The phrase “incisional hernia” refers to a disruption in the integrity of the abdominal wall in an area where a prior surgical procedure or injury occurred. As a consequence the tissue behind the abdominal wall starts to push out and a bulge will develop under the skin. These bulges contain abdominal fat and sometimes bowel. The development of these types of hernias are very frustrating, uncomfortable and occasionally dangerous for patients. No one likes to have surgery. Certainly no one wants to have a second procedure if it could have been prevented.
Approximately 3-20% of incisions will develop hernias, and 90% will occur within three years of the original operation. There are multiple risk factors that surgeons have discovered that contribute to poor healing after surgery and hernia formation. Some are controllable prior to elective surgery. Patients can get their diabetes under control, loose weight and stop smoking. All of these changes dramatically reduce the likelihood that a hernia may occur. Some issues risk factors cannot be reduced, particularly if the original surgery was emergent. Wound infections in the original incision have been shown to create a 4-fold increase in hernia formation.
Incisional Hernia Management
Unless a patient has risk factors that would make surgery unnecessarily risky most incisional hernias are repaired. Once a hole in the abdominal wall develops the body cannot repair it. It will plug it with tissues like fat and bowel but it cannot repair itself. This is not an issue of abdominal wall strength necessarily. Many patients have normal abdominal wall musculature prior to the original incision. Exercising, doing sit-ups and “core exercises” will never improve the situation and may actually make things worse by forcing tissues out through the defect creating pain and possible incarceration. The typical pattern is that the hernia either stays the same size or gradually increases in size and discomfort. It never gets smaller.
Surgical Options for Repair of Incisional Hernias
There is no “one type” of Incisional Hernia and therefore there is no “one best type” of repair option. Once a decision to operate is made the type of repair to be done is determined by a number of factors. Some of the factors that are considered include: how big is the defect, has there been an infection, activity level of the patient, experience of the surgeon with a particular technique.
We have an enormous amount of experience with all types of incisional hernia repairs. We often see patients who have been turned down by other surgeons or who only had one option given to them for repair. Dr. Gillian has a bias towards using laparoscopic repairs because in experienced hands it has shown to be associated with faster recovery, lower infection rates and minimal chance of recurrence.
Dr. Gillian is considered a national expert in these types of repairs and has been training surgeon in these types of repairs in Europe, Asia and across the USA since 1998.
Simple Suture Repair of defects results in recurrence rates of up to 50%. We rarely consider this a viable option. This involves re-approximating the edges of the muscle/fascia under tension. Typically the sutures gradually pull through the softer muscle and a larger hernia than we were trying to fix is the result.
Mesh repair of incisional hernias allow us to bridge the gap in the muscle without creating significant tension and it reduces the chance of the hernia coming back. Most meshes used in hernia repair are meant to be permanent. They come in various sizes, shapes, weaves, materials and strengths. The mesh can be placed on the surface of the muscle (onlay), in the defect only (inlay) or under the muscle (sublay).
Mesh can be placed via a traditional “open” incision or laparoscopically. The open techniques are associated with larger wounds, slower healing, increased infections and increased chance of recurrent hernia formation. Despite these negative issues, most surgeons will repair incisional hernia with an open technique because it is how they were taught and it takes less training/skill.
Laparoscopic Incisional Hernia repairs take a higher level of training/skill to accomplish but the upside to the patient is a significantly better experience when done properly by an experienced surgeon. Like other laparoscopic procedures we are able to use special cameras and equipment to do a significant amount of surgery with minimal tissue trauma. Most of these repairs can be done with three small incisions with at total combined length of 2 cm (which is less than one inch). Through these small ports we can repair very large hernias and utilize a variety of mesh sizes without the complications that larger incisions can create. Nearly all of these repairs can be done as an outpatient procedure with the patients going home the same day regardless of the size of the repair be performed.
Special Circumstances
We do see referrals for very complicated situations that require a procedure known as a Component Separation. Typically these patients have either a large and long neglected hernia or some complicating factors like an active wound infection or a prior history of multiple, unsuccessful mesh repairs. These are “open” type repairs that literally allow us to “separate” different muscle groups from each other on the abdominal wall. This effectively releases some of the muscle so that they can slide back towards the position they were in prior to the development of the hernia. Once the muscles are back in a more natural position we still reinforce the abdominal wall closure with a mesh to reduce the chance of further hernia formation. These are complicated repairs that take a lot of planning and experience and should only be done by an experienced team to maximize the result.
Risk Factors for Incisional Hernia
- Obesity
- Smoking
- Diabetes Mellitus
- Immunosuppression
- Chemotherapy
- Steroids
- COPD
- Malnutrition
- Wound infections
- Heavy Lifting after surgery
- Midline incisions
When do You Repair an Incisional Hernia?
We see a steady stream of patients seeking advice about the timing of their repair. Some have had their hernia for a relatively short period of time while others have gradually watched it grow larger for years. The motivation for repair is variable but the reasons patients describe are fairly typical:
Pain
Bowel Obstruction issues
Cosmetics – see it through clothing
My spouse told me to fix it…