Incisional hernia (medical term: incisional hernia) is a complication that occurs during abdominal surgery. In any case, the incisional hernia must be operated. If intestinal obstruction occurs, there is acute danger to life, so the hernia is treated – in the context of an emergency operation.
What is the incisional hernia?
An incisional hernia is a soft tissue hernia that usually occurs after surgery. In this case, the scar, which was formed when the abdominal wall and muscle were sewn together, cannot withstand the pressure and displaces. As a further consequence, bulges occur that can reach sizes of up to 30 centimeters. If a secondary hernia subsequently occurs, which can occur as part of an incisional hernia, and parts of the intestine become trapped in the hernial orifice, there is a danger to life.
Causes
The pressure that occurs in the abdominal cavity can be increased by obesity, coughing, pressing, pregnancy or even abdominal dropsy (known as ascites); the latter leads – in the case of an acquired weak point (scar) in the connective tissue or in the abdominal wall – to the incisional hernia. Scar hernia can also occur in the absence of rest, when the patient lifts heavy loads after surgery.
Symptoms, complaints and signs
Usually, incisional hernia occurs within the first postoperative year. The patient notices a palpable and visible protrusion that occurs in the area of the surgical scar. The protrusion occurs during standing, pressing, or physical exertion and may increase in size – over time. Occasionally, pain may occur during bowel movements, coughing, or physical exertion. Digestive problems or disturbed symmetry of the abdomen are also possible. Depending on how large the incisional hernia is, symptoms may vary. Small incisional hernias often do not require any symptoms at all. Characteristic of the incisional hernia is the fact that the protrusion can be pushed into the abdomen; as a rule, this process does not cause pain. If the patient complains of severe pain and suffers from nausea and vomiting, intestines or intestinal segments have become trapped. The protrusion, which can usually be pushed back into the abdominal cavity, remains hard and immobile.
Diagnosis and course of the disease
The physician can determine relatively quickly during the physical examination whether or not the hernia is an incisional hernia. He or she palpates the affected area with the fingers and can “feel” the hernial sac or hernial orifice. If the physician is unsure, further examinations can be performed. These include ultrasound examinations (sonography), X-rays or even a computer tomography. Sometimes a colonoscopy can also be performed to confirm the diagnosis. Further examination procedures are usually used for severely overweight individuals or very small hernias. The incisional hernia is – in almost all cases – harmless. If the hernia is not treated, it can increase in size, so that small hernias that are less than four centimeters in size can spread up to 30 centimeters. However, if an accessory hernia occurs, it can lead to a life-threatening intestinal obstruction. If this occurs, the patient must be operated on immediately. Since the intestines or intestinal segments become trapped, there is an acute danger to life – due to the fact that the trapped intestinal parts can die.
Complications
An incisional hernia is already a complication of previous abdominal surgery. It is favored by various risk factors such as obesity, wound infections, hereditary predisposition and age. However, an incisional hernia should always be operated on because of the risk of entrapment of fatty tissue or even intestinal tissue. In addition, the hernia constantly expands if left untreated and can then even assume monstrous dimensions with a diameter of over ten to fifteen centimeters. At this size, parts of the abdominal viscera always push their way into the hernia. The risk of entrapment of the abdominal tissue or intestine then depends on the size of the hernia gap. The smaller the hernia gap, the greater the risk of entrapment. Incarceration of part of the intestine is always a medical emergency that must be treated immediately. In this case, severe abdominal pain occurs within a short time, which may be permanent or colicky. A very pressure-sensitive abdomen is typical.Furthermore, there is nausea, vomiting, fever and chills. If surgery is not performed immediately, the trapped part of the intestine dies and the intestinal contents spill into the abdominal cavity. As a result, peritonitis develops, leading to death if left untreated. Long-term consequences of incarcerated incisional hernias can also include adhesions, chronic inflammation, and constant fecal stasis leading to intestinal obstruction.
When should you see a doctor?
Scar symptoms such as itching or inflammation do not necessarily need to be treated by a doctor. However, if complications develop or even scarring occurs, a doctor should be consulted immediately. People who notice bleeding or a complete tear in the area of the scar are best to inform the medical professional in charge. If the incisional hernia is treated immediately, further tearing and the associated complications can usually be avoided. However, if no treatment is given, serious infections can occur. Therefore, even the first signs of an incisional hernia should be clarified. Persons suffering from a disease of the connective tissue or hemophiliacs must immediately visit the nearest hospital. However, this also depends on the size of the scar. Smaller scars often heal quickly despite a scar hernia, while large scars always require medical attention if a scar hernia occurs in the affected region. A scar hernia can be cared for by a family doctor, dermatologist or a surgeon.
