incisional hernia detail and its managment

1. Incisional hernia
Dr Rana Pratap Singh
Assistant professor
Surgery
Jss medical college

2. Anatomy of the AbdominalWall

3. Function of Musculofascial Layers
5 paired muscles (3 flat, 2 vertical)
3 flat – int/ext oblique and transversalis
Increase abdominal pressure to
facilitate defecation, micturition, and
parturition,Stabilizes trunk
2 vertical – rectus abdominus and pyramidalis
Rectus - tensor of the abdominal wall,flexor
of the vertebrae, stabilize the pelvis during
walking, protects the abdominal viscera, aids
in forced expiration

4. Anatomy

5. Ventral Hernia
 Any protrusion of viscera through
anteriorabdominal wall
 Categorized as spontaneous and
acquired
 Spontaneous hernia:
 Umbilical and paraumbilical-71 %
 Epigatric-25%
 Others-4%

6. Acquired Hernia
 Incisional
Laparotomy
89%
Laparoscopy
5%
 Parastomal 6%

7. Umbilical Hernia:
• Umbilical hernia occurs when
the umbilical scar closes
incompletely in the child or
fails and stretches in later
years in the adult patient
• In infants
 Congenital and common
 Closes spontaneously by 2
years of age
 If persist after 5 years –
surgical repair

8. In adults
• Largely acquired
• Female>male
• hernia does not protrude through
umbilical cicatrix
• protrusion through the linea alba
just above the the umbilicus -
supraumbilical
• occasionally below the umbilicus
(infraumbilical) – so called as
paraumbilical hernia

9. Etiology
Multifactorial
Commonly found in associationwith processes
that increase intraabdominal pressure
 pregnancy
 obesity
 ascites
 persistent or repetitive abdominal distention
in bowel obstruction or peritoneal dialysis

10. Clinical Features
 Pain and swelling are the main
symptoms
 Pain increases on prolonged
standing or heavy exercise
 Content: mostly omentum

11. Treatment
Reduce weight of the patient
Treat the cause of ascites
Mayo’s operation – vest over pants
repair : imbrication of superior and
inferior fascial edges
For smaller defects – open umbilical
hernia repair
For larger defects - >2 cm – mesh
repair –open or laparoscopic

12. Epigastric Hernia :
• Hernia protruding through interlacing
fibres of thelinea alba anywhere
between umbilicus and xiphisternum
• Protrusion of extraperitoneal fat –
fatty hernia of linea alba
• Multiple in up to 20% ofpatients and
approximately 80% are in midline

13. Etiology:
Sudden strain leading to tearing of interlacing
fibers of linea alba
Clinical Features:
Symptomless
Painful- in partial strangulation of fat
On palpation – feels firm, generaly no cough
impulse and cannot be reduced

14. Treatment:
 Midline defect is usually elliptical in
nature with the long axis oriented
transversely
 Hernia will often not be seen on
laparoscopyowing to the lack of
peritoneal involvement through the
hernia defect
 Open repair – excision of incarcerated
preperitoneal tissue and simple
closure of defect

15. INCISIONAL HERNIA
• It is herniation through a weak
abdominal scar (scar of previous
surgery).
• It is common in old age and obese
individuals.

16. Predisposing Factors
• Vertical scar, midline scar, lower abdominal
scar— may injure the nerves of the
abdominal muscles.
• Scar of major surgeries (biliary,
pancreatic).
• Scar of emergency surgeries (peritonitis,
acute abdomen).

17. • Faulty technique of closure.
• Poor nutritional status of the patient.
• Presence of cough, tuberculosis,
jaundice, anaemia, hypoproteinaemia.

18. • Malignancy, immunosuppression.
• Smoking in postoperative period.
• Causes which increases the intra-
abdominal pressure (BPH, straining,
stricture urethra or rectum,ascites).

