INCISIONAL HERNIA REPAIR DIAGNOSIS PREPARATION
Category: General Surgery
Abstract : Diagnosis / Preparation Diagnosis Reviewing the patient’s symptoms and
medical history are the first steps in diagnosing an incisional hernia. All
prior surgeries will be discussed. The doctor will ask how much pain the patient
is experiencing, when it was first noticed, and how it has progressed. The
doctor will palpate (touch) the area, looking for any abnormal bulging or m
Diagnosis / Preparation
Diagnosis
Reviewing the patient’s symptoms and
medical history are the first steps in diagnosing an incisional hernia. All
prior surgeries will be discussed. The doctor will ask how much pain the patient
is experiencing, when it was first noticed, and how it has progressed.
The
doctor will palpate (touch) the area, looking for any abnormal bulging or mass,
and may ask the patient to cough or strain in order to see and feel the hernia
more easily. To confirm the presence of the hernia, an ultrasound examination or
other scan such as computed tomography (CT) may be performed. Scans will allow
the doctor to visualize the hernia and to make sure that the bulge is not
another type of abdominal mass such as a tumor or enlarged lymph gland. The
doctor will be able to determine the size of the defect and whether or not
surgery is an appropriate way to treat it. A referral to a surgeon will be made
if the doctor believes that medical treatment will not effectively correct the
incisional hernia.
Preparation
Many months before the surgery, the
patient’s doctor may advise weight loss to help reduce the risks of surgery and
to improve the surgical results. Control of diabetes and smoking cessation are
also recommended for a better surgical result. Close to the time of the
scheduled surgery, the patient will have standard preoperative blood and urine
tests, an electrocardiogram, and a chest x ray to make sure that heart and lungs
and major organ systems are functioning well. A week or so before surgery,
medications may be discontinued, especially aspirin or anticoagulant
(blood-thinning) drugs. Starting the night before surgery, patients must not eat
or drink anything. Once in the hospital, a tube may be placed into a vein in the
arm (intravenous line) to deliver fluid and medication during surgery. The
patient will be given a preoperative injection of antibiotics before the
procedure. A sedative may be given to relax the patient.
Aftercare
Immediately after surgery, the patient will be observed in a recovery area
for several hours, for monitoring of body temperature, pulse, blood pressure,
and heart function, as well as observation of the surgical wound for undue
bleeding or swelling. Patients will usually be discharged on the day of the
surgery; only more complex hernias such as those with incarcerated or
strangulated intestines will require overnight hospitalization. Some patients
may have prolonged suture-site pain, which may be treated with pain medication
or anti-inflammatory drugs. Antibiotics may be prescribed to help prevent
postoperative infection.
Once the patient is home, the hernia repair
site must be kept clean, and any sign of swelling or redness reported to the
surgeon. Patients should also report a fever or any abdominal pain. Outer
sutures may have to be removed by the surgeon in a follow-up visit about a week
after surgery. Activities may be limited to non-strenuous movement for up to two
weeks, depending on the type of surgery performed. To allow proper healing of
muscle tissue, hernia repair patients should avoid heavy lifting for at least
six to eight weeks after surgery, or longer as advised.
Risks
Long-term complications seldom occur after incisional hernia repair.
Short-term risks are greater with obese patients or those who have had multiple
earlier operations or the prior placement of mesh patches. The risk of
complications has been shown to be about 13%. The risk of recurrence and repeat
surgery is as high as 52%, particularly with open procedures or those using
staples rather than sutures for wound closure. Some of the factors that cause
incisional hernias to occur in the first place, such as obesity and nutritional
disorders, will persist in certain patients and encourage the development of a
second incisional hernia and repeat surgery. Each subsequent time, the surgery
will become more difficult and the risk of complications greater. Postoperative
infection is higher with open procedures than with laparoscopic procedures.
Postoperative complications may include:
• fluid buildup at the site
of mesh placement, sometimes requiring aspiration (draining off)
•
postoperative bleeding, though seldom enough to require repeat surgery
•
prolonged suture pain, treated with pain medication or anti-inflammatory drugs
• intestinal injury
• nerve injury
• fever, usually related to
surgical wound infection
• intra-abdominal (within the abdominal wall)
abscess
• urinary retention
• respiratory distress
Normal
results
Good outcomes are expected with incisional hernia repair,
particularly with the laparoscopic method. Patients will usually go home the day
of surgery and can expect a one- to two-week recovery period at home, and then a
return to normal activities. The American College of Surgeons reports that
recurrence rates after the first repair of an incisional hernia range from
25–52%. Recurrence is more frequent when conventional surgical wound closure
with standard sutures (stitches) is used. Recurrence after open procedures has
been shown to be less likely when mesh is used, although complications,
especially infection, have been shown to increase because of the larger
abdominal incisions. Laparoscopy with mesh has shown rates of recurrence as low
as 3.4%, with fewer complications as well.
Morbidity and mortality rates
Deaths are not reported resulting directly from the performance of
herniorrhaphy for incisional hernia.
Alternatives
The alternatives
to first-time and recurrent incisional hernia repair begin with preventive
measures such as:
• Losing weight; maintaining suitable weight for age and
height.
• Strengthening abdominal muscles through regular moderate exercise
such as walking, tai chi, yoga, or stretching exercises and gentle aerobics.
• Reducing abdominal pressure by avoiding constipation and the buildup of
excess body fluids, achieved by adopting a high-fiber, low-salt diet.
•
Learning to lift heavy objects in a safe, low-strain way using arm and leg
muscles.
• Controlling diabetes and poor metabolism with regular medical
care and dietary changes as recommended.
• Eating a healthy, balanced diet
of whole foods, high in essential nutrients, including whole grains, fruits and
vegetables, limited meat and dairy, and eliminating prepared and refined foods.
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