An incisional hernia (IH) develops as a result of an ostomy surgery. Part of the intestine lodges inside the incision. Then, the intestine emerges through an incision that was not fully closed (right after surgery) or that was not properly sealed, leaving a defect (an opening). Ostomy patients may develop an incisional hernia anytime soon after or years after the surgery.
Incisional Hernias after a Laparotomy
“Despite significant advances in surgical techniques and understanding of abdominal wall anatomy and function, the rate of incisional hernias following laparotomy incision remains high. Due to this and the realization that long-term outcomes of repair of incisional hernias are suboptimal, there has been an increased emphasis on hernia prevention. The two main focuses related to hernia prevention have been suture techniques for laparotomy closures and the concept of prophylactic mesh augmentation (PMA) in patients at high risk for incisional hernias.”1
High incidence of incisional hernias after laparotomies occurs due to the nature of the procedure. “During a laparotomy, the abdominal wall is incised to gain access to the abdominal cavity and its contents. At the end of the operation, the abdominal wall is closed by suturing the edges of the wound together. The skin is subsequently closed over it. When a defect develops in the abdominal wall scar, abdominal cavity contents may protrude through this defect, pushed outwards by the positive intra-abdominal pressure. Elevated intra-abdominal pressure, which occurs during defecation, vomiting, coughing, etc., may facilitate this event. The defect in the abdominal wall most likely develops because of an early partial separation of the abdominal wound edges, which makes collagen bridging during wound healing complicated.”2
Incisional hernias affect the quality of life of the patient, causing additional self-esteem and discomfort problems. “The incidence following major abdominal surgery is reported to range from 2% to 20% across studies, depending on patient and wound factors. Incisional hernias, as they enlarge over time, cause the patient discomfort, which in turn, result in patients restricting their work and other physical activities. Cosmetic concerns may also arise. Overall, patient quality of life can be greatly affected. Complications of incisional hernias include pain, bowel obstruction, incarceration and strangulation and the risk of the need for repeat surgery.”3
Risk Factors of Incisional Hernia
“Obesity is a risk factor for the occurrence of incisional hernias and leads to higher perioperative complication and recurrence rates after open repair. There are multifactorial reasons for this, such as delayed wound healing, impaired pulmonary function, and higher intraabdominal pressure.”4
Other risk factors of incisional hernia are patient-related, surgery-related and biological factors. The following image shows some of these risk factors.
Symptoms of an Incisional Hernia
The main symptom of an incisional hernia is a bulge in the abdominal area. Aside from a disturbing appearance, it is painless while at rest or under no exertion. If you are physically active or use the abdominal muscles, pain will surface. Once at rest, the pain vanishes. In case of pain, vomiting, ostomy blockage or no secretions, contact your ostomy health professional immediately.
Pay attention to the symptoms or their absence. “Symptoms can range from no symptoms to discomfort, pain or symptoms of complications like bowel obstruction and or strangulation. In most people, hernias limit patients’ physical activities either due to the associated symptoms or as a precaution to avoid worsening. The physical exam involves abdominal palpation. In most of the cases, hernial content can be palpated. Occasional the edges of hernia defect can be felt and the size can be estimated. Planning for a surgical approach can be discussed with the patient on that visit. Although most cases of an incisional hernia are diagnosed with a history and physical, imaging is sometimes warranted like in early stages, obese patients, or complex cases. Computed Tomography (CT) scanning focused on the abdominal wall is not only helpful to confirm the diagnosis when it is not clear, but helps in planning the surgical approach and extent of repair. Occasionally small incisional hernias are identified intraoperatively when the patients undergo another abdominal surgery. Incisions made at the same scar site or laparoscopic approach may show the fascial defects with occasional fat incarceration.”6
Certain situations may exacerbate incisional hernia symptoms. “Symptoms will usually be aggravated by coughing or straining as the hernia contents protrude through the abdominal wall defect. During the pre-antibiotic era, the recurrence rate was quite high and the cure rate was low. After the advent of good and safe anesthesia, antibiotics, closed suction drainage, use of prosthetic mesh, transfusion facilities, a better understanding of fluid therapy and proper care during the preoperative and postoperative period, the cure rate is almost cent percent”7
Diagnosis of an Incisional Hernia
“History and physical exam will allow for diagnosis of incisional hernias in the vast majority of cases. In cases of occult hernias, either small incisional hernias or hernias in obese patients, further workup with imaging is warranted. The computed tomography (CT) scan is the most commonly used method to diagnose an incisional hernia and can be useful in complex cases as well in helping plan operative management. Ultrasound techniques have also been described for evaluation of abdominal wall hernias (Dynamic Ultrasonography Assessment for Hernia-DASH). MRI can also be used to assess abdominal wall hernias but are less commonly used and is institution dependent.”8
Treatment of an Incisional Hernia
“Traditional incisional hernia repair is performed by primary closure of the abdominal wall defect. The wound edges are approximated and sutured. Overlap techniques, such as the Mayo repair, have also been in widespread use. Several abdominoplasty techniques have been developed to close large abdominal wall defects. The Ramirez component separation technique is currently the most popular. The results of primary closure are poor. Simple approximation and the Mayo repair result in recurrence rates of 25-54%. After use of the component separation technique recurrence rates of 32% were reported. Better results were reported since the use of prosthetic meshes was introduced.”9
An ostomy surgeon will determine a course of action that may include:
- Pressing on the hernia bulge. Watch and monitor if the hernia goes back into the defect (it recurs).
- Prescribing permanent use of a parastomal hernia belt to dislodge or keep the hernia in check.
