Incisional hernia: cause and treatment

How do I recognize an incisional hernia?
A typical incisional hernia symptom is a protrusion in the area of surgical scars on the abdomen, which becomes visible above a certain size when pressing, coughing or sitting up.

How dangerous is an incisional hernia?
Since an incisional hernia always carries the risk of dangerous incarceration, surgery is advisable in most cases – especially if the hernial sac contents can no longer be pushed back into the abdominal cavity.

How is an incisional hernia diagnosed?
Usually, an incisional hernia can be diagnosed by palpation and ultrasound examination; in complex cases, additional computed tomography may be required.

An incisional hernia refers to an abdominal wall hernia that occurs in the area of the scar after abdominal surgery. The incisional hernia can also occur as a repeated hernia after previous hernia surgery.

After abdominal surgery, the abdominal wall is closed with sutures. Normally, a firm scar is formed. However, in up to 30% of all cases, incisional hernias occur after abdominal surgeries. Cracks or holes appear in the scar on the abdomen. These can be single or multiple. The incisional hernia can cause abdominal contents such as bowel or fatty tissue to push out of the abdomen and become trapped.

An abdominal incisional hernia can become very large. It is not uncommon for so much viscera to leak into the hernial sac that the newly created space in front of the abdominal cavity is larger than the actual abdominal cavity. With such a pronounced incisional hernia, the abdominal organs often cannot be pushed back into the abdominal cavity. The abdominal contents lose their place in the abdominal cavity, in technical jargon “Loss of Domain” or LOD.

A very large incisional hernia presents a major challenge to surgical treatment. At the Hamburg Hernia Center, we rely on innovative surgical methods. We are the first major hernia center to have established the innovative Intraoperative Fascia Traction (IFT) procedure, co-developed by Professor Niebuhr and his team.

An incisional hernia is a complication after previous abdominal surgery. Usually, wound healing is disturbed due to a weakness of the connective tissue. Many incisional hernia patients are also overweight.

An incisional hernia is additionally favored by the following risk factors:

• nicotine abuse
• chronic cough
• chronic respiratory diseases
• mechanical ventilation after abdominal surgery
• alcohol abuse
• cirrhosis of the liver
• abdominal fluid
• intestinal obstruction
• protein deficiency
• renal dysfunction
• tumor disease
• wound infection
• diabetes
• repeated abdominal incisions
• incorrect wound closure technique

Typical incisional hernia symptoms are protrusions in the area of surgical scars on the abdomen. The incisional hernia can be recognized from a certain size, especially when pressing, coughing or sitting up from a lying position. In contrast, incisional hernias rarely show up in the supine position. In some cases, an incisional hernia also causes pain, a feeling of pressure or indigestion.

Incisional hernias can assume huge proportions. At the Hamburg Hernia Center, we see quite a few patients with gigantic protrusions in the area of an abdominal scar. In these complex cases, the hernial sac cannot be pushed back even when the patient is lying down. A very large incisional hernia is almost always accompanied by pain, a feeling of pressure and indigestion.

A larger incisional hernia is often not difficult to recognize. A suspicion can usually already be confirmed by palpation. A doctor can also usually feel a smaller incisional hernia. In addition, ultrasound examinations may be required in some cases.

If the incisional hernia is very large, a computed tomography (CT) scan is required. In this way, the size of the hernia gap as well as the volume of the hernial sac and the remaining abdominal cavity can be precisely determined. A CT scan for incisional hernia is necessary if the hernia gap is greater than ten centimeters.

An incisional hernia does not heal spontaneously. Even if the incisional hernia in many cases initially causes little discomfort, incisional hernia surgery is advisable. Because: There is always a risk of incarceration. An incarcerated incisional hernia is always a surgical emergency, an operation is then required immediately.

An incisional hernia operation is also urgently recommended if the contents of the hernial sac can no longer be pushed back into the abdominal cavity. Surgery is also recommended for skin lesions or inflammation due to the load caused by the incisional hernia. In these cases, there is regularly pain as well as significant digestive problems and restrictions in movement or activity.

Incisional hernia surgery – which method is the right one? This always depends on individual factors and heavily on the size of your hernia. In principle, we prefer gentle, minimally invasive procedures at the Hamburg Hernia Center.

MILOS/EMILOS: OP method from Hamburg

Our hernia center stands in particular for MILOS/EMLIOS – the surgical method developed by Dr. Wolfgang Reinpold and his team, which is based on minimally invasive mesh insertion outside the abdominal cavity. Developed in Hamburg, MILOS/EMILOS is now established worldwide.

Learn more: MILOS/EMILOS Center (click here)

Complex and huge incisional hernia: surgery

A very large incisional hernia requires special surgical expertise and surgical methods. Thus, in the past, re-herniation has often occurred after incisional hernia surgery. Because: An incisional hernia is due to a disturbed scar formation caused by a weakness of the connective tissue. A simple suture, which often has to be performed under tension, is therefore rarely successful in the long term in the case of incisional hernias.

A tension-free surgical method with mesh insertion to close the hernia gap is therefore advisable. To close the often huge hernia gaps, all organ parts must first be returned to the abdominal cavity – a complicated procedure that requires considerable preparation.

At the Hamburg Hernia Center, one of the methods we use to prepare for surgery is Botox. Artificial slackening of the lateral abdominal muscle layers using Botox infiltration about four weeks before the incisional hernia surgery can be very helpful.

Intraoperative Fascia Traction (IFT) for large incisional hernia: Innovation from Hamburg

We were the first major hernia center to introduce the innovative Intraoperative Fascia Traction (IFT), co-developed by Professor Niebuhr and his team: During the complex incisional hernia surgery, we achieve a stretching of the fascia (connective tissue) and muscles (with length gain) through standardized and defined traction on the middle abdominal wall layers. This is necessary to achieve tension-free closure of large abdominal wall defects.

To achieve a similar gain in length (so-called compartment separation), other procedures are based on a separation of the abdominal wall layers. These technically very complex methods can be avoided in many cases thanks to the IFT procedure from Hamburg.

The IFT method can also be used in combination with MILOS/EMILOS surgery – also one of the main focuses of our hernia center.

Incisional hernia – how long will I be sick? In principle, the following applies: After scar hernia surgery, you will be back on your feet quickly – usually on the day of surgery. Thus, everyday activities such as dressing, undressing, personal hygiene, walking, going for a walk can be taken up immediately. Eating and drinking are also immediately possible.

Further physical activities such as housework, light gardening, swimming, jogging, cycling and light lifting are possible at the latest after the wound has healed (7 to 10 days).

Depending on the nature of your incisional hernia surgery, you may also be able to return to heavy physical work 3 to 6 weeks after surgery.