INCISIONAL HERNIA
Definition
- Incisional hernia is the protrusion of abdominal contents through a weak area in the abdominal wall at the site of a previous surgical incision.
Anatomy Involved
- Previous surgical scar
- Fascial layers of abdominal wall
- Rectus sheath
- Peritoneum
- Omentum or intestine
Etiology of Incisional Hernia
Patient-related Factors
- Obesity
- Advanced age
- Poor nutritional status
- Anaemia
- Diabetes mellitus
- Chronic cough
- Constipation
- Smoking
Surgery-related Factors
- Poor surgical technique
- Inadequate closure of abdominal wall
- Use of absorbable sutures
- Midline incisions (most common)
- Emergency surgeries
Post-operative Factors
- Wound infection
- Wound dehiscence
- Post-operative sepsis
- Increased intra-abdominal pressure
- Early mobilization or strain
- Poor wound healing
Types of Incisional Hernia
- Early incisional hernia
- Late incisional hernia
- Small incisional hernia
- Large incisional hernia
- Multiple defect hernia
Clinical Features of Incisional Hernia
Symptoms
- Swelling at the site of previous surgical scar
- Swelling increases on coughing or straining
- Discomfort or dragging pain
- Feeling of heaviness
- Cosmetic disfigurement
Signs
- Visible bulge at scar site
- Positive cough impulse
- Reducible swelling in early stage
- Thin stretched skin over swelling
- Expansile impulse on coughing
Features of Complications
- Irreducibility
- Pain and tenderness
- Vomiting
- Abdominal distension
- Redness or ulceration of skin
Diagnosis of Incisional Hernia
- Clinical examination
- History of previous surgery
- Ultrasound abdomen
- CT scan for size, content, and planning surgery
Complications
- Incarceration
- Intestinal obstruction
- Strangulation
- Skin ulceration
- Recurrence
Management of Incisional Hernia
Conservative Management
- Only for unfit patients
- Abdominal binder
- Weight reduction
- Treatment of cough and constipation
- Control of diabetes
Surgical Management
- Definitive treatment
- Indicated in most patients
Surgical Options
- Anatomical repair (herniorrhaphy)
- Mesh repair (herniorplasty)
- Open mesh repair
- Laparoscopic mesh repair
- Component separation technique for large hernias
Principles of Surgical Repair
- Reduction of hernial contents
- Excision of hernia sac if required
- Closure of fascial defect
- Reinforcement with mesh
- Prevention of tension on repair
Post-operative Care
- Wound care
- Control of infection
- Use of abdominal binder
- Gradual mobilization
- Avoid heavy lifting
Prevention
- Proper surgical technique
- Adequate wound closure
- Prevention of wound infection
- Control of risk factors
Homoeopathic Therapeutic Approach
- Calcarea carbonica → Weak abdominal wall
- Silicea → Poor wound healing
- Arnica → Post-surgical pain
- Nux vomica → Hernia due to strain
- Graphites → Scar-related weakness
Important Points
- Common after midline abdominal surgeries
- Mesh repair has low recurrence rate
- Prevention is better than cure