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Incisional hernia repair

Definition

Incisional hernia repair is a surgical process performed to correct an incisional hernia. An incisional hernia, also called a ventral hernia, is a bulge or protrusion that occurs near or direct along a prior abdominal surgical incision. The surgical repair process is also known equally incisional or ventral herniorrhaphy.

Purpose

Incisional hernia repair is performed to right a weakened area that has developed in the scarred musculus tissue around a prior abdominal surgical incision, occurring as a consequence of tension (pulling in opposite directions) created when the incision was closed with sutures, or past any other condition that increases abdominal pressure level or interferes with proper healing.

Demographics

Because incisional hernias can occur at the site of any type of intestinal surgery previously performed on a wide range of individuals, there is no outstanding profile of an private most likely to have an incisional hernia. Men, women, and children of all ages and indigenous backgrounds may develop an incisional hernia after intestinal surgery. Incisional hernia occurs more usually amidst adults than among children.

Description

An incisional hernia can develop in the scar tissue around whatever 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 charge per unit of incisional hernia occurrence can be equally high as thirteen%

An incisional hernia occurs at the site of a previous incision (A). Intestinal contents break through the abdominal wall and bubble up under the skin. In a laparoscopic repair, the surgeon uses laparoscopic forceps to pull the material, omentum, from the hernia site (B). A mesh pad is inserted into the site to line the hernia site (C and D), and is tacked into place (E). (Illustration by GGS Inc.)

An incisional hernia occurs at the site of a previous incision (A). Abdominal contents suspension through the abdominal wall and chimera upwardly under the peel. In a laparoscopic repair, the surgeon uses laparoscopic forceps to pull the material, omentum, from the hernia site (B). A mesh pad is inserted into the site to line the hernia site (C and D), and is tacked into place (E). (

Illustration by GGS Inc.

)

with some abdominal surgeries. These hernias may occur after big surgeries such as intestinal or vascular (eye, arteries, and veins) surgery, or after smaller surgeries such as an appendectomy or a laparoscopy , which typically requires a small incision at the bellybutton. Incisional hernias themselves can exist very pocket-size or big and complex, involving growth along the scar tissue of a large incision. They may develop months later on 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 atmospheric condition that increase strain on the abdominal wall, such every bit obesity, advanced age, malnutrition, poor metabolism (digestion and assimilation of essential nutrients), pregnancy, dialysis, excess fluid retention, and either infection or hematoma (haemorrhage under the peel) later on a prior surgery.

Tension created when sutures are used to close a surgical wound may too exist responsible for developing an incisional hernia. Tension is known to influence poor healing conditions because of related swelling and wound separation. Tension and intestinal pressure level are greater in people who are overweight, creating greater adventure of developing incisional hernias post-obit any abdominal surgery, including surgery for a prior inguinal (groin) hernia. People who have been treated with steroids or chemotherapy are also at greater run a risk for developing incisional hernias because of the impact these drugs have on the healing procedure.

The outset 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 crave surgical treatment.

The effectiveness of surgical repair of an incisional hernia depends in office 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 expanse, bridging the hole or weakened area beneath it. Every bit the expanse heals, the mesh becomes firmly integrated into the inner abdominal wall membrane (peritoneum) that protects the organs of the abdomen. This method creates piffling or no tension and has a lower rate of hernia recurrence, as well as a faster recovery with less pain. Incisional hernias recur more than ofttimes when staples are used rather than sutures to secure mesh to the abdominal wall. Autogenous tissue (skin from the patient'south own body) has as well been used for this blazon 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 fastened to its tip; or a conventional open up 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 get twisted and its blood supply cut off (strangulation). Extremely obese patients may likewise crave an open up procedure considering deeper layers of fatty tissue volition accept to exist 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 complication of the repair. A catheter may be inserted into the bladder to remove urine and decompress the float. 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 fabricated merely large enough to remove fat and scar tissue from the abdominal wall well-nigh the hernia. The outside edges of the weakened hernial expanse are divers and excess tissue removed from within the area. Mesh is and then practical and then that information technology overlaps the weakened area by several inches (centimeters) in all directions. Non-absorbable sutures (the kind that must be removed past 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 ane incision and surgical instruments in the others to remove tissue and place the mesh in the aforementioned mode as in an open procedure. Significantly less intestinal wall tissue is removed in laparoscopic repair. The surgeon views the unabridged procedure on a video monitor to guide the placement and suturing of mesh.

Diagnosis/Preparation

Diagnosis

Reviewing the patient'southward symptoms and medical history are the starting time steps in diagnosing an incisional hernia. All prior surgeries will exist discussed. The medico 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 jutting or mass, and may inquire the patient to cough or strain in order to see and feel the hernia more than easily. To confirm the presence of the hernia, an ultrasound examination or other scan such every bit computed tomography (CT) may be performed. Scans volition allow the doctor to visualize the hernia and to brand sure that the bulge is not another blazon 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 md believes that medical treatment will non effectively correct the incisional hernia.

