PATIENT INFORMATION ON INCISIONAL HERNIA
What is an Incisional Hernia?
An incisional hernia is a defect in your abdominal (belly) wall at the site of a previous incision (cut) which permits the intra-abdominal contents to push out. Incisional hernias occur when the old incision does not heal properly. It occurs more often in overweight patients, smokers, after emergency surgery, and when there was a wound infection. This can lead to your bowel being trapped which may cause an obstruction (blockage) or a strangulation (the blood supply to the bowel is cut off) of the contents. You may notice a swelling at the site of the incision (scar) of your previous operation – this can be associated with discomfort or pain in the abdomen, nausea and vomiting, and an inability to open bowels or pass wind.
Diagnosis of Incisional Hernia
An incisional hernia can cause you difficulty in daily activities like getting up from bed, dressing, walking, carrying shopping etc. It can cause symptoms like discomfort, pain, increasing size etc. Sometimes a loop of bowel can get trapped in the hernia and cause colicky abdominal pain or you may develop complications like bowel obstruction or strangulation. The diagnosis will usually be made by your doctor following a clinical examination if you have appropriate history and symptoms. Your GP will usually refer you to a surgeon – the surgeon may request investigations like an abdominal x-ray, a barium follow-through x-ray or a CT scan. Sometimes, you may not have time to see your GP because of the severity and acuteness of your symptoms, forcing you to attend the Accident and Emergency Department of your local hospital.
Management of Incisional Hernia
Incisional hernias come in different sizes. If you have a small incisional hernia and it is not causing any symptoms, then this can be initially kept under observation. However, if it is large or increasing in size or produces symptoms like discomfort, pain, nausea, vomiting or constipation etc. then a surgical repair is advisable, provided you are fit for surgery. If you live a sedentary life and the hernia is not causing any symptoms or increasing in size then then your doctor may advise continued observation only. The risk of this approach is that the hernia may increase in size in the future or develop an obstruction or strangulation which may require emergency surgery – the outcome under these circumstances may be worse than an elective operation. Please note that it is very likely that your hernia will enlarge over time, especially if you are physically active. Hence, it is advisable to have this repaired if you are generally fit to undergo surgery, especially if it is producing symptoms like discomfort, pain, nausea and constipation. The hernia repair is usually performed as a day case. You will be able to go home on the day of the operation. Occasionally, patients who expect to go home on the day of surgery may need to stay in overnight. Less often, for medical reasons or because of home circumstances, the operation will be done as an in-patient.
How is the Surgery Performed?
Open Incisional Hernia Repair
An incisional hernia can be repaired through the traditional open technique which requires a cut in the abdomen – Surgery involves return of the abdominal contents back into their normal position and repair of the area of weakness. A mesh (made from non-reactive material) is used to safely reinforce the area in repairing the overwhelming majority of hernias (both primary and recurrent hernias). The mesh used is a plastic net-like material. This sits in position forever supporting the weak area. The mesh does not react with normal tissues and causes no damage. You are likely to get aching and pulling during the first month after the operation. As you become more active, the tissues are stretched and become supple again. Mild twinges in the area of the hernia can continue for some months after the operation – no damage is being done. The mesh patch becomes part of the body, giving strength and support to the abdominal wall. The mesh patch reduces, but does not eliminate, the chance of the hernia coming back.
Laparoscopic Incisional Hernia Repair
The hernia can is some cases also be repaired through a newer laparoscopic (keyhole surgery) technique which requires 4-5 small cuts in the abdomen (abdomen) – the trapped contents are released and the defect is closed with a mesh and staples from inside the abdominal cavity.
Risks of Incisional Hernia Surgery
All operations carry some risks which have to be weighed against the risks of complications if you do not undergo surgery. General risks of complications following an operation include risks of sore throat, pneumonia / atelectasis (collapsed lung), thrombo-embolism (clots in leg veins or in lungs), heart attack, stroke and death – these complications are rare.
The specific risks are different with the 2 techniques.
Open Incisional Hernia Repair
The wound is usually painful and there will be some swelling and discolouration which will usually settle with time. You may suffer from chronic wound pain, suffer an injury to structures, develop a leakage of bowel contents, intra-abdominal adhesions, a poor scar, seroma (body fluid collection), haematoma (blood clot collection), persistent obstruction, infection, recurrence of the hernia etc. – the risks of these happening are less than 5%.. You should be able to return to work within 4-6 weeks in most cases.
Laparoscopic Incisional Hernia Repair
The wounds are usually painful and there will be some swelling and discolouration which will usually settle with time. There is a 20% risk that your surgeon is unable to complete the operation laparoscopically and has to convert the procedure to open surgery due to intraoperative difficulty. You may suffer from chronic wound pain, suffer an injury to structures, develop a leakage of bowel contents, intra-abdominal adhesions, a poor scar, seroma (body fluid collection), haematoma (blood clot collection), persistent obstruction, infection, recurrence of the hernia etc. – the risks of these happening are less than 5%. You should be able to return to work within 2-6 weeks in most cases.
