Clinical Profile And Management Of Incisional Hernias: An Experience

Incisional hernia is one of the most common problems that a general surgeon is faced with. More often than not the problem is recurrent and tests the abilities of even the most experienced surgeons. We present our previous experience at repair of incisional hernias along with the analysis of results. A total of 76 patients (27 prospective and 49 retrospective) were studied. Only patients with postoperative incisional hernias and above an age of 15 years were included in the study. We conclude that prolene mesh hernioplasty by onlay technique provides excellent results especially in large sheath defects and recurrent hernias. INTRODUCTION Among the major catastrophes that can follow abdominal operations wound infection and wound dehiscence are two of the most serious. These complications are likely to be followed by incisional hernia within months or perhaps a few years. Besides increasing in size with time, an incisional hernia can incarcerate, obstruct, strangulate or cause necrosis and perforation, causing a risk to the patient’s life; hence the need to repair these hernias. Incidence of incisional hernias in the best centres is 10%, the recurrence rate after repair is around 40% but seems to be related to the technique of repair (1). Factors such as obesity, diabetes mellitus, wound infection and lower abdominal incision have a higher rate of incisional hernias and recurrence after repair. Hernias less than 4cm wide have a recurrence rate of 25% compared to 41% for those more than 4 cm wide (2). An incisional hernia can develop in any abdominal incision including the laparoscopic port sites (3). Patients usually complain of a bulge and a dragging sensation aggravated by coughing and straining. Occasionally, the overlying skin may ulcerate causing rupture of the hernia (4). Intestinal obstruction and strangulation are also well known presentations. Surgery is usually required for pain and discomfort or in those hernias which are large and have a small opening with a risk of strangulation (5). Figure 1 FIG. 1: INCISIONAL HERNIA FOLLOWING CESAREAN SECTION. Clinical Profile And Management Of Incisional Hernias: An Experience 2 of 9 Figure 2 FIG. 2: INCISIONAL HERNIA FOLLOWING OPEN CHOLECYSTECTOMY. Figure 3 FIG 3: INCISIONAL HERNIA FOLLOWING EXPLORATORY LAPAROTOMY. MATERIAL AND METHODS The study was conducted in the departments of general and plastic surgery at the Sheri-Kashmir Institute of Medical Sciences, Srinagar, India. The prospective study included all patients operated at this institute from November 1997 to March 2000, a total of 27 patients. The retrospective group included all patients operated here between January 1988 to October 1997, a total of 49 patients. HISTORY a. History of previous surgery and postoperative complications if any at that time. b. History of diabetes mellitus, COLD, renal disease, liver failure, malignancy and frequency and urgency of micturition. c. History of drug intake like steroids, immunosuppressants etc. EXAMINATION In addition to detailed general physical examination, thorough local examination assessing for the size and shape of defect, pulsatility, reducibility, other hernial orifices and previous scars etc. was carried out. INVESTIGATIONS Routine laboratory examinations were carried out in all patients. Depending on comorbidities, some patients needed lung function tests, echocardiography, lipid profile etc. TIMING OF SURGERY AND TYPE OF ANESTHESIA Surgery was timed at 12 to 18 months after the surgery leading to incisional hernia unless the patient presented late. Recurrent attacks of subacute intestinal obstruction, incarceration, irreduciblity and strangulation led to emergency surgery in some cases. Obese patients were encouraged to loose weight; smokers were encouraged to quit smoking. Patients with other comorbidities like COLD, diabetes and hypertension were optimized for surgery. All patients received preoperative antibiotics. All patients were operated under general anesthesia. OPERATIVE TECHNIQUE A uniform surgical approach is not possible in these patients. The surgical treatment needs to be individualized for each incisional hernia patient. Pre-operative pneumoperitoneum is used in some centres to stretch the abdominal cavity prior to hernia repair (6). Low molecular weight heparin and single dose antibiotic prophylaxis have been found to be beneficial (7). The incision to be made was decided by the operating surgeon according to the site and size of the incision. Any other abdominal problem was dealt with at the same time as the repair. Various surgical techniques used were as follows: 1. RESUTURE OF THE DEFECT Here the old scar was excised, the hernial sac was opened Clinical Profile And Management Of Incisional Hernias: An Experience 3 of 9 and adherent omentum and small gut loops dissected free. After closing the peritoneum the defect was closed by a continuous 1-0 prolene suture taking bites at least 3cm away from the edge and spaced at 2cm. The method was found useful for small defects. Figure 4 FIG. 4: THE HERNIA SAC Figure 5 FIG. 5: RESUTURE 2. KEELS REPAIR In this method, relaxing incisions were made on the lateral aspect of the anterior rectus sheath thus allowing easier and relaxed approximation of the anterior sheath in the midline. This method was found to be useful for large upper-midline incisions. 3. MODIFIED DOUBLE BREASTING TECHNIQUE Reconstruction of the linea alba was done by a modified double breasting technique and the sutures were placed in near-far and far-near sequence. On tying the suture, a 4layered linea alba was created. This method was useful for moderate-size defects. Figure 6 FIG. 6: 1st LAYER Figure 7 FIG. 7: 2nd LAYER Clinical Profile And Management Of Incisional Hernias: An Experience 4 of 9 Figure 8 FIG. 8: COMPLETED REPAIR 4. PROLENE MESH REPAIR On-lay technique was used. This technique was found to be useful for large defects and were previous repair had failed. This procedure produced the best results in our study. Figure 9 FIG. 9: MESH REPAIR 5. TENSOR FASCIAE LATAE MYOFASCIAL FLAP COVER Here a tensor fasciae latae myofascial flap was raised from the thigh and was tunneled onto the defect on the abdominal wall, to have a tension-free closure. The myofascial unit was bared on its single pedicle, the transverse branch of the lateral circumflex femoral artery. This method was useful where previous attempts at primary closure or prosthetic mesh had failed. It was especially helpful in the obese. Figure 10 FIG. 10: FLAP REPAIR POST-OPERATIVE MANAGEMENT After the operation, the patient was shifted to the recovery unit. Oral feeds were started in the late evening or on the first post-operative day. Post-operative antibiotics were given only in selected cases. Abdominal binders were used in all cases after repair. Drains, if used, were removed around the 2 post-operative day. Stitches were removed around the 10 to 12 postoperative day. Any post-operative complications were recorded. FOLLOW-UP The patients were followed in the out-patient clinic on the 13 post-operative day while continuing the use of abdominal binders. They were advised to refrain from lifting heavy weights or performing any kind of strenuous activity. Results were analysed by examining the patient for any late post-operative complications or recurrence. Finally, the acquired data was interpreted and analysed for: Presentation of hernia