Incisional Hernia

Gastroenterology (12%) Core Clinical Conditions

1B The Physician Associate is able to identify the condition as a possible diagnosis: may not have the knowledge/resources to confirm the diagnosis or to manage the condition safely, but can take measures to avoid immediate deterioration and refer appropriately.

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Definition Aetiology Pathophysiology Risk factor Sign and Symptoms Investigations Management

An incisional hernia refers to a condition where abdominal tissues or organs protrude through a weakened or disrupted area in the abdominal wall, typically near a surgical incision site. When an incision is made during a surgery, it weakens the natural strength of the abdominal wall, leaving it susceptible to herniation. This type of hernia is also known as a ventral hernia or postoperative hernia.
Incisional hernias can occur after various surgical procedures, including those related to the abdomen, such as appendectomies, C-sections, or abdominal exploratory surgeries. They can also develop after any surgical intervention that required an incision in the abdominal region.
The weakened area of the abdominal wall allows underlying tissues, such as the intestines or fatty tissue, to bulge through and form a hernia sac. This sac may become clearly visible or palpable under the skin, creating a noticeable lump or protrusion. Incisional hernias can range in size from small and barely noticeable to large and potentially causing significant complications.

• Weakening of the abdominal wall at the site of the surgical incision: during abdominal surgery, the incision disrupts the normal anatomical integrity of the abdominal muscles and fascia. This disruption weakens the connective tissue, making it more prone to subsequent herniation..

• Increased intra-abdominal pressure: following surgery, activities that increase intra-abdominal pressure, such as heavy lifting, coughing, or straining, can strain the weakened abdominal wall, leading to herniation. It is essential to educate patients on proper postoperative care, including the importance of avoiding activities that can increase intra-abdominal pressure during the healing process.

• Poor wound healing: factors such as infection, diabetes, smoking, malnutrition, and obesity can impair the normal healing process, leading to delayed wound closure and increased risk of herniation.

1. Weakening of tissue: Following surgery, the healing process ensues, during which collagen fibres are laid down to repair the incision site. However, these new collagen fibres may not have the same strength as the original tissue, leading to a weakened area.
2. Increased abdominal pressure: Factors such as obesity, chronic coughing, or heavy lifting can significantly increase intra-abdominal pressure.
3. Local tissue stress: The increased pressure inside the abdomen exerts stress on the weakened tissue near the incision, gradually stretching and disrupting the collagen fibres.
4. Herniation: With continued pressure and tissue stress, the weakened area eventually gives way, allowing the abdominal contents (such as intestines, fat, or organs) to protrude through the defect and form a hernia.
5. Complications: Once an incisional hernia forms, it can lead to various complications, including pain, discomfort, intestinal obstruction, and strangulation, a condition where the blood flow to the herniated organ becomes compromised.

1. Obesity: Obesity has long been identified as a significant risk factor for developing incisional hernias. Excessive body weight places extra strain on the abdominal muscles and weakens the connective tissues, making them more susceptible to herniation. Furthermore, increased body fat may impair wound healing, leading to a higher risk of hernia formation.
2. Age: Advancing age is another significant risk factor for incisional hernias. As individuals age, the natural strength and elasticity of abdominal muscles tend to decline. This age-related muscle weakness increases the likelihood of developing a hernia following surgery.
3. Smoking: The harmful effects of smoking extend beyond the respiratory system. Nicotine and other toxins in cigarette smoke impair blood flow, oxygenation, and collagen production, ultimately weakening the connective tissues. Smokers have an increased risk of developing incisional hernias and may experience delayed wound healing, making it vital for patients to quit smoking before undergoing surgical procedures.
4. Chronic Coughing: Conditions such as chronic obstructive pulmonary disease (COPD), bronchitis, or persistent coughing can strain the abdominal muscles, contributing to the development of incisional hernias. Frequent, forceful coughing episodes can significantly increase intra-abdominal pressure, placing additional stress on weakened incision sites.
5. Poor Nutrition: Inadequate nutrition before and after surgery can compromise the body's ability to heal wounds and repair weakened muscle tissues. A deficiency in essential nutrients, especially protein, may lead to delayed wound healing and weaker scar formation, increasing the risk of hernia development.
6. Diabetes: Individuals with diabetes are more prone to developing incisional hernias due to compromised tissue healing and weakened connective tissue strength. The high blood sugar levels in diabetes impede collagen production, impairing the normal healing process and increasing the likelihood of herniation at the surgical site.
7. Steroid Use: Prolonged use of corticosteroids or other immunosuppressive medications weakens the body's ability to heal wounds and inhibits the normal inflammatory response necessary for tissue repair. This prolonged impairment may contribute to the formation of incisional hernias.
8. Previous Abdominal Surgeries: Individuals who have undergone previous abdominal surgeries, especially those resulting in an emergency situation or complications, have a higher risk of developing incisional hernias. Scar tissue formed during previous surgeries can weaken abdominal muscles, making subsequent herniation more likely.
9. Excessive Physical Strain: Engaging in activities that involve heavy lifting, straining, or intense abdominal exertion soon after surgery can increase the risk of developing an incisional hernia. Excessive physical strain places added pressure on the surgical incision, potentially compromising its integrity and leading to herniation.
10. Poor Wound Care: Proper wound care is essential for preventing incisional hernias. Inadequate wound care, such as failure to keep the surgical incision clean and dry, can increase the risk of infection and impair wound healing. Infections and poor healing can weaken the surgical incision site, making it more susceptible to herniation.

