GIT lecture for doctors and medical students

1. Monday,
January 23,
2023
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Incisional hernia
PROFESSOR DR. HIWA OMER AHMED
GENERAL AND BARIATRIC SURGERY

2. Monday,
January 23,
2023
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Definition and incidence
 An incisional hernia represents a breakdown in the continuity of fascial
closure.
 All abdominal surgeries carry a 33 percent risk of a postoperative
incisional hernia
 Incisional hernias are most likely to occur within three to six months
post-surgery but can happen at any time.
 Approximately 5-15% of laparatomies and usually becomes apparent
within the first five years
 Over a 10-year period found that 31.5% developed incisional hernia within
6months
 88.1% of patients with incisional hernia developed the condition within 5
years.

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January 23,
2023
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Gender and age
1. Incisional hernia is said to be more
preponderant in females with a ratio of
occurrence of females to males as 1.6:1 4
2. The vast majority of cases is seen in the 4th
decade of life

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January 23,
2023
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Risk factors
 Risk factors for developing incisional hernia includes
1. Wrong suture materials for fascial repair
2. Midline incision
3. Wound sepsis
4. Excess weight .
5. Traumatic abdominal wall injuries
6. Women who had cesearean section were particularly at risk with
incisional hernia occurring in 0.47% of women with cesearean
section compared with 0.12% of women without cesearean section

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January 23,
2023
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Patient-related factors
1. Systemic chronic diseases like DM, renal failure
2. Lifestyle like smoking, and malnutrition conditions
3. Systemic long term medications like steroids and
immunosuppressants increase the likelihood of
developing an incisional hernia
4. Morbid obesity is a common associated risk factor

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January 23,
2023
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Disease-related factors
1. including incision site
2. Timing
3. Urgency of procedure,
4. Complications

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January 23,
2023
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Technical factors related
1. The surgical technique
The presence of gaps between the two healing edges
that will be filled with healing scar predisposes for
incisional hernia
2. Suture materials used for closure
 Poor surgical technique may result in acute wound
dehiscence or delayed healing failure in the form of
incisional hernia.

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January 23,
2023
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Postoperative risk factors
 An incisional hernia can occur for a number of specific
reasons;
1. individuals who participate in excessive or premature
physical activity after surgery
2. Gain considerable weight
3. Become pregnant
4. Increase abdominal pressure before the incision is
fully healed

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January 23,
2023
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Decision for surgery
 Depends on a few factors like
1. Symptoms
2. The size of a hernia
3. Complications
4. Patients' preference.
 Small and asymptomatic hernias can be observed safely with
a low risk of complication, 2.6% annually in some studies.
 Unless contraindicated, large or symptomatic hernias should be
surgically repaired to avoid complications, relieve symptoms, and
improve quality of life.

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January 23,
2023
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Types
1. True hernia It can be a
definite hernia with all the
hernia components of the
defect, sac, and content.
2. False hernia like
divarication of recti when
a weakness of the wall (
@ lina alba) with shallow
sac and occasional bulge
of content.

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January 23,
2023
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Surgery
 Incisional hernia can be repaired by the traditional open techniques
which can be difficult complicated and also the newer laparoscopic repair.
Large incisional hernias which require open repair are commonly
associated with significant postoperative pain.
 Recurrence rates after open repair can be up to 20%
 influenced by mesh size and fixation type found onlay technique to be
more appropriate than inlay technique when only prolene mesh is
preferred because recurrence rates are higher with inlay technique.

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January 23,
2023
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Types of mesh
1. In general, the fascial closure should be performed when the defect is
10 cm or smaller,
2. Meshes are characterized as
 Permanent vs. absorbable
 Synthetic vs. biologic.
 Permanent synthetic meshes are commonly used.
 Absorbable meshes are used in the contaminated or
infected field.

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January 23,
2023
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 There are different options for mesh placement.
1. Onlay (above the fascial defect)
2. inlay (between the fascial edges)
3. sublay (below the fascial defect but above the
posterior rectus sheet
4. Underlay posterior to rectus sheet, pro-pertitonial
5. Intraperitoneal onlay (intraperitoneally below the
fascial defect).

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January 23,
2023
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