INCISIONAL HERNIA

BULGES IN THE BODY WALL COULD MEAN INTERNAL

ORGANS ARE OUT OF PLACE, SO PROPERLY PLACE,
CLOSE, HEAL AND PROTECT THE WALL.
 Presenting complaint(s)
SM [NHN : 52020 2662]
Admission Date : 15/02/16 Discharged Date : 19/02/16

SM, 40 y/o i-T/F admitted with Right Iliac Fossa

Mass/Collection. She had RIF pain, vomiting,
fever and diarrhea. 3rd admission for the same
complaint(s). Planned open appendecectomy
for clinical appendicitis 5/12 ptca but NO appe.
done yet operative diagnosis was RIF abscess
thus <50ml of pus drained from the RIF under
general anesthesia.
Pathological Sieve – RIF
MASS±PAIN
Vascular-Aneurysms
Inflammatory-Crohn’s disease, Appendicitis,
Diverticulitis, Mesenteric adenitis, PID, Typhilitis
Trauma-Hematoma
Acquired- Incisional Hernia, Colocolic
Interssusception (AIDS), Ectopic kidney, Ectopic
pregnancy
Metabolic- Hyperlipidemia, Hypercortisolemia
Infection- Appendicular/Iliopsoas/Tubo-ovarian
abscess, Ileocecal TB
Neoplasm- Appendicular Carcinoid Tumor, Cecum
Tumor, Ovarian Tumor, CRC and non Hodgkin
Lymphoma
History of Presenting
Complaint(s)
Pt. says firstly she had “sharp-poky-persistent”
pain localized in the RIF region then developed
fever 3 days p.t.adm. 1 day prior she had (×2)
of vomiting and diarrhea (“clear watery” Ø
Bile/Blood/Mucus).
ROS
+(s): ↓ Appetite, ↓ Bowel output and Nausea (×1/7). PV Bleeding
(×2/7).
-(s): Generalized weakness, constipation, weight loss, pus vaginal
discharge, hematuria, urgency, frequency, hesitancy, dysuria,
menorrhagia, dysmenorrhea, amenorrhea
 History…
PMH
23/07/15 – 1st Admission
Referral – Navua Hospital – Dx. Clinical Appendicitis
Consented for Open Appendecectomy +/- Exploratory
Laparotomy
Surgical Notes: Under General Anesthesia, Pt. in supine position,
Betadine prepared and draped, Lanz was done. Entered peritoneum
safely and <50ml of pus drained from RIF. Mass noted (non-
differentiable) appendix was plastered to cecum. Drain left in-situ.
Closure of fascia with Safil 1/˚ and skin closure with Nylon 2/˚.
Post-op care [PARU] and transferred to ASW. [Discharge Date:
28/07/15]
20/12/15 – 2nd Admission
Presented with similar symptoms to the 3rd admission. Dx.
Appendicular mass. Abdominal CT showed phlegmon with
 History…
Allergies – Nil known
DH [as charted] – Cloxacillin 2g IV q6h
Gentamycin 200mg IV OD
Flagyl 400mg PO q8h
Panadol 1g PO q6h
Brufen 400mg PO q8h

OB/GYN – P6G6, LNMP: started 2/7 p.t.adm. and currently

was having her menses. Regular 2pds/d for 4 days. (-)
Contraception

SH – Married, Mother of 6, SDA

Lives in Tokatoka Highway, Navua, does D.D and does
gardening at home. Husband works at the local supermarket.
 Physical Findings
O/E: Middle aged woman, lying in a right lateral position. Pt. appears
to be in pain (pt. rates it 6/10)
Vitals: Temp: 37.9 BP: 112/82 PR: 89 RR: 20
HEENT: Nil(s)- pallor, jaundice, cyanosis.
ABDOMEN: Lanz incision scar, Soft tissue mass on RIF
~6×5cm,~5cm Below Umbilicus protrusion, (++) Tender (+) Guarding (-)
Rovsing’s sign, (-)distension
Resonant percussion, Bowel sounds heard. Cough impulse-pain
aggravated
CHEST: Dual HS. Normal S1 and S2. (-)s murmurs, thrills, heaves
Bilateral BS clear. (-)s creps, wheezes, stridor
EXTREMITIES: Well perfused and warm. CR <2 secs. (-) Edema
 Investigative Findings
Bloods Done – WCC: 9600
Hgb: 12.6 MCV/PCV: 81/38
Platelet: 234,000, ESR: 30,
Creatinine: 59 Albumin: 38

