Abdominal Incisional Hernias

and Eviscerations

DR. RADU IULIAN

Anatomy of the Abdominal Wall

Superior to the Inferior to the

arcuate line arcuate line
 Definitions

A hernia is the protrusion

of an organ through the
wall that normally
contains it.
An incisional hernia
occurs in the area of an
old surgical scar.
A ventral hernia occurs
in the abdominal wall.
 INCISIONAL HERNIA (VENTRAL HERNIA)

 About 10% of abdominal operations result in

incisional hernias. The incidence of this iatrogenic
type of hernia is not diminishing in spite of an
awareness of the many causative factors.
Etiology
 The factors most often responsible for incisional
hernia are listed below. When more than one factor
coexists in the same patient, the likelihood of
postoperative wound failure is greatly increased.
 INCISIONAL HERNIA (VENTRAL HERNIA)

 1. Poor surgical technique. Inadequate fascial

bites, tension on the fascial edges, or too tight a
closure are most often responsible for incisional
failure.
 2. Postoperative wound infection. An
infection in the wound increases the risk of hernia
formation to as high as 80%, the greatest single
risk factor for hernia.
 3. Age. Wound healing is usually slower and the
closure less solid in older patients.
 INCISIONAL HERNIA (VENTRAL HERNIA)

 4. General debility. Cirrhosis, carcinoma, and chronic

wasting diseases are factors that affect wound healing
adversely. Any condition that compromises nutrition
increases the likelihood of incision breakdown.
 5. Obesity. Obese patients frequently have increased
intra-abdominal pressure. The presence of fat in the
abdominal wound masks tissue layers and increases the
incidence of seromas and hematomas in wounds.
 6. Postoperative pulmonary complications that
stress the repair as a result of vigorous coughing. Smokers
and patients with chronic pulmonary disease are therefore
at increased risk of fascial disruption.
 INCISIONAL HERNIA (VENTRAL HERNIA)

 7. Placement of drains or stomas through the

primary operative fascial defect.
 8. Intraoperative blood loss greater than 1000
mL.
 9. Failure to close the fascia of laparoscopic trocar
sites over 10 mm in size.
 10. Defects in collagen or matrix
metalloprotease.
 Risk Factors

 Age Above 65 or 70  Abdominal Distension

 Male Gender  Obesity
 Malnutrition  Coughing / Retching
 Sepsis  Urinary Retention
 Anemia  Post-op Ileus
 Uremia  Peritoneal Dialysis
 Ascites / Liver Failure  Wound Infection
 Diabetes  Corticosteroids
 Pulmonary Disease  Chemotherapy
 Smoking  Immunosupression
 Clinical Presentation

 More than half of incisional hernias occur within the first

two years after primary operation.
 A diffuse bulge directly under or adjacent to a previous
incision.
 Increased protrusion with valsalva or standing.
 Cosmetic concerns or interference with work or activity
are common complaints.
 Pain is unusual as a presenting symptom unless there are
incarcerated or strangulated structures.
 The natural history of an incisional hernia is to enlarge
and become symptomatic.
Clinical Presentation
 Clinical Presentation and Workup

 Physical exam may not be

adequate in obese
patients, patients with
significant rectus
diastasis, patients with
laxity due to spinal injury
or patients who have had
multiple prior abdominal
surgeries. In this case
ultrasound or CT may be
used.
 Prevention of Incisional Hernias
“The strength of a wound lies in the musculoaponeurotic layer.”

Oblique or transverse incisions

are preferred in many cases
 because the pull of the lateral
abdominal wall muscles is
parallel to the incision and
there is less distracting tension
than that on vertical incisions.
 because the tension on the
suture lies perpendicular to the
orientation of fibers in the
abdominal wall fascia. Thus the
suture is less likely to pull
through.
1. Kocher or Right Subcostal
Incision: oblique abdominal
incision paralleling the thoracic
cage on the right of the abdomen
for cholecystectomy.

5. Pfannenstiel Incision: A
transverse incision through the
external sheath of the rectus
muscles, about an inch above the
pubes. It follows natural folds of
the skin and curves over mons
pubis in such a way that the pubic
hairs cover the scar.

8. Rocky-Davis Incision: muscle

splitting transverse abdominal
incision employed in
appendectomy.
 The Paramedian Incision

 The paramedian incision is a vertical incision

made parallel to and approximately 3 cm from
the midline
 Rectus - retracted laterally
 The potential advantages of this incision are:
 The rectus muscle is not divided
 The incisions in the anterior and posterior rectus
sheath are separated by muscle
 The incision is closed in layers –peritoneum and
posterior sheath the anterior sheath
 Lower incidence of incisional hernia
 Midline Incision:

 The most common and most versatile

approach.
 Closure
 2 No. 1 continuous polypropolene sutures that meet in the
middle
 Bites incorporating all layers of the abdominal wall except
skin and fat - no need to close the peritoneum
 Suture Techniques
“ One centimeter back and one centimeter apart.”

