drive due to some new symptoms that started about a month ago, I wa in the hospital for 4 mdays and I left there the same way I went. In June 2010 I developed dizziness, nausea, very upset stomach,my balance was off, after taking anything by mouth, medicine food anything, I'd get really weak, extremly tired and a sleepiness would fall on me and I just start going to sleep on and until I would just give into it and take a nap. This is anytime of day. And I gained about 30 pounds eating hardly nothing, one of my doctors increased my lassix from 80mg to 120 mg, that started taking the weight off, but did nothing for the other symptoms. My med list is as follows:
Promethazine w/codine 120mg one tsp every 6 hrs as needed,Pulmicort Flexhaler 180mg 2 puffs a day, Loratab 10mg, 2 tabs every 4 hrs as needed, hydrochlorothiazide 25mg i a day,atenolol 50 mg itab twicw a day,amlodipine 10mg 1 tab a day,trazodone 50mg 1 tab at bedtime,klor-con m 20 1 tab a day,promethazine hcl 25mg 1 tab every 6 hrs as needeed, hyralazine 25mg 1 tab a day, morphine 15mg i tab twice a day, ranitidine 150mg 1 tab twice a day, furosemide 80mg, 1 tab a day, also a 40 mg tab every afternoon, zolpiden tartrata 5mg, 1 at bedtime, meclizine 25mg, 1 tab twice a day, tracleer 125mg, 1tab twice a day, carisoprodol 350mg 1 tab twice a day as needed, diphenox/atropine 2.5mg, 1 tab twice a day as needed..
What a list, even with the pain meds they give me, I'm never pain free. I've taken loratab for 8 years and just recently the morphine was added on for what it does'nt help.
I need a surgery that no one will do, where ca I get help, I'm fron wichita kansas and i have a medical card through the state, do you know anyone who will at least look at my case, I can travel with a referral, please someone help me. Myphone number is 316-832-9633 and my cell phone number is 316-217-6099. Leave a message if theres no answer. Thank You for at least reading this plea for help. GOD BLESS YOU!
And I'm going to murder someone if I need a drain.
1.Use of hernia belt to prevent the protrusion and reduce pain. Special type of hernia belts is available for each type of hernia.
2.Treat constipation, recurrent cough, urinary obstruction, etc. whenever they occur.
3.Lose some weight will increase the strength of abdominal wall.
4.Accommodate a healthy diet
â—¦Eat food rich in fiber in the form of fruits, vegetables and grains for easy bowel movements. Leafy vegetables such as cabbage, dandelion, sweet potatoes, artichoke, etc. are some of good choice. Have grains like barley and millet.
â—¦Eat six small meals instead of 3 big meals
â—¦Eat Cayenne pepper
â—¦Drink warm tea in hot room and sweat it out
â—¦Keep away from foods which are hard to digest
5.Healing hernia without surgery through a healthy lifestyle changes
â—¦Do abdominal exercises regularly to increase the muscle tone.
â—¦Avoid bending or lying after eating
â—¦Stop smoking
â—¦Avoid weight lifting that put pressure into the intra-abdominal leading to severe risk of hernia
â—¦Keep off from alcohol
◦Don’t get depressed
◦Don’t wear tight clothes
â—¦Keep a cloth soaked in rupturewort tea to the affected area for some relief
6.Try other systems like homeopathic treatment, herbal medicine, etc.
I'm currently living in Korea so I cant get an exact answer. Doctor says I dont need surgery, but what about running, kick-boxing and sit-ups?
I already have had 2 repaired.
Dorothy Shertzer
The pain from this surgery has been pretty bad. I was not expecting this much pain especially since the surgery was done laparoscopic with 7 holes and an eighth with the belly button!
I am hoping for a successful outcome when the healing is complete. Has anyone had success?
The pain from this surgery has been pretty bad. I was not expecting this much pain especially since the surgery was done laparoscopic with 7 holes and an eighth with the belly button!
I am hoping for a successful outcome when the healing is complete. Has anyone had success?
The pain from this surgery has been pretty bad. I was not expecting this much pain especially since the surgery was done laparoscopic with 7 holes and an eighth with the belly button!
