Incisional Hernia: What It Is and How It's Treated

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An incisional hernia happens when a weakness in the muscle of the abdomen allows the tissues of the abdomen to protrude through the muscle. The hernia appears as a bulge under the skin and can be painful or tender to the touch.

In the case of an incisional hernia, the weakness in the muscle is caused by the incision made in a prior abdominal surgery. To paint a clearer picture: during surgery, an incision is made in the muscles that make up the abdomen.

For some reason, that muscle doesn't heal, so a gap opens up as the muscles tighten and release during activities. Instead of a flat, strong piece of muscle, you have a piece of muscle that has a small gap in it.

After a while, the tissues underneath realize there is an escape route through the muscle and they start to poke through the opening, to the point where they can be felt under the skin. An incisional hernia is typically small enough that only the peritoneum, or the lining of the abdominal cavity, pushes through. In severe cases portions of organs may move through the hole in the muscle, but this is much less common.

Overview

A history of multiple abdominal surgeries may increase the risk of an incisional hernia, as each incision provides a new opportunity for a formation. If a hernia develops in the abdomen and the patient has not had surgery, it is not an incisional hernia.

A patient who gains significant weight after an abdominal surgery, becomes pregnant, or participates in activities that increase abdominal pressure (like heavy lifting) is most at risk for an incisional hernia.

The incision is weakest, and most prone to a hernia, while it is still healing. While incisional hernias can develop or enlarge months or years after surgery, they are most likely to happen 3 to 6 months after surgery.

Diagnosis

Incisional hernias may seem to appear and disappear, which is referred to as a "reducible" hernia.

The hernia may not be noticeable unless the patient is involved in an activity that increases abdominal pressure, such as coughing, sneezing, pushing to have a bowel movement, or lifting a heavy object.

The visibility of a hernia makes it easily diagnosable, often requiring no testing outside of a physical examination by a physician. The physician may request that you cough or bear down in order to see the hernia while it is "out."

Routine testing can be done to determine what area of the body is pushing through the muscle. If the hernia is large enough to allow more than the lining of the abdominal cavity to bulge through, testing may be required.

Treatment

An incisional hernia may be small enough that surgical repair is an option, not a necessity. If the hernia is large, causes pain, or is steadily growing, surgery may be recommended.

Another option is a truss, a garment that is similar to a weight belt or girdle, that applies constant pressure to the hernia.

When Is Incisional Hernia an Emergency?

A hernia that gets stuck in the "out" position is referred to as an incarcerated hernia. While an incarcerated hernia may not be an emergency, medical care should be sought, as it can quickly become an emergency.

An incarcerated hernia becomes an emergency when it becomes a "strangulated hernia," where the tissue that bulges out is being starved of its blood supply. Untreated, a strangulated hernia can cause the death of the tissue that is bulging through the hernia.

A strangulated hernia can be identified by the deep red or purple color of the bulging tissue. It may be accompanied by severe pain, but is not always painful. Nausea, vomiting, diarrhea, and abdominal swelling may also be present.

Think of it as the hernia equivalent of typing a string around your finger until it turns purple and hurts and then you cannot get the string off.

A strangulated hernia is a medical emergency and requires immediate surgical intervention to prevent damage to the intestines and other tissues.

When Else Is Incisional Hernia Surgery Necessary?

An Incisional hernia may require surgery if:

  • It continues to enlarge over time
  • It is very large
  • It is cosmetically unappealing
  • The bulge remains even when the patient is relaxed or laying down
  • The hernia causes pain

In some of these cases, the decision on whether to have surgery is up to you. You may want to have surgery if you're feeling uncomfortable or are concerned about how the hernia looks, for example. It's best to discuss the surgery to get the details and understand the process and what recovery looks like.

Surgical Procedure

Incisional hernia surgery is typically performed using general anesthesia and is done on an inpatient basis. The surgery is typically performed using the laparoscopic method, using small incisions rather than the traditional, and much larger, open incision. Surgery is performed by a general surgeon or a colon-rectal specialist.

Once anesthesia is given, surgery begins with an incision on either side of the hernia. A laparoscope is inserted into one incision, and the other incision is used for additional surgical instruments. The surgeon then isolates the portion of the abdominal lining that is pushing through the muscle. This tissue is called the "hernia sac." The surgeon returns it to its proper position then begins to repair the muscle defect.

If the defect in the muscle is small it may be sutured closed. The sutures will remain in place permanently, preventing the hernia from returning. For large defects, the surgeon may feel that suturing is not adequate. In this case, a mesh graft will be used to cover the hole. The mesh is permanent and prevents the hernia from returning, even though the defect remains open.

If the suture method is used with larger muscle defects (approximately the size of a quarter or larger), the chance of reoccurrence is increased. The use of mesh in larger hernias is the standard of treatment, but it may not be appropriate if the patient has a history of rejecting surgical implants or a condition that prevents the use of mesh.

Once the mesh is in place or the muscle has been sewn, the laparoscope is removed and the incision can be closed. The incision is typically closed with sutures that are removed at a follow-up visit with the surgeon, at which point a special form of glue is used to hold the incision closed. Small sticky bandages called steri-strips may also be used.

Recovery

Most hernia patients are able to return to their normal activity within two to four weeks. The belly will be tender, especially for the first week. During this time, the incision should be protected during activity that increases abdominal pressure by applying firm but gentle pressure on the incision line. This is especially important for incisional hernia patients, as they are predisposed to an incisional hernia and can be at risk for another one at the new incision sites.

Activities during which the incision should be protected include:

  • Rising from a seated position
  • Sneezing
  • Coughing
  • Bearing down during a bowel movement. Contact your surgeon if you are constipated after surgery, a stool softener may be prescribed.
  • Vomiting
  • Lifting heavy objects

Many of the activities listed are tasks you'll be doing every day, so avoiding them all may not be possible. However, it's in your best interest to conduct them with caution to prevent further complications. Be sure to keep an open line of communication with your doctor if you suspect something went wrong.

Sources:

National Institutes of Health. Inguinal Hernia Surgery. 2015.

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