Ultrasonography Done –
Mixed echoic mass at RIF over
the surgical site
[6.3×3.3×5.0cm], AV Uterus
measures 9.7×3.6cm, regular
outlines and echoes.
Endometrium measures
1.1mm.
 Assessment
Lanz Incisional Hernia secondary to:
• 5 months post planned appendecectomy +

Exploratory Laparotomy incision

• Suture technique

• ≥ 40 yo

• Poor healing
 Treatment Plan
Non Surgical
Pain Relief: IV Morphine 4g PO q4h and Panadol 1g PO q6h
Fluids: IV Normal Saline 1L q6h,
Antibiotics: IV Antibiotics as charted: Cloxacillin 2g q6h,
Gentamycin 200mg OD q8h, Flagyl 400mg PO q8h
Surgical
Hernia Repair: Seek consent if agree prep. Pt. NBM for >6hrs
before OT. Proper pre-op, intra-op and post-op care. (Monitors: Vitals,
O2 sat., Hgb levels, A/B, IDC, pain free)
 Operative Assessment
Surgical Operation – Incisional Hernia Repair
Procedure – Under Spinal Anesthesia, Pt. vitals
stabilized, Pt. in supine position, Betadine prepared and
draped over abdomen, Incision through old scar, entered
peritoneum safely, identified opened neck of sac,
examined contents of sac (ORMENTUM AND CECUM)
and was REDUCED. Appendectomy done also.
Repaired by mattress stitches of non-absorbable (0/˚
Monofilament Premilene) suture for wound fascia
closure. Complete skin closure with absorbable (4/˚
Monofilament Monocryl). Sterile dressing and admitted
to PARU.
Operative Diagnosis – Cecum Herniation (Cecum-
 HERNIA
Hernia: Abnormal protrusion of a
viscus or part of a viscus through an
abnormal or weak opening out of the
confines of its normal original
extremities.
Classification(s):
[Anatomic Location] – Inguinal,
Femoral, Umbilical, Hiatus,
Epigastric, Spigellian, Incisional,
Obturator, Littre’s, Lumbar
[Cause and Severity] – Congenital,
Intra-parietal, Internal, Reducible,
Irreducible, Incarcerated,
Strangulated, Ischemic.
Common Classification Used –
Reducible or Irreducible with either
Incarcerated, Strangulated, Ischemic
with respect to its anatomic location.
Pathophysiology – Incisional
Hernia
• Incisional hernia (EHS)-any
abdominal gap with or without
a bulge in the area of postop.
scar perceptible or palpable
by clinical examination or
imaging. 12-15% of
abdominal surgeries may
lead to IH.
 Pathophysiology – Incisional
Hernia
Risk Factors:
Surgical Technique
Type of incision, Suture Material,
Suture Technique
Patient Related
 Poor wound healing
 Local infection and seroma
formation
 >45 yo and M
 Concomitant disease(s)-Obesity,
Anaemia, Immunosuppression,
COPD, Malignancy, DM, AAA
 Exogenous toxins-Smoking
 Hereditary connective tissue
disorder-type III pro-collagen
disorder, Ehlers Danlos syndrome
Evidence Based Medicine:
IH is most likely associated with -
• Vertical/midline incisions
 Non- synthetic suture e.g. catgut
 Multifilament sutures
 Absorbable fascia closure/sutures
 Non-Tricsolan coated sutures
 Incorrect Needle and Insecure knot
 Layered closure
 1st post operative week-<5% tensile
strength unwounded sutures
 <4 suture length/wound length ratio
 >10mm or <5mm stitch width
 No prophylactic mesh
 Patient related factors
 Incisional Hernia Repair
Simple Suture Advantages
 Hernia diameter is <3-4cm  Cost effective
 Open approach  Less OT time
 Incision through previous scar  Low rate of infection
 Hernia sac dissected sharply from Disadvantages