I am hoping for a successful outcome when the healing is complete. Has anyone had success?
Does this assume the person already has a hernia and may be able to avoid first time incisional hernia repair, or does it refer to how to avoid an incisional hernia in the first place which would necessitate incisional hernia repair?
Betty White
The drainage tube was removed too early, and after discharge from hospital the skin opened at my umbilicus and serous fluid emerged... about 300 mls daily but eventually subceded. I now have a hernia from above the umbilicus to an ulcer at the umbilicus that is slowly healing, and hernia right down to the pubic symphasis. Ultrasound shows small intestine a few mls below the skin all the way. What should I expect my surgeon to do in repairing this? And will the ulcer that is small but still there present any problem if it is cut out ... joining the two sides if the umbillicus together again?
I'm looking for another primary care doctor in my area. My PCP didn't think the hernia was anything to worry about. My OB/GYN was quite alarmed by just feeling it & refered me to see a surgen ASAP. The surgen agreed it should not wait. So I really want a PCP I can have faith in like the OB/GYN or Surgen. I'm frustrated in trying to find a really good PCP. My search on the internet gives me such anziety. So do I have another hernia? Who can I see?
It took 3 days before I had a bowel movement. I ate lightly as I knew I would have constipation if I over ate.
I am off any medication. 2 Extra strength Tylenol every 6 hours, 2 regular Ibuprophen is all I took for 4 days. I still have some pain when I sneeze or cough. And it hurts to sleep on my right side. Otherwise I can walk for an hour and take care not to lift heavy objects. The key is to wait for at least 3 months before one can get back to normal activities.
My surgery went really well, I had no complications, mild discomfort for a few weeks and I am now able to resume to my previous life.
I wanted to balance the comments and let peoiple know that not all repairs end with complications.
HOPE THSI HELPS TO YOU
Thank you
His entire stomach has a skin graph and the hernia is very very large. (the entire stomach). He wears a brace and is in alot of pain. The plastic surgeon who applied the skin graph said he needed to lose at least 100 pounds which he has exceeded 100 pounds. The have to remove the skin graph and repair the hernia. We are very afraid of the proceedure and dont' know what the risks are, and the recovery. Also because of his 3 surgery's in 9 days he has lost the function of one of his kidneys. Can you help?
Respectfully,
Laura
I had my incisional hernia repaired with mesh about 8 weeks ago. I had fluid build-up, which was drained twice. The second time I asked the doctor if the build-up could be reduced by wearing an abdominal binder (a wide elastic belt fastened with velcro and that compresses the abdomen or waist)or hernia support belt. He explained if the gap between the mesh and the skin is minimised in this way, there is not so much space for fluid to form in. It's not that fluid is leaking from anywhere, it's just the tissue producing it in response to the operation. OK so I wore the abdominal binder, not very tight, day and night for 2 weeks and there was much less fluid produced, so little that there has been no need to drain it again! It will be reabsorbed into the body over time. I still wear the binder during the day but leave it off at night.
I still get pain, but the surgeon just smiles and says that is not surprising after a major operation. Laughing, coughing and sneezing hurt, but I put my arms across my belly and hold tight and that makes it less painful. Healing takes time, we have to be patient and let the body do its job. Hope this helps.
The doc told me to resume gym activities after another month. Just for grins I waited until last Nov before working out again. BAD mistake.. I get to go on 11/29/11 for 5K deductible to have the hernia fixed via a standard fascia suturing with an underlay of a newly developed biosyntheic mesh by a five star Doc well versed in both procedures...It better work, or I am going have to sue TWO doctors instead of one. I'll let you all know how it turns out.
I had a colon resection gone bad, then a year later needed large ventral hernia repair from surgery site. My whole abdomen bulges now and am concerned about future hernia due to bulging.
Any one know how to reduce the bulge? I've been losing weight, but bulge is still huge.
I have not insurance and no family, so I need to plan every step of the way : cost of surgery ( montly payment),how to pay my bills while recovering time ( rent, etc, etc. ). I have this for the last 5 years and was waiting to save some money to do this but with this economy I've worked wherever I could just to survive; I'm feeling pain last few weeks and my line of work is heavy lifting all the time.