Advantages of key-hole operation
- The recovery is quicker, so usually you can return to normal activity within 2-3 weeks.
Recovery is up to six weeks after an open repair
- There is a much lower risk of long-term pain after a key-hole repair
Specific risks of the procedures
Infection -A wound may become infected causing pain, redness and possibly discharge. The rate of risk is less than 2%.Infection is less common and less troublesome after a key-hole operation.
Bleeding – Bleeding under the skin can produce a firm swelling – like a bruise. Some bleeding may occur in around 2% of operations.
The hernia recurs – The hernia comes back. Further surgery for repair is required. The risk is up to 15%.
Swelling at the site of your previous hernia – There is often a swelling where the hernia had been, this is a localised bruise and not the hernia returned. This swelling settles over time
Seroma – 5% – more common after laparoscopic repair
Unable to pass urine after operation
Damage to an internal structure – Rare (2%)
Some patients have discomfort from the staples for some months after keyhole surgery.
Pain is usually far less after a key-hole operation
Risks specific to the key-hole operation
Hernia at the site of instrument insertion
Need for open surgery – Keyhole surgery may not work and open surgery is needed – less
Outcome of Incisional Hernia Surgery
It is usual to experience some pain and discomfort for several weeks but this gradually subsides. Occasionally there may be a collection of clotted blood (haematoma) or body fluid (seroma) between the mesh and the skin – usually these are absorbed spontaneously though in a proportion of cases a further operation may be required. Following surgery there is resolution of symptoms in 95% of patients. You can sometimes experience significant pain after a repair – this is usually due to a nerve being trapped in the healing scar tissue. There is a 5% risk of you experiencing recurrent symptoms after some time following surgery requiring a further operation.
Returning to work:
You may return to light work as soon as you feel comfortable – this is usually possible within 2-4 weeks oafter the operation. You should avoid strenuous physical activity or heavy lifting for 4-6 weeks.
What happens if you decide not to undergo surgery for incisional hernia?
Some patients are content to continue observation until the hernia causes symptoms. However, if you do not undergo surgical repair of your hernia then you can experience progressive symptoms requiring an operation at a later date. The hernia may develop a blockage (intestinal obstruction) or develop strangulation (the blood supply to the bowel is cut off) which may require emergency surgery – the outcome under these circumstances may be worse than an elective operation. It is likely that a hernia will enlarge over time, especially in physically active persons.
WHAT HAPPENS AFTER THE OPERATION?
After surgery, you will be active and able to walk. Patients with small first-time hernia repairs are offered a light snack, and are usually discharged on the day of surgery safely and comfortably. Patients with larger, complex, or recurrent hernias will have to stay overnight in hospital. When you are discharged, a prescription for pain medication will be provided. Beware that pain medicines can cause drowsiness and constipation, so do not drive, eat lots of fruits and vegetables, drink plenty of water, and consider Metamucil or stool softeners while on pain medicine. You will have a waterproof dressing in place. Please leave it there until the first post-operative visit. I will remove it then. Discomfort, swelling, and bruising in the week or two after the operation are normal. Recovery and return to work and normal activity depends on how large or complex your hernia was and what type of work you do. You will be encouraged to be out of bed and walking within a few hours of the operation. This reduces the risk of complications like blood clots and pneumonia.
WHAT CAN I DO AFTER SURGERY?
You may shower the day after surgery. You can eat and drink whatever you like, unless I tell you otherwise. You can walk, climb stairs, and do light activity without delay. Activities such as jogging, tennis, and sexual activity can be resumed when your body feels comfortable doing them. You should not drive or operate heavy machinery as long as you need prescription pain medicine. I will discuss your expected recovery with you and give you specific instructions for return to heavier activity and work.
WHAT IF I DON’T HAVE THE HERNIA REPAIRED?
While hernias in babies sometimes heal, hernias in adults will never get better without surgery. In fact, they tend to enlarge and get worse over time. Many patients ask about a truss (external hernia support.) A truss may support the weak area and provide some comfort, but is generally ineffective and can cause pressure sores. Hernias can be aggravated by chronic cough, constipation, or heavy lifting. Contents of the hernia, like intestine, may occasionally become trapped within the hernia leading to intestinal blockage or damage ( incarceration or strangulation), creating an emergency surgical situation. If you notice constant severe pain at the site of the hernia, a lump that does not reduce in size when you lie down and relax, or symptoms such as pain with associated vomiting, you should call my office or report to a hospital emergency department without delay.