Incisional hernia / Abdominal wall hernia
In about 15% of all patients with an abdominal incision (laparotomy), an incisional hernia develops in the further course (often only after many years), i.e. the scar dehisces at one or several points: a more or less large gap is formed in the solid abdominal wall (defect: hernial orifice) through which the peritoneum (hernial sac) along with parts of the abdominal organs (hernial contents=usually intestines) bulges out under the skin, comparably to inguinal hernia.
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The causation is not completely clear. Significant factors are: type of the primary abdominal incision (longitudinal or transverse), surgical technique of the primary suture closure (single or continuous suture, stitch distance, taking of individual or all abdominal wall layers), suture material (absorbable or non-absorbable) as well as general factors such as nicotine abuse and weakness of the connective tissue (referred to as collagen disease).
In Germany more than 50,000 incisional hernia surgeries are carried out annually, so that this type of surgery is of high clinical and economic significance, particularly because it is technically challenging and may become very expensive due to the necessity of using a large mesh.
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In Germany more than 50,000 incisional hernia surgeries are carried out annually, so that this type of surgery is of high clinical and economic significance, particularly because it is technically challenging and may become very expensive due to the necessity of using a large mesh.
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The symptoms include protrusion, feeling of pressure, pulling abdominal pain, above all upon physical exertion. The hernial contents may be incarcerated (acute severe pain), which results in a life-threatening situation so that surgical measures must be taken immediately. In addition to the clinical examination and sonography (ultrasonic examination), computer tomography is required to make a precise diagnosis, above all for the exact measurement of the hernial defect.
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The indications for an emergency surgery are the acute situation of strangulation, complaints as well as increase in size. The smaller the hernia, the easier the surgery and the less number of complications occur.
In case of hernias with a hernial gap of more than 2-3 cm, today’s surgical principle is the abdominal wall reinforcement with a synthetic mesh, since when closing the hernial gap with sutures only, the risk of repetitive hernias (recurrence) is very high (more than 30%). When implanting a mesh, the recurrence rate can be reduced to approx. 5%.
The surgical method of implanting the mesh is either open or laparoscopic. Basically, not only the entire scar has to be reinforced with the mesh (augmentation) but the mesh has to overlap all gaps by at least 3-5 cm. This is the only way to largely avoid recurrences. The surgery is challenging in dependence on the size of the scar and the size of the hernia. The mesh can be implanted open or using a minimally invasive technique. The disadvantage of the open surgery is that a large incision has to be made, which results in a corresponding traumatism of the abdominal wall and a large wound surface. The risk of wound healing complications (infection) and fluid accumulations (seroma) in the wound involving the risk of infections is increased. This may substantially lengthen the course of the treatment and ruin the surgical success. The advantages of the laparoscopic method are the avoidance of large abdominal wall incisions (usually incisions of only 2-3 cm length are necessary), resulting in less pain, shorter hospital stay as well as only rarely occurring haematomas and wound healing complications (scientifically proved). It may be of disadvantage that extensive adhesions in the abdomen often have to be divided, involving a certain risk of intestinal injuries. Furthermore: Since the direct contact between the mesh and the intestines cannot be avoided with this surgical method, a special mesh needs to be implanted, which excludes adhesions with the intestines, involving possible disadvantageous consequences for the intestinal passage. Such an ideal mesh, however, is not available yet. Two additional disadvantages of the laparoscopic method are: 1. The mesh has to be fixed. In this case, in contrast to the mesh implantation in case of inguinal hernia, the fixation substantially contributes to the stabilisation of the reconstruction. The mesh can only be fixed with sutures, clips or tacks. The most effective method is the suture fixation, which is, however, technically challenging and time-consuming. Furthermore, the patient may have considerable pain at the fixation points in the first few days following the surgery. 2. The reconstruction of the median line including approximation of the straight abdominal muscles is usually not possible. This may lead to a functional impairment of the abdominal wall muscles.
In summary it has to be said at this point that no general recommendation can be given regarding the issue discussed. The still unresolved questions concerning the mesh and the fixation as well as the missing reconstruction of the median line speak against laparoscopy. The significantly reduced occurrence of wound healing complications, which could ruin the surgical success, speaks in favour of laparoscopy. We decide in favour of the laparoscopy or the open surgery in consultation with the patient, depending on the size and the location of the abdominal wall defect, the patient’s adiposity and risk factors for an infection (“tailored approach”).
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In case of hernias with a hernial gap of more than 2-3 cm, today’s surgical principle is the abdominal wall reinforcement with a synthetic mesh, since when closing the hernial gap with sutures only, the risk of repetitive hernias (recurrence) is very high (more than 30%). When implanting a mesh, the recurrence rate can be reduced to approx. 5%.
The surgical method of implanting the mesh is either open or laparoscopic. Basically, not only the entire scar has to be reinforced with the mesh (augmentation) but the mesh has to overlap all gaps by at least 3-5 cm. This is the only way to largely avoid recurrences. The surgery is challenging in dependence on the size of the scar and the size of the hernia. The mesh can be implanted open or using a minimally invasive technique. The disadvantage of the open surgery is that a large incision has to be made, which results in a corresponding traumatism of the abdominal wall and a large wound surface. The risk of wound healing complications (infection) and fluid accumulations (seroma) in the wound involving the risk of infections is increased. This may substantially lengthen the course of the treatment and ruin the surgical success. The advantages of the laparoscopic method are the avoidance of large abdominal wall incisions (usually incisions of only 2-3 cm length are necessary), resulting in less pain, shorter hospital stay as well as only rarely occurring haematomas and wound healing complications (scientifically proved). It may be of disadvantage that extensive adhesions in the abdomen often have to be divided, involving a certain risk of intestinal injuries. Furthermore: Since the direct contact between the mesh and the intestines cannot be avoided with this surgical method, a special mesh needs to be implanted, which excludes adhesions with the intestines, involving possible disadvantageous consequences for the intestinal passage. Such an ideal mesh, however, is not available yet. Two additional disadvantages of the laparoscopic method are: 1. The mesh has to be fixed. In this case, in contrast to the mesh implantation in case of inguinal hernia, the fixation substantially contributes to the stabilisation of the reconstruction. The mesh can only be fixed with sutures, clips or tacks. The most effective method is the suture fixation, which is, however, technically challenging and time-consuming. Furthermore, the patient may have considerable pain at the fixation points in the first few days following the surgery. 2. The reconstruction of the median line including approximation of the straight abdominal muscles is usually not possible. This may lead to a functional impairment of the abdominal wall muscles.
In summary it has to be said at this point that no general recommendation can be given regarding the issue discussed. The still unresolved questions concerning the mesh and the fixation as well as the missing reconstruction of the median line speak against laparoscopy. The significantly reduced occurrence of wound healing complications, which could ruin the surgical success, speaks in favour of laparoscopy. We decide in favour of the laparoscopy or the open surgery in consultation with the patient, depending on the size and the location of the abdominal wall defect, the patient’s adiposity and risk factors for an infection (“tailored approach”).
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