What Is An Incisional Hernia?
An incisional hernia is a weakness or a defect in the abdominal wall in the area of a prior surgical incision. A piece of fat or bowel from the abdomen will protrude through the defect and causes a bump that you can see. Because of the previous incision, this area of the abdominal wall is weaker and prone to hernia formation.
What Causes Incisional Hernias?
Just like other types of hernias, multiple factors can contribute to incisional hernia formation.
- Previous surgery: Prior surgical incisions are needed in order to have an incisional hernia.
- Obesity: Excess weight is not only a risk factor for developing incisional hernias but also for recurrence after repair.
- Pregnancy: As the abdominal wall expands during pregnancy the weak area around a prior incision can form hernias.
- Heavy lifting: Heavy work or heavy sports (CrossFit, Football).
- Coughing: Patients with emphysema or COPD, smokers or chronic allergies.
- Genetics: Many patients have close family members with a history of hernias.
- Prior Hernias: Personal history of other hernias or previous hernia repairs at the incision site.
- Liver disease: Due to the formation of ascites and abdominal distention.
Symptoms Of An Incisional Hernia
Many patients with an incisional hernia are asymptomatic. This is particularly true for small and reducible hernias. Hernias tend to enlarge over time and symptoms can develop at the time. The most common symptom associated with an incisional hernia is pain around the incision site.
Symptoms can be more pronounced during certain activities. Most patients complain of pain during lifting, coughing, jumping, reaching or standing/walking for long periods of time. The pain is usually described as a burning sensation.
If a hernia becomes incarcerated or strangulated the pain can get severe. The patient can also develop abdominal pain, abdominal distention, nausea and/or vomiting. Lack of flatus or bowel movements can also be present if a portion of the bowel is incarcerated or strangulated. If any of these symptoms develop rapid medical attention is needed.
How Is An Incisional Hernia Diagnosed?
The diagnosis of an incisional hernia is usually very straight forward. A good history and physical exam is normally the only thing needed to make an accurate diagnosis.
In more complex cases radiologic evaluation might be needed. A CT scan is the test of choice for most surgeons. CT scans are very sensitive at diagnosing hernias but unfortunately, very small hernias are difficult to visualize. The CT scan is also very useful in patients that had previous hernia repairs. The images can assist in visualizing the abdominal wall muscles, previous mesh and more accurately measured the hernia defect.
See the image of the CT scan provided. There is a clear incisional hernia in the anterior abdominal wall. A portion of the colon can be seen protruding through the defect in the abdominal wall.
An MRI can also be useful but usually not necessary.
How Are They Treated?
Many years ago the recommendation was that every hernia had to be repaired. In more recent years that has changed. Currently, the decision to repair an incisional hernia is base on the symptoms. For a completely asymptomatic hernia that doesn’t limit the patients daily activities, watchful waiting is not unreasonable.
For an incisional hernia that is enlarging, causing pain or limiting the patients daily activities, elective surgical repair is routinely recommended.
For larger incisional hernias cosmetic concerns are a big reason for patients to seek repair.
For hernias that are incarcerated and/or strangulated that are causing significant pain, surgical repair is usually mandatory and sometimes an immediate repair is warranted.
Below we will discuss the three main approaches to repair an incisional hernia. We will also discuss a very common question that patients have nowadays. Do I need mesh?
Open Incisional Hernia Repair
An open incisional hernia repair is routinely done by reopening the prior incision. The defect in the abdominal wall is identified and using a combination of sutures and mesh the defect is repaired. The surgery time can vary base on the size of the hernia, the body habitus, and prior hernia repairs. Patients with complex hernias will require admission to the hospital for pain control and observation.
The decision to go with an open approach is made base on several factors. The hernia size, prior surgeries, body habitus and the need for complex repair. The surgeon’s experience is also a significant factor in deciding between an open approach versus a minimally invasive one.
A giant incarcerated or strangulated incisional hernia is also better suited for an open approach were reducing the intestine back into the abdominal cavity can be a significant challenge.
We will discuss some of the different techniques used to repair complex hernias in a different section. Dr. Caban has ample experience in performing many of the techniques available. Dr. Caban has taught other surgeons in national meetings on how to perform many of these techniques.
Laparoscopic Incisional Hernia Repair
The laparoscopic approach is done with 3-4 incisions on the sides of the abdominal wall. The surgical time is approximately 30-60 minutes and it can be an ambulatory surgery. A laparoscopic incisional hernia repair has to be done under general anesthesia.