 Bite – to prevent the suture from pulling

through it should be placed at least 1 cm
from the wound edge
 Spacing – to distribute the tension on
the tissues while also preventing
herniation between the sutures stitches
are placed about 1 cm apart
 Continuous vs. Interrupted Sutures –
continuous suturing may better
distribute the tension but if one bite
pulls loose it compromises the whole
closure
 Tension Sutures – Full thickness sutures
that help prevent dehisance in cases of
difficult abdominal closure
Port Site Closure Technique
 Indications for Incisional Hernia Repair

The presence of the hernia is indication for repair in

patients able to tolerate surgery.
Strangulation and acute incarceration are indications
for urgent operation.
 Incarceration – Occurs in about (6-15%) of
incisional hernias
 Strangulation – Occur in about 2% of all
incisional hernias
 Principles of Repair

 Tension Free Repair

 Incision - Chosen to Provide
Good Exposure of the Defect
 Do Not Expose Bowel to
Reactive Mesh
 Clear Adequate Margins of the
Defect
 Skin Hygiene
 Antibiotic Prophylaxis
 Choice of Anethesia
 Avoid Counter-incisions
 When to Excise the Sac
Direct Open Repair
“Pants over Vest”
 Direct Open Repair

 Other techniques for open, primary repair include

simple interrupted or continuous suturing of the
fascial edges or the use of mattress, figure of eight
or even internal retention sutures.
 Direct repair is reserved for small defects with the
upper size limit cited as being between 3 and 5 cm.
 Even in small hernias recurrence rates of up to
50% have been reported with these techniques.
Direct Open Repair For Larger
Defects
Open Onlay Mesh Repair
Open Inlay Mesh Repair
Rives-Stoppa Technique
Intraperitoneal Underlay Mesh Repair

Pascal's principle—wide mesh overlap of defect

distributes pressure equally over larger surface area.
 Laparoscopic Repair
Set Up and Trocar Sites
Laparoscopic Hernia Reduction and
Adhesiolysis

Hernia contents are gently reduced using broad

grasping instruments. External counter-pressure
aids the reduction.
 The extent of the defect is assessed.

The margins of the defect may be marked on the skin. The

patch is measured and trimmed to fit. With the smooth side
down, 4-6 large fixation sutures are placed around the patch
and tied
Laparoscopic Mesh Insertion
Laparoscopic Mesh Fixation
 Complications of Incisional Hernia
Repair
 Enterotomy
 Respiratory Distress
 Wound Infection
 Abdominal Compartment
 Mesh Infection
syndrome or IVC
 Persistent seroma compression
 Prolonged Pain
 Ileus
 Bleeding/Hematoma
 Recurrance
 Wound and Mesh Infection
Is mesh was just a large foreign body in an otherwise clean
surgical wound?

 many wounds are inflamed but not necessarily

infected
 infected wounds need to be opened
 avoid exposing the underlying mesh if possible
 infections that involve polypropylene meshes can be
managed with surgical drainage, excision of exposed,
segments and antibiotics
 Meshes (ePTFE) require removal in most cases
because they lack tissue ingrowth that could combat
the infection
 Seroma

 The development of seroma is virtually guaranteed

after lap incisional hernia repair and probably after
repair with mesh in general. They typically resolve
spontaneously without intervention and are not
considered a complication unless they are clinically
apparent more than 8 weeks postoperatively.
 Complications: Prolonged Pain

 In Rives-Stoppa or other open mesh implantation

it occurs in more than 10% of patients
 Transabdominal suture site pain after laparoscopic
ventral hernia repair occurs in 1% to 3% of
patients.
 Contraindications to Lap Incisional
Hernia Repair