- Conducting surgery, if the ostomy professional determines that there is an incarcerated incisional hernia (a strangulated hernia), or if symptoms are enough evidence to perform the procedure. The surgeon may opt for an open surgery or a Keyhole (laparoscopic) surgery. Consider that neither option is infallible. Chances of hernia recurrence will require precautionary measures.
Incidence of Incisional Hernias
“Incisional hernia is more seen in female housewives who are multiparous, it is mostly presented with swelling and pain abdomen. Previous elective and emergency surgeries in lower midline have higher percentage of incisional hernia. Post-operative wound infection, seroma formation, associated anemia and respiratory tract infection are the risk factor for incisional hernia. Proper pre-operative preparation, choice of surgery for repair, aseptic technique, and careful closure of the abdominal wound decreases the incidence of incisional hernia.”10
Even though several studies address the occurrence of incisional hernias, certain authors indicate that the exact incidence is unknown. “Presumably, the wide variation in abdominal approaches, comorbidities among patients and techniques for surgical closure of the abdominal wall leads to a broad range of incidence rates, significantly differing between the various patient populations.”11
Surgical Techniques that Reduce Incisional Hernia Incidence
“A consensus on the closure of the surgical incisions recommended that a continuous suture technique of the main fascial layer, with slowly absorbable or nonabsorbable suture material is followed by a low incidence of IH. The technique of closing the abdominal incisions that respect the rule of good bite and short interval (a minimal distance of 1 cm from the fascial margin, and <1 cm distance between stitches) that keeps the ratio of suture length to incision length equal to 4:1, is valid and it can reduce the incidence of IH. Prophylactic mesh placement reduces the rate of IH and so the use of mesh in stoma formation. Preoperative control of the risk factors is mandatory to achieve good results and reduce postoperative complications. Prophylactic antibiotics are recommended for patients with high‑risk factors and in the presence or anticipation of complications (contaminations, long operative time, usage of drains, urinary catheters). Thromboembolic prophylaxis should be administered according to the presence of risk factors for individual patients.”12
“Untreated IH enlarges by time and makes repair difficult. IH can cause abdominal pain or discomfort, limitation of the daily activity and unsightly appearance. The complication of IH is not common, but can be very serious and even life‑threatening. Intestinal obstruction, incarceration or strangulation, and enterocutaneous fistula can develop. Skin ulceration spontaneous rupture can threaten the life of patients with untreated IH.”13
An effective diagnosis for incisional hernia is based on the patient’s general health, physiology, severity, and position of the hernia. These factors, along with how the hernia has affected the outcome of the initial surgery, will determine the complexity of the diagnosis and potential result of an open hernia repair or a laparoscopy.
(1) Fundamentals of incisional hernia prevention. Heathcote, S., Williams, Z., Borden Hooks, W., & Hope, W. International Journal of Abdominal Wall and Hernia Surgery. 2018. http://www.herniasurgeryjournal.org/article.asp?issn=2589-8736;year=2018;volume=1;issue=1;spage=32;epage=36;aulast=Heathcote
(2, 9) Incisional Hernia Etiology, Prevention, Treatment. Burges, J. Erasmus University Rotterdam. 2006. https://repub.eur.nl/pub/7857/060630_Burger-JWA.pdf
(3) Closure methods for laparotomy incisions for preventing incisional hernias and other wound complications. Patel, S., Paskar, D., Nelson, R., Vedula, S., & Steele, S. Cochrane Library. 2017. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005661.pub2/full
(4) Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)—Part 1. Bittner, R., Bingener-Casey, J., Dietz, U., Fabian, M., Ferzli, G., Fortelny, R., Köckerling, F., Kukleta, J., Leblanc, K., Lomanto, D., Misra, M., Bansal, V., Morales-Conde, S., Ramshaw, B., Reinpold, W., Rim, S., Rohr, M., Schrittwieser, R., Simon, T., Smietanski, M., Stechemesser, B., Timoney, M., & Chowbey, P. Surgical Endoscopy. 2013. https://link.springer.com/article/10.1007%2Fs00464-013-3170-6
(5, 13) Incisional hernia: Risk factors, incidence, pathogenesis, prevention and complications. Mutwali, I. Sudan Medical Monitor. 2014. http://www.sudanmedicalmonitor.org/temp/SudanMedMonit9281-6073111_165211.pdf
(6, 8) Incisional Hernia. Hope, W., Waheed, A., & Tuma, F. StatPearls. 2019. https://www.ncbi.nlm.nih.gov/books/NBK435995/
(7) A prospective study on incisional hernia, its incidence, etiology and management. Pattanaik, S. & Firodous, Afroza & John, Ajax & Pattnaik, Harsha & Mishra, Biplab & Sahu, Biswajit. International Surgery Journal. 2019. https://www.researchgate.net/publication/332028858_A_prospective_study_on_incisional_hernia_its_incidence_etiology_and_management_in_a_tertiary_care_hospital_of_Odisha
(10, 11) Clinical study of incidence and surgical management of incisional hernia. Rangaswamy, P., Afzal Rubby, S., & Stephen, E. International Surgery Journal. 2016. https://www.ijsurgery.com/index.php/isj/article/view/112/112
(11) The Treatment of Incisional Hernia. Dietz, U., Menzel, S., Lock, J., & Wiegering, A. Deutsches Ärzteblatt International. 2018. https://www.aerzteblatt.de/int/archive/article?id=195731
(12) Incisional hernia management. Mutwali, I. Sudan Medical Monitor. 2015. http://www.sudanmedicalmonitor.org/temp/SudanMedMonit10117-6076894_165248.pdf