Incisional Hernia Repair

What is an incisional hernia?

An incisional hernia is a hernia that has developed at the site of a previous surgical incision in the abdominal wall. Incisional hernias may occur soon after an operation or may develop months or years later. Incisional hernias are quite common and when small may go unnoticed. If incisional hernias are left untreated, they will tend to get larger with time.   Not all abdominal incisions result in the development of a hernia but there are several recognised risk factors. Incisional hernias are more common after emergency abdominal surgery. Contamination of the wound during surgery, particularly bowel surgery and wound infections after surgery may lead to incisional hernia formation. Incisional hernias are more common if an incision has used for more than one operation. Other factors that can lead to hernias are:

• Excessive coughing or straining after an operation
• Increasing age
• Steroids
• Obesity
• Smoking

As hernias enlarge, they can become unsightly or noticeable through tighter clothes. They can start to give aching or dragging discomfort as they increase in size.

What is an incisional hernia repair?

An incisional hernia repair is an operation performed to repair an incisional hernia i.e. a hernia that has developed at the site of a previous surgical incision in the abdominal wall.

When is an incisional hernia repair recommended?

 A hernia repair is usually advised if a hernia becomes symptomatic i.e. starts enlarging, causing discomfort, or generally interferes with the activities of daily living. Generally, it is better to repair hernias whilst they are still small. Sometimes hernias will not disappear on lying flat and they may have become ‘irreducible’. The inability to ‘reduce’ or push back the bulge into the abdomen usually means the hernia is ‘incarcerated’. When this happens, there is a risk of other serious complications such as obstruction or strangulation. Whilst this complication is relatively uncommon it does require emergency treatment. For small hernias that are not causing any symptoms a surgical repair may not be necessary. All surgery carries the risk of complication so for some patients watchful waiting is advised. A hernia belt may be beneficial for some patients and these can provide additional support to the abdominal wall. The belt is worn over the hernia site to prevent it coming out. These belts are usually made-to-measure by a specialised appliance fitter.

What does the procedure involve?

Incisional hernia can vary in size from very small to very large and no single operation is suitable for all types of hernia. Your surgeon will discuss which is the best options for you.

Most incisional hernias are repaired using a mesh. This provides for a stronger repair of the abdominal wall with a lower risk of a hernia recurrence. When patients arrive at the hospital, they will meet a nurse the anaesthetist and their surgeon. Incisional hernia repair is carried out under a general anaesthetic. In some cases (for small hernias) this can be done as a day case procedure for larger hernias patients may need to stay in hospital for one or more nights.

For an open hernia repair the surgeon will use the original incision, they will find the hernia and reduce or remove it. The layers of the abdominal wall are opened to create a space in which to place a mesh behind the muscles. The muscles are then closed over the mesh and the skin wound is usually closed with an absorbable stitch. For larger hernias a drain may be placed close to the repair to prevent fluid accumulating.  

Keyhole repair may be possible for some incisional hernias. Several small incisions are made in the abdominal wall through which a camera and small instruments are passed. The hernia is identified and pulled back into the abdomen. The defect in the abdominal muscles is then covered by a mesh that is held in place on the inside of the abdominal wall with tacks. This type of repair may be performed as a day case procedure. It may not be possible to carry out a keyhole procedure particularly if there are lots of adhesions and this type of repair may not be suitable for very large hernias.

For very large hernias a technique known as component separation may need to be employed to ‘reconstruct’ the abdominal wall. This is a complex and highly specialist procedure that can take several hours. The surgeon separates the muscles of the abdominal wall so that they can be brought together. The repair is supported with the use of a large piece of mesh, in some cases more than one may be required. This type of surgery carries greater risks and usually results in longer hospital stays.

What the potential risks and complications?

Sometimes bruising may occur around the wound(s) or a swelling develop beneath the wound(s). This is usually blood and/or tissue fluids which accumulates in the space where the hernia was. The fluid will normally gradually resolve.

Wound infections can occur after this type of surgery. When they do occur patients may need a course of antibiotics. This is particularly important if a mesh has been used. With bad infections sometimes a re- operation is required, and the mesh may need to be removed.

You should contact your doctor if after the operation you develop any of the following:

• Redness around or drainage from the incision(s) 
• Fever
• Bleeding from the incision(s)
• Pain that is not relieved by medication or pain that suddenly worsens

In cases of large hernias, particularly when a mesh has been used, a collection of fluid can collect in the space once occupied by the hernia. This is known as a seroma. Small seromas can safely be left alone, and many will disappear completely over time. Larger or tense collections may need to be drained off with a needle.

After open procedures some patients might experience some numbness or a slightly odd sensation in the skin around the scar. This happens when a nerve is bruised or damaged during the procedure. In many cases the numbness will improve over period of time.

A few patients may develop a recurrence of the hernia. Recurrences are far less common these days with the use of mesh, but recurrent hernias do happen. The surgeon will discuss potential risks with you before the operation.

After the procedure

Patients are encouraged to stay active following surgery. Walking regularly is the most useful exercise after the operation. Following the operation patients are advised to avoid heavy lifting for four to six weeks. After about four weeks patients may feel able to increase their exercise activities. Starting with gentle rhythmic exercises such as cycling or cross-training and gradually building up to your normal exercise regimen. Provided there are no wound problems swimming can also be good at this stage.

Patients may be able to return to work within one or two weeks, but this will be dependent of the size of the surgery and if their job involves any strenuous activities, they may need to be off work for longer or carry out only light duties. The surgeon will give you specific instructions regarding this. It is difficult to be specific about driving as this will be dependent on the site and size of the hernia repaired. After repair of a small hernia some patients can usually drive again after one to two weeks but this may be four weeks or more for larger hernias, the surgeon will give you specific instructions regarding this.