Hernia
Dr. med. Mira Seidel is a freelance writer for the medical team.
More about the experts All content is checked by medical journalists.An incisional hernia is a bulge (hernia) that occurs in the area of a scar. The incisional hernia is a common complication of previous abdominal surgery. The causes include obesity and impaired healing of the scar. A hernia should always be operated on, as the further divergence of the scar tissue cannot be stopped. You can find out everything about the hernia here.
ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. K43
Incisional hernia: description
What is a hernia? In the case of a hernia, the scar tissue deviates and the contents of the abdomen turn out. This weak point is usually located in the area of the anterior abdominal wall in the case of a hernia. An incisional hernia generally consists of a hernial port, a hernial sac and the contents of the hernia, which can be felt and seen, especially when the pressure in the abdomen is increased.
Incisional hernia: abdomen
Any operation on the abdominal wall carries the risk of an incisional hernia. About ten to twenty percent of the patients develop a hernia after an abdominal wall operation. This makes the incisional hernia the most common long-term complication after an operation. It is estimated that around 80,000 incisional hernias occur annually, in a third of patients during surgery.
The incisional hernia usually occurs after operations with a median incision, a common surgical method in which the skin and the layers of the abdominal wall are severed in the middle along the body axis. This is where the so-called linea alba is located, where various abdominal muscles attach. The muscle layers consist of the external oblique abdominal muscle (M. obliquus externus abdominis), the internal oblique abdominal muscle (M. obliquus internus abdominis), the transverse abdominal muscle (M. transversus abdominis) and the straight abdominal muscle (M. rectus abdominis).
If an incision is closed along the linea alba, the sutures made usually offer a good hold despite the high tensioning force.
Incisional hernia: symptoms
Incisional hernias differ in size, the place of occurrence and the size of the hernial sac. The symptoms range from complete freedom from symptoms to pain, which can result in complete incapacity for work. The pain usually occurs when the abdominal muscles are tense, for example when coughing, lifting heavy loads or pressing.
In the case of a hernia, the doctor usually feels a bulge in the area of the scar as the first symptom. A small incisional hernia is sometimes not visible at all and only becomes clear when the pressure in the abdomen increases. If the hernia increases in size, it may contain parts of the intestine. Irregular stool or blood in the stool can result.
In addition to redness and pain at the hernial port, which are significantly increased when the hernial sac is pinched, physical performance can also decrease.
Incisional hernia symptoms: monstrous hernia
Each incisional hernia can expand into a so-called "monstrous" incisional hernia, which is then ten to fifteen centimeters in diameter. In this incisional hernia there are always abdominal viscera that have to be pushed back into the abdominal cavity during an operation.
Incisional hernia symptoms: entrapment
The smaller the hernia gap, the more likely the hernia can get trapped. Severe, permanent or colicky abdominal pain - mostly in the area of the incisional hernia - can occur within a few hours. The stomach is very sensitive to pressure. Severe abdominal pain, fever, nausea, and vomiting indicate that parts of the intestine, for example, have been pinched. Entrapment is always an emergency and must be operated on immediately.
Incisional hernia: causes and risk factors
The cause of an abdominal wall rupture is a combination of increased internal pressure in the abdominal cavity and a congenital or acquired weak point in the connective tissue of the abdominal wall. The pressure in the abdomen can be increased by obesity, pregnancy, coughing, straining or ascites. In the case of small hernias, only fatty tissue may be contained in the hernial sac, while in the case of large hernias there may also be small or large intestines.
About half of the incisional hernias occur within the first six months after the operation - incisional hernias are possible up to five years after the operation.
Incisional hernia: risk factors
In addition to the patient's underlying or concomitant illnesses, surgical-technical factors also play a role. In summary, the following risk factors for a scarring hernia apply:
Patient-dependent factors:
- Obesity
- Wound infection
- older age
- Nicotine use
- Cortisone and drugs that suppress the function of the immune system
- Hereditary collagen diseases
- Concomitant diseases such as anemia, tumor diseases, diabetes mellitus, abdominal aortic aneurysms
Surgical technical factors:
- Cut
- Sutures
- Seam technique
Obesity from a body mass index of 25 is one of the most important risk factors for the development of incisional hernias. The main cause is the increased pressure in the abdomen. In addition, due to the increased fat tissue, the doctor is often less able to sew up the surgical wound in overweight people.