19. Factorsresponsiblefor development of
Incisionalhernia
• Vertical incision has got higher chances of
incisional hernia than horizontal incision
• Layered closure of the abdomen has got higher
chance than single layer
• Continuous closure has got higher chances than
interrupted closure

20. • Using absorbable suture material has got
higher chances of hernia than non-absorbable
sutures.
• Emergency surgical wound has higher chances
than elective surgical wound.
• Laparotomy for peritonitis, acute abdomen, and
trauma can commonly cause incisional hernia.

21. • Drainage through the main laparotomy wound
may precipitate formation of incisional hernia
• Chronic cough, smoking, obstructive uropathy,
constipation can precipitate incisional hernia

22. • Diabetes, old age, malnutrition,
malignancy, anaemia,
hypoproteinaemia, jaundice, ascites,
liver disease, uraemia, steroid therapy,
immunosuppressive diseases are other
precipitating factors

23. ClinicalFeatures
• Swelling in the scar region.
• Pain.
• Impulse on coughing.
• Gurgling sound.
• Often bowel peristalsis may bevisible
under the skin.

24. Eventually features of irreducibility,
obstruction, strangulation is seen.
• Hernia is common in lowerabdomen.
• It may be small or large; huge or
massive (diffuse)

25. • Scar, its extent and location, whether
healed primarily or secondarily,
• skin over the scar and swelling is noted.
• Details of the swelling with expansile
impulse on coughing and examination
both in lying down and standing aredone.
• Gap cannot be assessed in an irreducible
hernia.

29. defectsin Incisional Hernia
•Small defect
•Large and wide defect
•Very large defect
•Massive / diffuse
•Multiple defects

30. Investigations:
Always the precipitating factors must be looked
for:
•Chest X-ray.
• U/S abdomen.
• Tests relevant for causes.

31. Complicationsof incisional hernia
•Irreducibility,
•Obstruction,
•Strangulation,
•Incarceration.

32. Treatment :
 Preventive measures
 Reduction of weight in obese before elective
procedures
 Treat any respiratory diseases- chr.bronchitis
 Very careful closure of abdomen
 Single layer closure 5-8mm
 5mm apart
 2-0 suture
 4:1 suture length
 All precautions to prevent immediate postoperative
wound infection should be taken

33. Operative treatment:
Primary repair
• Defect small <2cm
• Viable surrounding tissue
Prosthetic repair
• Larger defect >2 to 3cm

34. Mesh placement options:
Onlay technique: after primary
closure of the fascial defect
mesh is placed over the
anterior fascia
Advantages: no direct contact
with viscera.
Disadvantages:
 More chances of
seroma formation
 superficial location of
mesh- more prone for
infection

35. Inlay technique: interposition of prostheticmesh
between the fascial edges.
Very high recurrence rates
Sublay/ underlay technique:
prosthetic mesh placed below the fascial
components

36. Retromuscular technique:
 also called as Rives-Stoppa-Wantz Retrorectus Repair
 placement of mesh under the rectus muscle & abovethe
posterior rectus sheath
Advantage
•intraabdominal forces hold the prosthesis
against the muscles.
•Forces that created the hernia now are used to
prevent its
•recurrence

37. Component separation technique
skin and subcutaneous fat
dissected free from the
anterior sheath of the
rectus abdominis muscle
and the aponeurosis of
the external oblique
muscle.
external abdominal
oblique is incised 1 to
2 cm lateral to the
rectus abdominis
muscle
.

38. • External oblique
separated from the
internal oblique
Dissection carried to
posterior axillary wall
Additional length can be achieved by incising
post rectus sheath
above the arcuate line

39. Laproscopic surgical repair
IPOM (intraperitoneal onlay mesh)
IPOM plus: IPOM + DEFECT CLOSURE
Laproscopic TAR(Transverseabdominisrelease)
Robotic TAR

42. Disadvantages
Higher operating cost
Expertise needed

43. Parastomal hernia
Common complication after stomacreation
• Incidence highest in colostomies-50%
• Usually asymptomatic
Complications like bowel obstruction and
strangulation rare
•Treatment :
Primary fascial repair-recurrence
Stoma relocation
•Prosthetic repair.

44. Thanks