 Major loss of abdominal domain

 Severe debilitation
 Fewer than 5 years life expectancy
 Respiratory distress
 Pregnancy
 Portal hypertension
 Renal failure with presence of peritoneal dialysis
catheter
 Possible Advantages of Laparoscopic
Repair
 Minimization of soft-tissue dissection
 To visualize much of the abdominal wall leads to
fewer missed hernias
 In obese patients
 Recurrent hernias- Avoids dissection through the
previous operative site.
 Abdominal Evisceration
 Evisceration is the separation of the layers of an
abdominal wound before complete healing has taken
place.
 It occurs when a wound fails to gain
sufficientstrength to withstand stresses placed upon
it. The separation may occur when overwhelming
forces break sutures, when absorbable sutures
dissolve too quickly or when tight sutures cut
through tissues.
 Abdominal Evisceration
 Evisceration is a rare but severe surgical
complication where the surgical incision opens
(dehiscence) and the abdominal organs then
protrude or come out of the incision (evisceration).
Evisceration is an emergency and should be treated
as such.
 Evisceration can range from the less severe, with the
organs (usually abdominal) visible and slightly
extending outside of the incision to the very severe,
where intestines may spill out of the incision.
 Epidemiology
 Occurs in 2% of
Laparatomies
 M:F=2:1
 All ages->>over 50
yrs
 Commonest time
of disruption= 7-12
days post
operatively
 Emergency>>
Elective
 Vertical incisions
>>>transverse
incisions
 Predisposing factors and causes of
wound separation are:
c
 (1) Infection.
 (2) Malnutrition, particularly insufficient protein and
vitamin C, which interferes with the normal healing
process.
 (3) Defective suturing or allergic reaction to the suture
material.
 (4) Unusual strain on the wound from severe vomiting,
coughing, or sneezing.
 (5) Extreme obesity, an enlarged abdomen, or an
abdomen weakened by prior surgeries may also
contribute to the occurrence of wound dehiscence and
evisceration
 Cause of Disruption
c

 Increased Intra-abdominal Pressure vs.

Weakness of Wound
 Pre-operatively vs. Operatively vs.
Postoperatively
 Patient factors vs. Physician factors
 Pre-operatively:
c
Causes of ↑ed IAP Causes of Wound
 Chronic cough weakness
 Vomiting  Hypoprotienamia
 Abdominal distension  Vitamin C Deficiency
 Bladder outflow  Malignancy
 Obstruction  Anaemia
 Uraemia
 Prolonged Steroid Therapy
 Jaundice
 Radiation
 Operatively:
 Causes of ↑ed IAP
c Causes of Wound Weakness
 Excessive tissue handling • Vertical vs. Transverse
 Failure to decompress incision
 grossly distends bowel • Damage to nerves after
subcostal or para-rectal
incision
• Use of absorbable sutures
to close rectus
• Poor suturing technique
• Persistent leakage of
pancreatic enzymes
• Failure of asepsis
 Post-operatively

 • Persistence of pre-operative factors

 • Wound haematoma
 • Wound infection
 • Post-op ileus
 Classification
 Superficial and Revealed-
– When skin and stitches are removed with
separation of skin and subcutaneous layers only
 Deep and Concealed
– There is separation of all layers of the abdominal
wall with exception of skin
 Complete and Revealed (Burst abdomen)
– Protrusion of loop of bowel or portion of
omentum
 Clinical Featuresc

 Symptoms  Signs
 • Nausea  • Serosanguinous (pink)
 • Fever  or blood stained
 • Local pain/Discomfort  discharge
 • Bowel or omentum
 protruding through the
 wound spontaneously
 after removal of sutures
Burst Abdomen
 Operative Treatment
 Resuscitation if shock (+)
 Reassurance
 Appropriate analgesics
 Nothing by mouth
 Nasogastric tube insertion and suction
 Antibiotic
 Cover the wound with saline soaked sterile towel and
transfer to OT
 Emergency operation for replacement of bowel and
 re-suturing of wound
 Operative Procedure
 Each coils of intestine are washed with normal saline gently
 and thoroughly
 Return to abdominal cavity
 Clean the abdominal wall
 Re-approximated with through and through
monofilament nylon
 Buttressed by tension suture
 Abdominal wall is supported by many-tail bandage, Adhesive
plaster
 Post-operative -General build-up
 -Treat/Avoid predisposing factors
 Prevention

Preoperative
 Correct the precipitating factors
 Manage causes of increased intra-abdominal
pressure
 Omit medications like steroids if possible
 Prophylactic antibiotics
 GI decompression (Ryle’s tube suction) in case of
intestinal obstruction
 Prevention
Per-operative
 Reduce septic load –peritoneal toilet
 Choice of suture –non-absorbable suture for wound
closure
 Tension free closure
 Follow Jenkin’s rule in closing midline laparotomywound
– Mass closure technique (include peritoneum +
rectus sheath in closure)
– Continuous suture
– Suture should be FOUR times the length of the
incision and bites should be taken 1cm from the wound edge
at 1cm intervals
 Prevention

Post-operative
 Prevention of wound sepsis
 Manage causes of increased intra-abdominal
pressure and GI distension
 Urgent recognition and treatment of wound
dehiscence
 Follow-up
 Conclusion

Abdominal wound high mortality rate and no

single cause being responsible: rather it is a
multi factorial problem