Grooming

Many months before the surgery, the patient'south doctor may advise weight loss to assistance reduce the risks of surgery and to better the surgical results. Control of diabetes and smoking cessation are also recommended for a improve surgical result. Shut to the time of the scheduled surgery, the patient will have standard preoperative blood and urine tests, an electrocardiogram, and a chest ten ray to make sure that centre 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 nighttime before surgery, patients must not eat or drink anything. One time in the hospital, a tube may exist 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 process. A sedative may be given to relax the patient.

Aftercare

Immediately later surgery, the patient will exist observed in a recovery area for several hours, for monitoring of body temperature, pulse, blood pressure level, and heart function, besides equally ascertainment of the surgical wound for undue haemorrhage or swelling. Patients will unremarkably exist discharged on the day of the surgery; only more complex hernias such as those with incarcerated or strangulated intestines will crave overnight hospitalization. Some patients may have prolonged suture-site hurting, which may be treated with pain medication or anti-inflammatory drugs. Antibiotics may be prescribed to help prevent postoperative infection.

One time the patient is domicile, the hernia repair site must exist kept make clean, and any sign of swelling or redness reported to the surgeon. Patients should too report a fever or whatever abdominal pain. Outer sutures may have to be removed by the surgeon in a follow-up visit about a calendar week later on surgery. Activities may be express to non-strenuous move for up to 2 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 half-dozen to eight weeks afterward surgery, or longer as brash.

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 exist about 13%. The chance of recurrence and repeat surgery is as high equally 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 equally obesity and nutritional disorders, volition persist in certain patients and encourage the development of a second incisional hernia and repeat surgery. Each subsequent fourth dimension, the surgery will become more difficult and the gamble 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 plenty to crave repeat surgery
prolonged suture pain, treated with pain medication or anti-inflammatory drugs
abdominal injury
nerve injury
fever, commonly related to surgical wound infection
intra-abdominal (inside the abdominal wall) abscess
urinary retention
respiratory distress

Normal results

Skillful outcomes are expected with incisional hernia repair, particularly with the laparoscopic method. Patients will usually get habitation the solar day of surgery and can wait a i- to two-calendar week recovery period at home, and and then a render to normal activities. The American College of Surgeons reports that recurrence rates after the beginning 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 probable when mesh is used, although complications, especially infection, accept been shown to increase considering of the larger abdominal incisions. Laparoscopy with mesh has shown rates of recurrence every bit low as iii.4%, with fewer complications besides.

Morbidity and bloodshed rates

Deaths are not reported resulting directly from the performance of herniorrhaphy for incisional hernia.

Alternatives

The alternatives to commencement-time and recurrent incisional hernia repair begin with preventive measures such equally:

Losing weight; maintaining suitable weight for age and meridian.
Strengthening abdominal muscles through regular moderate exercise such as walking, tai chi, yoga, or stretching exercises and gentle aerobics.
Reducing intestinal force per unit area by avoiding constipation and the buildup of excess body fluids, achieved past adopting a high-fiber, low-salt nutrition.
Learning to lift heavy objects in a safe, low-strain fashion using arm and leg muscles.
Controlling diabetes and poor metabolism with regular medical care and dietary changes as recommended.
Eating a good for you, balanced nutrition of whole foods, high in essential nutrients, including whole grains, fruits and vegetables, express meat and dairy, and eliminating prepared and refined foods.

Resource

books

Maddern, Guy J. Hernia Repair: Open vs. Laparoscopic Approaches. London: Churchill Livingstone, 1997.

organizations

American College of Surgeons (ACS), Part of Public Information. 633 Northward Saint Clair Street, Chicago, IL 60611-3211. (312) 202-5000. http://www.facs.org .

The National Digestive Diseases Information Clearinghouse (NIDDK). ii Information Way, Bethesda, Physician 20892-3570. http://world wide web.niddk.nih.gov/health/assimilate/nddic.htm .

other

"Focus on Men's Wellness: Hernia." Jan 2003. MedicineNet Home. http://world wide web.medicinenet.com .

Incisional and Ventral Hernias (Patient Information). Central Montgomery Medical Heart, Outpatient Surgery Department. 2100 Due north. Broad Street, Lansdale, PA 19446. (215) 368-1122.

L. Lee Culvert

WHO PERFORMS THE Process AND WHERE IS IT PERFORMED?

Incisional hernia repair is performed in a hospital operating room or a one-day surgical centre 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 process? How often do yous perform this procedure?
Why must I have the surgery?
What are my options if I exercise not take the surgery?
How can I expect to feel afterward surgery?
What are the risks involved in having this surgery?
How apace will I recover? When can I return to schoolhouse 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?

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Source: https://www.surgeryencyclopedia.com/Fi-La/Incisional-Hernia-Repair.html