The Incisional Hernias

​

A hernia is when on organ or structures that are usually enclosed in an outer layer start to protrude through this. In the case of an incisional hernia, contents within the abdomen (fat, intestines/bowel etc) start to protrude and cause a lump through a previous incision/operation site.  

At the time of a previous operation, a cut would have been made through the abdominal wall to carry out the operation in the abdomen, It is at this site that a weakness can occur leading to the incisional hernia, usually months or years later. This can cause pain, limit activities of daily living and over time a danger with not repairing hernias is that abdominal contents may get stuck in the neck of the hernia and require an emergency operation. Obstruction or strangulation of bowel with compromise to the blood supply can be a life threatening condition.

Surgery aims to repair the hernia, improve pain and avoid the complications above.

 

Alternatives to Surgery

​

Surgery is the only way to potentially prevent recurrent symptoms and complications associated with hernias.

 

What does an operation involve?

 

The operation is aimed at either closing the defect of the hernia or re-enforcing closed the hernia defect with mesh to prevent contents from the abdomen protruding through. This operation can be done through an open operation or a laparoscopic (keyhole) procedure and can take several hours. If started laparoscopically, in about 5 in 100 people it is not possible to complete the operation via keyhole surgery and will be converted to an open operation. 

 

In an open operation, once under anaesthesia and asleep, you will have a cut in the abdomen made. Abdominal contents are freed within the hernia and replaced back into the abdomen. The defect is closed with sutures and/or a mesh placed to re-enforce the closure. The skin will then be closed and occasionally a drain left in place to reduce chances of a collection if appropriate. The operation can last between 1 to 5 hours and if required then may be done in conjunction with a plastic surgeon to remove excess skin and abdominal deformity that was caused by the incisional hernia.

If the operation is done through ‘keyhole’ surgery, then a number of ports are inserted to the side of the abdomen and after freeing the contents from the inside, they are pulled back into the abdomen. A mesh is then placed over the inside of the abdomen and stapled into place. A laparoscopic repair (keyhole) does not necessarily correct the skin disfigurement that a hernia can make but stops the abdominal contents from passing into it.

 

Before the operation.

 

Ensure you tell your specialist and anaesthetist about all medication you take. You will usually also have a pre-assessment appointment to ensure you are optimised before your surgery.

 

General recommendations for all operation are to reduce or stop smoking as this decreases complications of wound infections, breakdown, chest infections and longer term health problems. Regularly exercising even leading up to your operation has shown to improve on outcomes post-operatively by leading to better ‘pre-habilitation’. It is also recommended to not shave the week before surgery over the abdomen and is advisable to have a shower/bath the day before or morning of surgery to decrease infection risks.

 

On the day operation day. 

 

The procedure is usually done as a day case procedure and therefore be admitted and discharged from the hospital on the same day. After the anaesthetic, you will be given local anaesthetic to help with any pain post-operatively and may be given antibiotics.

 

Potential Complications

 

Complications can be both general for any operation and specific for the particular procedure.

Your specialist will be able to go over specific ones with you.

 

General Complications of Laparoscopic Surgery:

​

1. Pain (and local numbness): Local anaesthetics are given at the time of surgery and would be important to continue oral pain killers after the operation. Pain should be well controlled to enable you to take a deep breath in to expand the lungs and prevent chest infections from occurring. Shoulder tip pain (if this occurs from retained air after the operation) should settle within 24 hours.

2. Bleeding: Bleeding is rare but if occur may require a blood transfusion or re-operation.

3. Infections: This usually causes a high temperature, redness, swelling and increased pain at wound sites and can happen in around 1 in 100 cases if done laparoscopically and 1 in 10 people if done as an open operation. Antibiotics are used to treat this. It is safe to shower after 2 days following the operation. This this does not settle within a few weeks to months then a further operation may be required.

4. Blood clots in the legs or lungs: Keeping mobile is important to prevent this along with the use of TED stockings.

5. Damage to Other Structures: This is more with laparoscopic (keyhole) surgery and can occur rarely in less then 3 in 1000 people and is not obvious in one third of people. Previous surgery and scar tissue (adhesions) can increase the risk of this.

6. Hernias: Where cuts are made in the skin, there is a risk of 1 in 100 people of developing a hernia at these sites which can be repair at a later date if this does occur.

 

Specific Complications:

​

1. Collections of fluid: Blood (haematoma) or fluid (seroma) can form where the hernia was under the wound (6 in 100 people). This usually settles spontaneously over a few weeks. Very rarely this needs to be drained. If there is a high risk of collections at the time of the operation then a drain may be left in place for a few days.

2. Bowel injury: This is very rare. If laparoscopic repair is undertaken, then bowel can get stuck between the mesh and abdominal wound (1 in 200 people) causing bowel obstruction. This complication can lead to a re-operation.

3. Mesh Infection: This can be treated with antibiotics and may require removal of the mesh through another operation.

4. Removal of the umbilicus: Sometimes the umbilicus needs removal to repair the hernia and a scar will replace it.

5. Recurrence: There is a risk of recurrence of any hernia (1 in 20 people). You can minimise this by avoiding any heavy lifting and straining for at least 6-8 weeks after the operation.

 

Recovery from the Operation

 

Following the operation, you will be wake up in recovery and usually go home the same day. You will require a responsible adult to be with you at home for the first 24 hours and have access to a telephone in case you help or advice is required. It is important to continue to take regular pain killers to avoid chest infections as mentioned above.

You will need to seek medical advice if you develop worsening pain, high temperature, shortness of breath, abdominal swelling/distension or problems in passing urine or opening your bowel.

​

 

Activities following surgery

​

For the first 24 hours following a general anaesthetic or sedation, do not drive, operative machinery, carryout dangerous activities, drink alcohol or sign legal paperwork. You can usually start driving once you can control and make an emergency stop.  It is important to be mobile to avoid blood clots and may need to wear stockings to prevent these. Depending on the type of work you do, you can usually return within 2-4 weeks but should avoid heavy lifting for 6-8 weeks (or longer for lager hernias – your surgeon will advise you for your individual case).

 

You will usually have a follow-up after you operation between 4-12 weeks depending on the operation carried out.