A reduced blood flow and thus oxygen supply to the scar tissue due to anemia, shock or malnutrition has a negative impact on wound healing, as does smoking, collagen metabolism diseases, wound infections or cortisone therapy. Smokers are four times more likely to develop a scarring hernia.
Although incisional hernias cannot be prevented even with special incisions, significantly fewer incisional hernias occur in so-called keyhole operations (laparoscopic operations), which are characterized by small incisions. Sutures and sutures also play a role in the development of an incisional hernia.
Incisional hernia: examinations and diagnosis
If you have a hernia, you should definitely consult a doctor. The doctor will take a medical history and perform a physical exam both lying down and standing. He will also ask you to push once to increase the pressure in your abdomen. Possible questions from the doctor can include:
- When did you have an operation?
- How many operations have been performed?
- How long have the complaints existed?
The doctor will feel the hernial sac with the protruding hernial sac - if the contents of the hernial sac can easily be pushed back into the abdominal cavity, the diagnosis is easy to make. In the case of smaller incisional hernias, a physical examination is often more difficult because the hernia ring is inconspicuous and there is usually only local pressure pain.
An incisional hernia is characterized by the size of the hernial orifice, whether the protrusion can be pushed back spontaneously, how far the hernia is from the costal arch and its location - for example in the upper or lower abdomen.
Scar hernia diagnosis: imaging tests
It is often difficult to examine a hernia in overweight patients. It is helpful to visualize internal organs and tissues using methods such as ultrasound, computed tomography or magnetic resonance tomography. Imaging methods are also used in patients with severe symptoms for whom the physical examination alone could not provide a clear finding. Cancer patients are examined for new tumors that may have developed.
Incisional hernia: treatment
A hernia is usually operated on because it does not resolve on its own. A small incisional hernia should also be operated on, as the hernial sac can become trapped. In patients with a large hernia, it makes sense to lose weight before the operation and to do breathing exercises regularly.
Incisional hernia surgery is not an urgent procedure for patients without symptoms. However, the muscle layers diverge further and further over time, so that the incisional hernia steadily enlarges.
Incisional hernia surgery should be carried out at the earliest three months to one year after the previous operation - only then are the wound edges stable enough.A hernia can either be operated openly or with the so-called keyhole technique (laparoscopy).
Incisional hernia surgery: Open surgery
In an open incisional hernia operation, the surgeon opens the abdominal wall with an incision. Then he exposes the hernial sac and pushes it back into the abdominal cavity. Depending on the size of the hernial sac and the patient's state of health, there are different methods of closing the abdominal wall again:
A very small incisional hernia is usually closed with a direct suture. From a chunk size of three centimeters, a stabilizing plastic net is usually used. The mesh is used in such a way that it overlaps the hernia by at least five centimeters on each side. Depending on the layer of the abdominal wall in which the plastic mesh is used, a distinction is made between the inlay, onlay or sublay technique.
So-called "bio-nets" can be used for large hernias. They are extracted from the small intestine of pigs and later broken down by the body after the affected tissue has been stabilized.
Incisional hernia surgery: keyhole technique
With the keyhole technique (laparoscopy), a small abdominal incision is operated with camera optics. This method is considered to be very gentle on the patient - repeated fractures and wound healing disorders occur less often. The use of painkillers and the length of stay in hospital are also shorter.
Incisional hernia: disease course and prognosis
A hernia can usually be operated on without problems and treated successfully. If a hernia is not operated on, it will continue to expand. Complications such as bowel obstruction, pain and digestive problems can result. With new surgical procedures, plastic implants and standardized treatment steps, hernia surgery has continued to develop. The latest developments in plastic mesh technology reduce pain and the feeling of foreign bodies and enable better abdominal wall mobility.
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