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SSAT Patient Care Guidelines

Surgical Repair of Incisional Hernias

Introduction

Surgery in the abdomen requires creation and subsequent closure of an abdominal incision that is never as strong as the original abdominal wall. Weakening of surgical closures over time may result in the development of an incisional hernia, which is estimated to occur in 3-13% of primary abdominal incisions. Recurrence rates after incisional hernia repair are markedly higher, estimated to range from 25-50%. Factors that contribute to the development of incisional hernias include wound infections, obesity, diabetes and smoking. Reasons for repairing incisional hernias are 1) symptoms, 2) gradual enlargement over time, and 3) avoidance of incarceration and strangulation of bowel.

Symptoms and Diagnosis

Incisional hernias can present in a variety of different ways, but the most frequent complaint is pain. The pain is usually located over the abdominal wall defect and is greatest at the fascial margins. It is usually dull in nature and typically does not radiate. Straining maneuvers may exacerbate symptoms or demonstrate a previously unnoticed defect. Patients may describe changes in bowel habits that can result from incarceration of abdominal viscera. The presence of an irreducible hernia should prompt surgical referral. Sharp pain or peritoneal signs suggest the possible diagnosis of strangulation with tissue necrosis; urgent surgical referral is necessary.

The diagnosis can usually be made by physical examination. Findings may include a visible bulge or palpable fascial edges. The size and number of fascial defects are often difficult to determine preoperatively. Usually, the clinical exam represents the "tip of the iceberg"; additional fascial defects not appreciated preoperatively are often identified at surgery. A palpable mass in a suspected incisional hernia should not be aspirated since this mass may contain bowel. A CT scan may be a useful adjunct in confirming the diagnosis as well as determining the contents and extent of the hernia. This is particularly helpful in obese patients.

Treatment

There are many ways to surgically repair incisional hernias. Smaller incisional hernias (< 3 cm.) can be repaired with primary tissue approximation. Repair of larger defects generally requires the use of prosthetic materials, which allows for a tension free repair. Techniques for application of the mesh include onlay, preperitoneal, and intraperitoneal locations. There are advantages and disadvantages of the different prostheses utilized in various circumstances. Alternatively, tissue release techniques such as component separation, use of tissue flaps, and the application of tissue expansion techniques may obviate the need for a prosthetic repair. Laparoscopic techniques may be used for repair of incisional hernias in selected patients. Potential benefits of laparoscopy include good visualization of all fascial defects, large overlap, and smaller incisions with fewer infection rates, less pain and quicker recovery.

Risks

The risks of incisional hernia repair include: seroma, wound infection, injury to intra-abdominal structures, and recurrent hernia. Major complications such as a mesh infection or enterocutaneous fistula may result in prolonged morbidity and require reoperation.

Expected Outcomes

Successful repair can be expected in the majority of cases. Recurrence rates range from 25-50% following an initial primary repair. The risk of recurrence increases dramatically in patients who have had previous failed repairs, in patients with very large hernias, obese patients, and in cases where one or more margins of the hernia defect is bone or cartilage. The use of a mesh support during open surgical repair has been shown to decrease recurrence rates to 5-35%.

After surgery, patients are instructed to limit activity for varying lengths of time, according to surgeon preference. Limitations on lifting and straining are generally recommended for several weeks after surgery. Limitations on activity after the laparoscopic approach are generally of shorter duration than following traditional open repairs.

Qualifications for performing incisional hernia repairs

Surgeons who are certified or eligible for certification by the American Board of Surgery, the Royal College of Physicians and Surgeons of Canada, or their equivalent should perform both elective and emergent incisional hernia repair. These surgeons have completed at least five years of surgical training after medical school graduation and are qualified to perform open incisional hernia repair with and without tension-free techniques. The level of training in advanced laparoscopic techniques necessary to conduct minimally invasive incisional herniorrhaphy has not been formally determined but surgeons with advanced laparoscopic experience are qualified to perform this procedure.

Suggested Readings

  1. Leber GE, Garb JL, Albert AI, et al. Long-term complications associated with prosthetic repair of incisional hernias. Arch Surg 1998: 133:378-382.
  2. Stoppa RE. The treatment of complicated groin and incisional hernias. World J Surg 1989;13:545-554.
  3. Henniford BT, Park A, Ramshaw BJ, Voelle Gr. Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg 2000;190(6):645-650.
  4. Tran NV, Petty PM, Bite U, et al.Tissue expansion-assisted closure of massive ventral hernias. J Am Coll Surg 2003;196:484-488.
  5. Shestak KC, Edington HJD, Johnson RR. The separation of anatomic components technique for the reconstruction of massive midline abdominal wall defects: anatomy,surgical technique, applications, and limitations revisited. Plast. Reconstr. Surg 2000;105: 731-738
  6. Sukkar SM, Dumanian GA, Szczerba SM, Tellez MG, Challenging abdominal wall defects Am J Surg 2001; 181: 115-121
  7. Mathes SJ, Steinwald PM, Foster RD, et al. Complex abdominal wall reconstruction: A comparison of flap and mesh closure. Ann Surg 2000;232: 586-596
  8. Goodney PP, Birkmeyer CM, Birkmeyer JD. Short-term outcomes of laparoscopic and open ventral hernia repair. Arch Surg 2002; 137: 1161-1165
  9. Luijendijk RW, Hop WCJ, Van Den Tol MP, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 2000;343:392-398
  10. Rohrich RJ, Lowe JB, Hackney FL, et al. An algorithm for abdominal wall reconstruction. Plast Reconstr Surg. 2000;105: 202-216


Keywords
hernia, incisions, laparoscopy, prosthetic mesh, component separation, tissue expansion, patient, guideline

Written 9/01
Revised 10/01
Revised 5/02
Revised 12/02
Board Approved 2/1/03
Revised 1/20/05
Board Approved 5/14/05
Revised and Board Approved 5/6/14

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Disclaimer
SSAT Patient Care Committee Guidelines

These patient care guidelines were written for the primary care physicians on a variety of digestive diseases to assist on when to refer the patient for surgical consultation.
Their goal is to guide PRIMARY CARE physicians to the appropriate utilization of surgical procedures on the alimentary tract or related organs and they are based on critical review of the literature and expert opinion. Both of the latter sources of information result in a consensus that is recorded in the form of these Guidelines. The consensus addressses the range of acceptable clinical practice and should not be construed as a standard of care. These Guidelines require periodic revision to ensure that clinicians utilize procedures appropriately but the reader must realize that clinical judgment may justify a course of action outside of the recommendations contained herein.

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