1. Visible bulge: One of the most noticeable signs of an incisional hernia is the presence of a visible bulge or protrusion at the site of the surgical incision. This bulge may be more prominent when coughing, straining, or standing up.
2. Discomfort or pain: Many individuals with an incisional hernia experience discomfort or pain at the site of the hernia. This pain can range from mild to severe and may be intermittent or continuous. The discomfort may worsen with physical activity or prolonged periods of standing.
3. Swelling or redness: In some cases, the area around the incisional hernia may appear swollen or red. This can be a sign of inflammation or infection, requiring immediate medical attention.
4. Bowel obstruction symptoms: If the herniated tissue becomes trapped or incarcerated, it can lead to a bowel obstruction. Symptoms of bowel obstruction include nausea, vomiting, abdominal distension, constipation, and an inability to pass gas or have a bowel movement. Bowel obstruction is a serious complication and requires urgent medical attention.
5. Changes in bowel habits: Some individuals with incisional hernias may experience changes in their bowel habits. These changes can manifest as constipation, diarrhoea, or alternating between the two.
6. Surgical site complications: If an incisional hernia occurs after a surgical procedure, it may be accompanied by other surgical site complications. These can include wound infections, slow or poor wound healing, or the presence of pus or discharge from the incision.
7. Feeling of pressure or fullness: The presence of a hernia can create a feeling of pressure or fullness at the site of the bulge. This sensation might be more pronounced after eating, straining, or physical exertion.

Physical Examination: A thorough physical examination is often the first step in diagnosing an incisional hernia. A PA should inspect the surgical incision site, looking for any bulging or abnormality. You may ask the patient to cough or strain during the examination to help detect the hernia. The size, location, and reducibility of the hernia are assessed to categorize it properly.
Medical History: check for risk factors such as smoking, obesity, or chronic coughing.
Imaging Techniques:

• Ultrasound: Ultrasonography is a commonly used non-invasive imaging technique. It helps visualize the hernia sac, its contents, and assess the size and location of the defect. Ultrasound is especially useful during dynamic manoeuvres like coughing or straining, as it allows for real-time evaluation of the hernia.

• Computed Tomography (CT) Scan: A CT scan can provide a detailed cross-sectional view of the hernia, assisting in determining the extent and possible complications. It is particularly useful in complex hernias or cases where other organs may be involved.

• Magnetic Resonance Imaging (MRI): MRI scans may be employed to evaluate the hernia and its associated structures, especially in cases where the involvement of nearby blood vessels or organs is suspected.

As a PA you should refer to general surgery, if symptomatic. Otherwise the following apply:

Non-surgical Management
1. Observation: Small, asymptomatic incisional hernias may be closely monitored without immediate intervention, especially in patients with multiple comorbidities or significant surgical risks.
2. Lifestyle Modifications: Encouraging weight management through a healthy diet, regular exercise, and smoking cessation can help reduce the risk of hernia progression and complications.

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