INCISIONAL HERNIA REPAIR VENTRAL HERNIORRHAPHY
Category: General Surgery
Abstract : Incisional hernia repair Definition Incisional hernia repair is a surgical procedure performed to correct an incisional hernia. An incisional hernia, also called a ventral hernia, is a bulge or protrusion that occurs near or directly along a prior abdominal surgical incision. The surgical repair procedure is also known as incisional or ventral herniorrhaphy. Purpose Incisional
Incisional hernia repair
Definition
Incisional hernia repair is a surgical procedure performed to correct an incisional hernia. An incisional hernia, also called a ventral hernia, is a bulge or protrusion that occurs near or directly along a prior abdominal surgical incision. The surgical repair procedure is also known as incisional or ventral herniorrhaphy.
Purpose
Incisional hernia repair is performed to correct a weakened area that has developed in the scarred muscle tissue around a prior abdominal surgical incision, occurring as a result of tension (pulling in opposite directions) created when the incision was closed with sutures, or by any other condition that increases abdominal pressure or interferes with proper healing.
Demographics
Because incisional hernias can occur at the site of any type of abdominal surgery previously performed on a wide range of individuals, there is no outstanding profile of an individual most likely to have an incisional hernia. Men, women, and children of all ages and ethnic backgrounds may develop an incisional hernia after abdominal surgery. Incisional hernia occurs more commonly among adults than among children.
Description
An incisional hernia can develop in the scar tissue around any surgery performed in the abdominal area, from the breastbone down to the groin. Depending upon the location of the hernia, internal organs may press through the weakened abdominal wall. The rate of incisional hernia occurrence can be as high as 13% placewith some abdominal surgeries. These hernias may occur after large surgeries such as intestinal or vascular (heart, arteries, and veins) surgery, or after smaller surgeries such as an appendectomy or a laparoscopy, which typically requires a small incision at the navel.
Incisional hernias themselves can be very small or large and complex, involving growth along the scar tissue of a large incision. They may develop months after the surgery or years after, usually because of inadequate healing or excessive pressure on an abdominal wall scar. The factors that increase the risk of incisional hernia are conditions that increase strain on the abdominal wall, such as obesity, advanced age, malnutrition, poor metabolism (digestion and assimilation of essential nutrients), pregnancy, dialysis, excess fluid retention, and either infection or hematoma (bleeding under the skin) after a prior surgery.
Tension created when sutures are used to close a surgical wound may also be responsible for developing an incisional hernia. Tension is known to influence poor healing conditions because of related swelling and wound separation. Tension and abdominal pressure are greater in people who are overweight, creating greater risk of developing incisional hernias following any abdominal surgery, including surgery for a prior inguinal (groin) hernia. People who have been treated with steroids or chemotherapy are also at greater risk for developing incisional hernias because of the affect these drugs have on the healing process.
The first symptom a person may have with an incisional hernia is pain, with or without a bulge in the abdomen at or near the site of the original surgery. Incisional hernias can increase in size and gradually produce more noticeable symptoms. Incisional hernias may or may not require surgical treatment.
The effectiveness of surgical repair of an incisional hernia depends in part on reducing or eliminating tension at the surgical wound. The tension-free method used by many medical centers and preferred by surgeons who specialize in hernia repair involves the permanent placement of surgical (prosthetic) steel or polypropylene mesh patches well beyond the edges of the weakened area of the abdominal wall. The mesh is sewn to the area, bridging the hole or weakened area beneath it. As the area heals, the mesh becomes firmly integrated into the inner abdominal wall membrane (peritoneum) that protects the organs of the abdomen. This method creates little or no tension and has a lower rate of hernia recurrence, as well as a faster recovery with less pain. Incisional hernias recur more frequently when staples are used rather than sutures to secure mesh to the abdominal wall. Autogenous tissue (skin from the patient’s own body) has also been used for this type of repair.
Two surgical approaches are used to treat incisional hernias: either a laporoscopic incisional herniorrhaphy, which uses small incisions and a tube-like instrument with a camera attached to its tip; or a conventional open repair procedure, which accesses the hernia through a larger abdominal incision. Open procedures are necessary if the intestines have become trapped in the hernia (incarceration) or the trapped intestine has become twisted and its blood supply cut off (strangulation). Extremely obese patients may also require an open procedure because deeper layers of fatty tissue will have to be removed from the abdominal wall. Mesh may be used with both types of surgical access.
Minimally invasive laporoscopic surgery has been shown to have advantages over conventional open procedures, including:
• reduced hospital stays
• reduced postoperative pain
• reduced wound complications
• reduced recovery time
Surgical procedure
In both open and laparoscopic procedures, the patient lies on the operating table, either flat on the back or on the side, depending on the location of the hernia. General anesthesia is usually given, though some patients may have local or regional anesthesia, depending on the location of the hernia and complexity of the repair. A catheter may be inserted into the bladder to remove urine and decompress the bladder. If the hernia is near the stomach, a gastric (nose or mouth to stomach) tube may be inserted to decompress the stomach. In an open procedure, an incision is made just large enough to remove fat and scar tissue from the abdominal wall near the hernia. The outside edges of the weakened hernial area are defined and excess tissue removed from within the area. Mesh is then applied so that it overlaps the weakened area by several inches (centimeters) in all directions.
Non-absorbable sutures (the kind that must be removed by the doctor) are placed into the full thickness of the abdominal wall. The sutures are tied down and knotted. In the less-invasive laparoscopic procedure, two or three small incisions will be made to access the hernia site—the laparoscope is inserted in one incision and surgical instruments in the others to remove tissue and place the mesh in the same fashion as in an open procedure. Significantly less abdominal wall tissue is removed in laparoscopic repair. The surgeon views the entire procedure on a video monitor to guide the placement and suturing of mesh.
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