Incisional Hernia

Symptoms

• A noticeable bulge or lump at or near the site of a previous surgical scar.
• The bulge may become more prominent when standing, coughing, or straining.
• Discomfort or a dull ache in the area of the hernia, which may worsen with activity.
• A feeling of pressure or weakness in the abdomen.
• Sharp or localized pain (less common).
• Changes in bowel habits, such as constipation or diarrhea (less common).
• Skin irritation or breakdown over the hernia bulge (less common).
• Sudden, severe, and persistent pain at the hernia site (emergency symptom).
• Nausea and vomiting (emergency symptom).
• Inability to have a bowel movement or pass gas (emergency symptom, suggesting bowel obstruction).
• The hernia bulge becomes firm, tender, and cannot be pushed back in (emergency symptom, non-reducible).
• Redness, warmth, or discoloration (purple or dark) of the skin over the hernia (emergency symptom).
• Fever (emergency symptom).

Causes & Risk Factors

• Failure of the abdominal wall fascia (strong connective tissue) to heal and close properly after a surgical incision.
• Technical surgical factors, such as the type of incision (midline incisions have higher risk).
• Inappropriate suture material, incorrect suture placement, or excessive tension during the initial surgical closure.
• Use of rapidly absorbable sutures, which may not provide enough long-term support.
• Increased intra-abdominal pressure from conditions like chronic cough, constipation, obesity, or fluid buildup (ascites).
• Impaired wound healing due to factors such as smoking, diabetes, poor nutrition, infection at the surgical site, or a weakened immune system.
• Underlying collagen abnormalities, which can lead to weaker connective tissue and a predisposition to fascial breakdown.
• Obesity (Body Mass Index, BMI, greater than 30 kg/m²).
• Smoking, which impairs wound healing and collagen production.
• Poor nutrition, including low protein levels (hypoalbuminemia) and vitamin deficiencies.
• Postoperative pulmonary complications, such as chronic coughing, which increase pressure within the abdomen.
• Use of corticosteroids, which can impair wound healing.
• Diabetes mellitus, especially when blood sugar levels are not well controlled.
• Surgical site infection (SSI) after the initial surgery.
• Increased age.
• Male sex (some studies show a higher incidence).
• Genetic predisposition, including conditions affecting collagen metabolism (e.g., Ehlers-Danlos syndrome, Marfan syndrome) or a family history of hernias.
• History of a previous hernia repair.
• Presence of an aortic aneurysm, associated with connective tissue abnormalities.
• Emergency surgery, which carries a higher risk compared to planned (elective) procedures.
• Type of initial surgery, with midline abdominal incisions having the highest risk.
• The specific technique used for fascial closure during the initial surgery.

Diagnosis

• A detailed medical history, including information about previous abdominal surgeries, the onset and characteristics of any bulge, associated symptoms, and presence of risk factors.
• A physical examination where the doctor inspects the abdomen for a bulge along a surgical scar, both when lying down and standing.
• Palpation (feeling) of the abdominal wall to identify the fascial defect (the opening where the hernia protrudes).
• Asking the patient to cough or strain (Valsalva maneuver) to make the hernia more prominent.
• Assessing if the hernia can be gently pushed back into the abdomen (reducible) or if it is stuck (non-reducible).
• Ultrasound (US) imaging, which can confirm the presence of a hernia, identify its contents, and measure the size of the defect, especially useful in obese patients or when the physical exam is unclear.
• Computed Tomography (CT) scan, which provides detailed anatomical information, including the size of the defect, the volume of the hernia sac, and its relationship to surrounding structures, often preferred for surgical planning.
• Magnetic Resonance Imaging (MRI), used less frequently but can help differentiate hernias from other soft tissue masses or in cases of chronic pain.
• The diagnosis is confirmed by the presence of a palpable or visible fascial defect at the site of a prior surgical incision, identified through physical examination or imaging.

Treatment Options

• Watchful waiting may be an option for patients with small, asymptomatic, or minimally symptomatic hernias, especially if they have other health conditions that increase surgical risks. Patients choosing this option must be aware of and monitor for signs of emergency complications.
• Surgical repair is the definitive treatment for most symptomatic incisional hernias. The goal is to return the herniated contents to the abdominal cavity and close the fascial defect.
• Mesh reinforcement, using a surgical mesh (prosthesis), is the standard of care for most incisional hernia repairs. It significantly reduces the risk of the hernia returning compared to simply stitching the defect closed.
• Open repair, a traditional surgical approach involving an incision over the hernia site, where mesh can be placed in various positions.
• Laparoscopic repair, a minimally invasive approach using small incisions, a camera, and specialized instruments to place mesh inside the abdomen.
• Robotic repair, a variation of minimally invasive surgery that may allow for more complex reconstructions with smaller incisions.
• Emergency surgical intervention is required for incarcerated (trapped) or strangulated (blood supply cut off) hernias to release the trapped tissue and remove any damaged bowel if necessary.

Frequently Asked Questions