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  • • Bulge elicited by the Valsalva maneuver immediately over or adjacent to a laparotomy incision

    • Main complaint associated with ventral hernias is the cosmetic appearance

    • Patients may note discomfort or a heaviness sensation associated with the hernia bulge

    • Small incisional hernia defects appear to be most dangerous and are more commonly associated with an incarcerated presentation

    • The fascial defects progressively increase in size and may result in loss of abdominal domain

    • Classification of incisional hernias:

    • -Reducible: Visceral contents of the hernia sac able to retract into the abdominal cavity

      -Incarcerated: Visceral contents cannot be returned to the abdominal cavity

      -Strangulated: Incarcerated hernia where the blood flow to the entrapped viscera is compromised

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Epidemiology

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  • • 11% of all laparotomies result in incisional hernia formation

    • Incidence of this iatrogenic hernia is not diminishing despite awareness of the many causative factors

    • Highest incidence associated with midline and transverse incisions

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Symptoms and Signs

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  • • Asymptomatic bulge associated with prior laparotomy incision most common presentation

    • Patients may complain of a discomfort, fullness or heaviness associated with the hernia bulge

    • The fascial defects progressively increase in size

    • Hernia bulge may or may not be reducible

    • Incarcerated hernias are exquisitely painful to palpation

    • Patients with a strangulated hernia may present with an acute abdomen

    • Small bowel obstructive symptoms may be present with incarcerated incisional hernias

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Imaging Findings

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  • • Plain films are typically normal

    • US can be used to detect fascial defects as well as differentiate between an incarcerated incisional hernia and a solid mass

    • Abdominal pelvic CT scan is excellent in the detection of incisional hernias and characterization of involved viscera

    • -CT is particularly useful in diagnosing acute incarceration in morbidly obese patients in whom physical exam is difficult and unreliable

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  • • Diastasis recti

    • Stitch granuloma

    • Epigastric hernia

    • Incisional metastasis

    • Desmoid tumor

    • Parastomal hernia

    • Chronic incisional seroma

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Rule Out

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  • • Incarcerated or strangulated hernia

    • Incisional metastasis or other primary abdominal wall neoplasm

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  • • Thorough history and physical exam usually will accurately diagnosis incisional hernia

    • Abdominal CT scan when diagnosis is in doubt or to anatomically define the adjacent intestinal viscera in complicated cases

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When to Admit

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  • • Depends on the magnitude of repair and comorbidities

    • -Patients may require postoperative hospitalization

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When to Refer

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  • • Plastic surgery referral may be advantageous in instances where alloplastic reconstruction contraindicated:

    • -Infected wound

      -Fistula present

      -No omentum present to bridge between bowel and mesh

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  • • Minimize or eliminate medications deleterious to wound healing, such as corticosteroids

    • Weight loss in obese patients

    • Preoperative pulmonary conditioning in patients with large hernias who smoke or are chronically debilitated

    • Consider native tissue reconstruction ...

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