What is an Incisional Hernia?
An incisional area occurs through a weak area on a previous incision site for a prior operation. There is usually a bulge of tissue (internal fat called omentum, pre-peritoneal fat or intestines) that pushes through the weak area. They can be located anywhere in the abdomen. Some incisional hernias occur over a previous “port” site (the small holes made to put the instruments) after a laparoscopic or robotic surgery. Port site hernias have an incidence of 1-5% and incisional hernias in general up to 30%.
Symptoms of an Incisional Hernia
Patients with incisional hernias usually have a visible bulge in the area that increases in size with coughing, straining, pushing, heavy lifting or any maneuver that increases the intra-abdominal pressure. Most of the times there is also pain or pressure at the hernia site. When the hernia is strangulated, sharp pain, redness of the surrounding skin, nausea, vomiting and intestinal obstruction can occur.
Diagnosis of an Incisional Hernia
Most incisional hernias are diagnosed on physical examination by an experienced physician or Hernia specialist. Sometimes with non-palpable hernias or in the obese patient additional tests are indicated to help in the diagnosis including ultrasound, CT scan of the abdomen and pelvis or MRI. A hernia is called a “reducible hernia” when the bulge can be pushed back into the abdomen. An incarcerated or a “non-reducible hernia” occurs when the contents inside the hernia sac cannot be pushed back into their normal anatomic position inside the abdomen. Incarcerated hernias can sometimes become “strangulated” when the blood supply to the organs that are entrapped (intestines or fat or other organs) becomes compromised and the tissue dies. This is a surgical emergency that requires immediate operation.
Treatment of Incisional Hernias
Incisional hernias can be repaired either via an open approach or a laparoscopic / robotic approach. With an open approach an incision is made in the area of the bulge or the previous incision and the hernia is repaired either using the placement of a prosthesis or mesh or using a “suture” technique, where no mesh is placed and the muscles and tissues are sutured together in order to close the defect. For laparoscopic and robotic approaches, four small incisions are made in the lateral part of the abdomen through which long instruments are placed and the hernia is repaired with mesh. At the Miami Hernia Center when we perform open or laparoscopic repair of incisional hernias with mesh, most of the time we place the mesh in the pre-peritoneal space, that way the mesh is not in contact with the intra-abdominal organs (Intestines), decreasing the risk of complications. For very large hernias we used the retro-rectus technique where the mesh mesh is placed “sandwiched” in between the muscles. This technique is considered the “gold standard” for open repair of large ventral and incisional hernias.
Some open small incisional hernias can be fixed with local anesthesia and intravenous sedation. Most of the time general anesthesia is required depending on the patient’s conditions and the size of the hernia. For laparoscopic or robotic repair, general anesthesia is required.