surrounding tissue of abdominal
wall until fascia identified  Recurrence rate >50%
circumferentially.  Tension sutures
 Debrided fascial edges sutured
together with mass closure  High post operative pain
technique  More seroma formation
 Non-absorbable monofilament
continuous sutures placed ~1cm
from fascial edge and 1cm
adjacent to the prior suture to
avoid tight closure.
 Absorbable skin closure with
monofilament sutures or staples or
adhesive glue (Dermabond)
 Incisional Hernia Repair
Mesh Placement Advantages
 Hernia diameter is >4cm  Low recurrence rate 2-12%
 Open/Laparoscopic approach
 Less seroma formation
 Synthetic mesh e.g. polypropylene,
ePTFE  Low post operative pain
 Mesh can be placed above fascia  Tension free
(onlay), below (sublay) or in between
fascial edges (inlay). SUBLAY-GOLD
 Reinforcement and
STANDARD. reconstruction
Disadvantages
 High rate of infection
 Costly
 More OT time
 Summary and Conclusion
Summary Conclusion
 IH typically develops  Highest Incidence rate of
after abdominal incisions IH are due to midline
incisions
 Risk factors of IH maybe
due to surgical  Poor suture technique and
techniques and patient wound healing are the
major risk factors of IH
related factors
 Simple suture repair is for
 Treatment of IH can be <3-4cm hernia diameter
by open simple suture and has a higher
technique or recurrence rate but a lower
open/laparoscopic mesh risk of infection
repair  Mesh repair is for >4cm
hernia diameter and has a
lower recurrence rate but a
higher risk of infection
 THM and Recommendation
Take Home Message
 IH is best assessed by
thorough clinical history,
examination and radiological
investigation esp. USS and
CTS
 Synthetic non absorbable,
monofilament, continuous
fascia closure sutures in
simple suture technique is
more effective
 Sublay (Gold Standard)
method in mesh repair is
more effective
 Laparoscopic approach has
minimal complications
 Patient related factors such
as BMI and smoking is
modifiable
Recommendation
 Decide on giving the most
proper, less invasive and cost
effective surgical technique:
 Make incisions as short as
possible unless long incisions
needed otherwise
 Close fascia with synthetic, non
absorbable, monofilament,
continuous suture
 Ensure Jenkins SL:WL ratio of
4:1 and <10mm->5mm stitch
width
 More supply of mesh and should
be made affordable
 Make the least invasive
approach as you can
laparoscopically unless open
approach is needed otherwise
 Close F/U and R/V of pt. on post
op
 Educate patient on Modifiable
 References
 David C Brooks, MD and John Cone, MD-UpToDate-
Incisional Hernia-Feb 2016
 Jason S Mizell, MD FACS-UpToDate-Principles of
Abdominal wound closure-Feb 2016
 British Hernia Centre. 1990. British Hernia Centre.
[ONLINE] Available at: https://www.hernia.org/.
[Accessed 22 March 16].
 European Hernia Society. 1979. European Hernia
Society. [ONLINE] Available
at:https://www.europeanherniasociety.eu/hernia.html.
[Accessed 22 March 16].
 SURGEONS WHO HAVE MADE ABDOMINAL
WALL SURGERY THEIR SPECIAL FIELD OF
INTEREST.

GROUPE DE RECHERCHE ET D'ETUDE DE LA

PAROI ABDOMINALE (GREPA) 1979, AVICENNE
HOSPITAL IN BOBIGNY, PARIS, FRANCE.
PROFS: CHEVERAL, RIVES, STOPPA, HUREAU,
PERISSAT, ALEXANDRE

ALWAYS THINK FULL

HOUSE!

~Burotukula