Incisional (Ventral) Hernia

• • 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

Epidemiology

• • 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

Symptoms and Signs

• • 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

Imaging Findings

• • 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

• • Diastasis recti

  • Stitch granuloma

  • Epigastric hernia

  • Incisional metastasis

  • Desmoid tumor

  • Parastomal hernia

  • Chronic incisional seroma

Rule Out

• • Incarcerated or strangulated hernia

  • Incisional metastasis or other primary abdominal wall neoplasm

• • 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

When to Admit

• • Depends on the magnitude of repair and comorbidities

  • -Patients may require postoperative hospitalization

When to Refer

• • 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

• • 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 ...