Treatment and therapy
Since the incisional hernia does not regress on its own, surgical treatment is usually required. This is because the incisional hernia – if left untreated – will grow larger, and so will the risk of entrapment of parts of the intestines. Even if the incisional hernia does not cause any symptoms, it is advisable to treat the hernia surgically. Smaller hernias do not require immediate surgery; however, the longer the surgery is waited, the more the hernia increases in size. It should be noted that the primary surgery that ended up being responsible for the incisional hernia should be three to six months prior to another surgical procedure. In fact, in order for a successful incisional hernia surgery to be performed, the original surgical scar must have healed completely. However, if there are life-threatening circumstances that require immediate surgery, such a period cannot be waited for. During the operation, the incisional hernia is exposed and the resulting hernia sac is moved into the abdominal cavity. The physician then closes the hernial orifice; various suture techniques or plastic meshes are available to ensure that the hernial orifice remains closed. Which variant the physician ultimately chooses also depends on the size of the fracture and the patient’s physical condition. Sometimes the circumstances why the incisional hernia occurred must also be taken into account. Smaller fractures that are just four centimeters in diameter or less are closed using special suturing techniques. In the case of larger fractures, which can be up to 30 centimeters in size, the plastic mesh is mainly used. Jene is to stabilize the weak point and ensure that no further fracture occurs.
Outlook and prognosis
An incisional hernia is usually unproblematic. The hernia is closed surgically and the wound is treated with medication and directly. Modern surgical procedures and plastic implants can reliably close even larger injuries. If the incisional hernia is not treated or is treated too late, it continues to expand. Possible complications include gastrointestinal distress, severe pain and intestinal obstruction. The prognosis may worsen if the patient suffers from obesity or connective tissue weakness. The prognosis is based on the size and location of the scar and the patient’s health. Important factors are also the type of scar and the chosen treatment procedure. If a suture-only procedure is used, there is a greater risk that the scar will reopen. Therefore, mesh or implants, which are less prone to recurrence, are usually used nowadays. Modern procedures such as laparoscopic treatment provide information about the condition of internal scars. This enables targeted treatment and prevention of scar rupture.If the treatment is carried out in time, the incisional hernia will resolve without further complications. The patient can lead a symptom-free life. Life expectancy is not affected by a positively progressing incisional hernia.
Prevention
To prevent an incisional hernia, the patient should avoid risk factors that sometimes cause an incisional hernia or minimize them in such a way that the risk can be significantly reduced. Therefore, after surgery, the patient should avoid lifting heavy loads – for about six months. If overweight, the focus is on weight reduction; smokers should stop smoking or quit smoking altogether.
Aftercare
After scar hernia surgery, the patient can get up to go home about one to two hours later after some rest. Usually, no major follow-up care is required, but physical rest should be provided during the first week after surgery. It is also important that the patient does not lift heavy loads of more than 20 kilograms for up to three months. Pronounced physical movements must also be avoided. Depending on the occupation of the affected person, the period of incapacity to work is between two and three weeks. After 14 days, the patient may resume light sporting activities. Longer periods of lying down after the operation should be avoided in order to counteract possible risks such as thrombosis (blood clots) and embolism. Light analgesics can be administered against the wound pain. Following the surgical procedure, a normal intake of food is usually possible. If necessary, a special diet can be established step by step. To check the progress after the incisional hernia surgery, examinations by ultrasound (sonography) take place. Immediately after incisional hernia surgery, the patient often puts on a special abdominal girdle. It is elastic and can be worn for several weeks, both during the day and at night. Approximately ten to twelve days after the surgical procedure, the skin sutures are removed.
What you can do yourself
Patients with an incisional hernia should avoid pressure in the abdomen. This mainly occurs when weight is increased or when the patient is overweight. Therefore, for prevention, weight reduction should take place and meals should not be too abundant. Likewise, physical overexertion of the affected region of the body should be avoided. Sports activities should be adapted to the needs of the organism. Sufficient rest is necessary after an intensive activity and taking regular breaks is recommended. Processes such as coughing or pressing have a negative influence on the discomfort of the scar hernia. Therefore, the affected person should prevent the development of infectious diseases or flu in time. When the general risk of illness is reduced, discomfort can be alleviated. For this, the organism needs a stable and strong immune system. This can be acquired with a healthy and balanced diet. In addition, the consumption of harmful substances such as nicotine should be refrained from. Since constipation causes tension in the abdominal wall and an unhealthy diet promotes the formation of air in the abdomen, nutritional counseling can be helpful. A complete change in food intake will prevent discomfort and relieve existing symptoms. In the case of an incisional hernia, the scar should be checked regularly for damage. If tears occur, sterile wound care is necessary.
