Incisional hernia

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ,Assistant Editor-in-Chief: Soumya Sachdeva

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An incisional hernia occurs when the area of weakness through which the hernia occurs, is the result of an incompletely healed surgical wound. Since median incisions in the linea alba are frequent for laparotomy, ventral incisional hernias are termed ventral hernia. These can be the most frustrating and difficult hernias to treat! These hernias present as a bulge or protrusion at or near the area of the prior incision scar. Virtually any prior abdominal operation can subsequently develop an Incisional Hernia at the scar area, including those from large abdominal procedures (intestinal surgery, vascular surgery), to small incisions (Appendectomy, or Laparoscopy). These hernias can occur at any incision, but tend to occur more commonly along a straight line from the breastbone straight down to the pubis, and are more complex in these regions. Hernias in this area have a high rate of recurrence if repaired via a simple suture technique under tension and it is especially advised that these be repaired via a TENSION FREE repair method using mesh (a type of synthetic net).

Causes

1. Infection - Cases operated for peritonitis such as perforated duodenal ulcer, gangrene of the intestines.
2. Anatomical site - The midline of lower abdomen is highly prone, due to absence of posterior rectus sheath below the arcuate line.
3. Obesity with weak muscular tone.
4. Faulty sutures
5. Faulty technique of closure of the abdomen.
6. Ascites
7. Wrongly placed incisions tampering the nerves.
8. Persistent postoperative cough.

Clinical features

1. Presence of bulge/swelling in relation to a scar.
2. Scar is thin, evidence of secondary healing in the form of irregular scar may be present.
3. Expansile cough impulse.
4. Reducibility
5. After reduction of the contents, a defect can be palpated through the scar.
6. History of infection during the surgery, postoperative cough.
7. History of serosanguinous discharge through the suture line ,few days after operation.

Treatment

Surgical treatment is necessary if the hernia causes discomfort to the patient, if there is danger of impending obstruction or if the defect is narrow.

1. Anatomical Repair - All the anatomical layers are closed one after another by using non absorbable suture material.
2. Mesh Repair - Best repair in obese, multiparous female patients. A mesh is placed in the peritoneal sac and covered by rectus muscles. Tensionfree non absorbable suture materials are used. Prolene mesh or marlex mesh is commonly used.
3. Laproscopic mesh repair - Procedure of choice today. Recovery is fast and recurrence is very low.

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