A mesh is placed against the abdominal wall and it is secured with small “nails” and sutures to the abdominal wall. The mesh has a special coating to prevent adhesions of the bowel to the mesh.
One of the big advantages of the laparoscopic approach is the ability to place a larger mesh. That will create more coverage of the defect and potentially decrease recurrence.
A small disadvantage is pain, in my experience, the laparoscopic approach can be very painful depending on how the mesh is anchored to the abdominal wall.
Robotic Incisional Hernia Repair
Robotic surgery is a game-changer when it comes to incisional hernia repair. The DaVinci surgical system allows the surgeon more options when repairing complex and larger incisional hernias. Several years ago the only way to fix some of those larger hernias was with an open technique and now Dr Caban can repair those hernias with just a few small incisions.
In Dr. Caban’s practice, most incisional hernia repairs are done with the DaVinci robotic system. Doctor Caban has found that patients have less pain when compared to the laparoscopic approach. They also have less wound complications (infection) when compared to open hernia repairs.
Large complex hernias are usually better repaired by releasing some of the lateral muscle layers in order to approximate the muscles to the middle of the abdominal wall. The Robotic system allows Dr. Caban to do these procedures minimally invasive.
As you can see on this picture the large recurrent hernia with a long midline incision can be repaired with six small 8-12 mm incisions. In Marion County, no other surgeon has the skills or training to do these surgeries at the time of this writing.
Incisional Hernia Repair
Mesh Or No Mesh?
If you watch any television most likely you have seen a commercial about mesh recall or mesh complications. The truth is that these commercials are not new. Mesh complications, recalls, and infections have affected patients for decades. Mesh is like any other medical device, they can be defective or they can cause issues in certain patients.
Many clinical trials have looked into these issues and the conclusion is always very similar. The best way to fix a hernia is with mesh. Mesh placement has proven to decrease the recurrence rate by reinforcing the tissues and by creating tension-free repairs. Some patients complain of chronic pain due to the “mesh”, but the chronic pain can also develop in patients with a non-mesh repair. The incidence of chronic pain after a hernia repair is around 2-5% for all hernias.
There are many types of mesh, permanent mesh, absorbable mesh, and hybrid meshes. Also inside these three broad catergories, you can find different materials made by different manufacturers. Selection of the type of mesh is usually determined by the surgeon and many times the surgeon is limited to whatever product is available at the institution where he or she operates.
If you have concerns about the mesh product that will be used in your surgery you should ask your surgeon. Dr. Caban is an advocate of mesh placement in most hernia repairs, but he is also opened to discussions with the patients regarding what product will be used and what the outcomes data is for that product.
So to answer the question of mesh or no mesh. The short answer is that most hernias are better repaired with mesh.
Post Operative Period
What Happens After Incisional Hernia Surgery?
An incisional hernia repair can be an ambulatory surgery. Larger and more complex hernias will require admission to the hospital for several days. This is particularly true for open incisional hernia repairs. Admission to the hospital is usually required for pain control and observation for complications.
The operative time can vary significantly based on the hernia. A small hernia can be repaired in 30 minutes. A larger complex hernia with a Transversus Abdominus Muscle Release robotically can take up to 8 hours.
At discharge from the hospital, you will be given a prescription for pain medications and other basic instructions.
You will follow up with Dr. Caban in 2-3 weeks and then at three months.
Most patients that have office type job can expect to return to work after several days to a couple of weeks. For those of you that have a labor intense job were heavy lifting more than 15-20 pounds is necessary, you should account for 4-6 weeks out of work or sooner if light duty is an option.
Other activities like playing golf, pickleball, bowling or any other sports were using the core muscles is necessary should be postponed for 4-6 weeks. Swimming should be limited until the incisions are completely healed.
What People are Saying
“Dr. Angel Caban performed my surgery almost 5 years ago on 6/2/2014. He is a kind doctor and always treated me fairly. I always felt welcome in his office. I recommended him to many over the past 5 years”.
“Me encanta no lo cambio. Exelente el doctor caban y su personal. Muy buen grupo”.
“Another successful experience”
“Dr. Caban did my colon resection and did an outstanding job all the way across the board. I highly recommend him as well”.
“Very fortunate to have him”
“I have the privilege of working with Angel M Caban in the hospital environment. I also have had him be the surgeon to one of my family members. I would like everyone to know that he is a great surgeon. We are fortunate to have him here in Ocala. He is personable, easy to talk too and has excellent bedside manners”.
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