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Hernias > Incisional Hernias

Mr Charles Leinkram

Incisional hernias occur at the site of a previous abdominal operation. The common types of abdominal operations which lead to incisional hernias are those for bowel surgery or gynaecological surgery. Others occur following stomach or gallbladder surgery and even at the entry site used for “key hole” surgery, (i.e, the “port’)

It has been reported that after major abdominal operations, incisional hernias occur in up to 30% of cases. The reasons for this are that a long incision is made and the tissues are sutured together over an extensive area. Following major surgery there is often abdominal distension with gas or fluid, weakening of the tissues from infection or from excessive straining, e.g. vomiting or constipation. In addition, systemic factors such as poor nutrition, diabetes or smoking also affect wound healing. All of these factors may lead to a break down of the abdominal wound. This may occur very soon after surgery or even years later.

Mr Leinkram has developed a wide experience in repairing incisional hernias. In his opinion, virtually all incisional hernias are anatomically different, and that their repair must therefore be tailored to suit the individual patient. We can illustrate this by showing some examples of incisional hernias that Mr Leinkram has repaired. However, before doing so, several general points need to be made:-

1) We prefer to use the “open” method of repair, that is to make an incision on the abdomen.

2) The hernia sac is opened and its contents are completely freed.

3) The hernia sac is then excised.

4) A large sheet of double-sided mesh (this consists of a smooth inner surface designed to prevent bowel from becoming adherent to it.) is sutured to the anterior abdominal wall musculature either from within the peritoneal cavity or if possible, from outside it, (see Case 1).

5) The muscle layer of the anterior abdominal wall at the margin of the defect can almost always then be closed over the mesh.

6) Another sheet of mesh (single layer) is then applied on top of the closed anterior abdominal wall musculature.

7) If there is a significant amount of associated skin laxity, this can also be excised, thus improving the cosmetic appearance, (see Case 4).

 

Mr Leinkram prefers the “open” method of incisional hernia repair over the alternative “key-hole” method because:-

a) The hernia sac is excised completely.

b) The mesh is securely sutured to the anterior abdominal wall musculature rather than being stapled or glued as is often done in the “key-hole” method. The mesh is therefore less likely to slip or become detached using the “open” technique.

c) The muscle layer of the anterior abdominal wall can almost always be closed, thereby avoiding the creation of a “dead space”. A “dead space” can result in the accumulation of a significant amount of subcutaneous fluid postoperatively, giving rise the presence of a large swelling in the abdomen which can take weeks to resolve.

d) The open method in effect constitutes a 3-layered closure of the hernia defect (an inner layer of the double-sided sheet of mesh, and middle layer of the closed muscle itself and an outer layer of the single sided sheet of mesh.) In the key-hole method, only the placement of the inner layer is performed.

e) The incisional hernia repair operation can also incorporate a “tummy-tuck” if required.

Case 1.
Incisional hernia in a patient who had previously undergone vascular surgery for aorto-iliac disease.

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Case 2.
Incisional hernia in a patient who had previously undergone surgery for removal of a rectal cancer.

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Case 3.
Incisional hernia in a patient who had previously undergone a cholecystectomy (removal of the gallbladder)

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Case 4.
Incisional hernia adjacent to the umbilicus in a patient who had previously undergone key-hole surgery for removal of the gallbladder. An abdominoplasty ("tummy-tuck") was also performed.

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Case 5.
Recurrent incisional hernia in a patient who had previously undergone an attempted repair of this same problem. Prior to this, he had undergone multiple abdominal operations for complications following a key-hole umbilical hernia repair.

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