Background Information:

What are the other Names for the Procedure?

• Incisional Herniorrhaphy
• Repair of Incisional Hernia
• Ventral Incisional Hernia Repair

What is Incisional Hernia Repair surgical procedure?

• Hernia is a protrusion of a piece of tissue or a loop of bowel, through a weak spot or opening in the abdominal wall
• An incisional hernia is a type of hernia that bulges out of a weak spot, which occurred from a previous surgery in the abdomen. The hernia occurs through the previous incision scar
• An Incisional Hernia Repair or Incisional Herniorrhaphy is a surgical procedure performed to repair incisional hernia

What part of the Body does the Procedure involve?

An Incisional Hernia Repair surgical procedure may be performed anywhere in the abdomen, where there is a previous incisional scar.

Why is the Incisional Hernia Repair surgical procedure Performed?

An Incisional Hernia Repair procedure is done, to reduce the patient's risk of a future surgical emergency. If a repair is not performed, the hernia may reduce or become irreducible, obstructed, or strangulated.

• A reducible hernia occurs, when a hernia can be pushed back into the abdomen, either spontaneously or with manipulation. This is the most common type of incisional hernia and it is usually a painless condition
• An irreducible hernia occurs, when a hernia becomes stuck. This can cause pain and a feeling of illness
• An obstructed hernia occurs, when a part of the intestine enters the hernia sac and gets blocked, causing an intestinal obstruction
• A strangulated hernia occurs, when a hernia blocks blood supply to a part of the bowel. If the herniated bowel has its blood supply diminished, because of pressure from other nearby organs or structures, the affected tissue can die and be invaded by bacteria. This is a life-threatening surgical emergency condition

What are some Alternative Choices for the Procedure?

• All incisional hernias need to be repaired surgically, even if they do not cause any symptoms, unless the patient is medically unfit for surgery
• Also, there remains a risk of strangulation and as such there is no real alternative choice to surgical repair

What are the Recent Advances in the Procedure?

Minimally-invasive (laparoscopic approach) techniques are recent advancements in Incisional Hernia Repair surgical procedure.

What is the Cost of performing the Incisional Hernia Repair surgical procedure?

The cost of Incisional Hernia Repair surgical procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding Incisional Hernia Repair surgical procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple surgeries or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

http://www.surgeryencyclopedia.com/Fi-La/Incisional-Hernia-Repair.html

http://www.umm.edu/general_surgery/lap_hernia_repair.htm

http://www.ssat.com/cgi-bin/incisionalhernia.cgi

http://surgery.about.com/od/proceduresaz/a/IncisionalHerni.htm

Prior to Incisional Hernia Repair surgical procedure:

How is the Incisional Hernia Repair surgical procedure Performed?

There are two kinds of Incisional Hernia Repair: Open repair and laparoscopic repair

Open repair:

• An incision is made in the region of the previous incision scar (either through or around the scar)
• The incisional hernia sac is identified and separated from the tissues around it
• The sac is opened and its contents are examined for viability
• The scar tissue attaching the bowel to the inside of the abdominal cavity are divided (lysed)
• The defect is then obliterated, either by approximation of the adjacent tissue, or by placement of a prosthetic mesh
• In cases of compromised bowels, mesh placement is contraindicated, due to an increased risk of mesh infection

Laparoscopic repair:

• Using a narrow tube-like instrument (cannula), the surgeon enters the abdomen in the area that is farther away from the previous scar
• A laparoscope (a tiny telescope) connected to a special camera is inserted through the cannula, giving the surgeon a magnified view of the patient's internal organs on a television screen
• Other cannulas are inserted, which allow the surgeon to delicately divide the scar tissues that attach the bowel to one another, and also to the abdominal wall
• Once the bowel is separated from the abdominal wall, the surgeon identifies the defect and covers it with a piece of prosthetic mesh
• A laparoscopic repair is not performed in cases of strangulated hernia, where the bowel viability is compromised

Where is the Procedure Performed?

Incisional Hernia Repair is performed in a hospital. The patient is admitted and discharged after the procedure, as per the instruction of the physician.

Who Performs the Procedure?

The Incisional Herniorrhaphy procedure is performed by a physician trained in general surgery, assisted by an anesthesiologist.

How long will the Procedure take?

The time for an Incisional Hernia Repair varies and it may take anywhere between 1-6 hours, depending on the amount of scar tissues inside the abdominal cavity.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the surgical procedure and helps avoid unnecessary complications.

• Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
• If you or your family members, have a history of bleeding disorders, or if there is a tendency to bleed more than normal
• If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)
• A list of all previous surgical procedures you have undergone, like for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

• The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient including information related to the medications that are being currently taken
• Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
• Blood tests may be performed to determine, if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
• Do inform the physician if you are allergic to any local anesthetics, lidocaine, etc.
• Avoid application of any cosmetics, deodorant, or topical medicines on the area, prior to the procedure
• It is advisable to quit smoking and the use of any nicotine based products, for a while, before the surgery
• Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
• The patient must avoid eating or drinking at least 8 hours prior to the surgical procedure, depending on when the procedure is arranged
• For persons suffering from diabetes, it is important that the blood sugar stays within the normal range; if not their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

What is the Consent Process before the Procedure?

A physician will request your consent for Incisional Hernia Repair procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What Tests are needed, before the Incisional Hernia Repair surgical procedure?

• The diagnosis is largely a clinical one, generally done by physical examination of the abdomen/groin region
• However, in some patients (especially obese patients), imaging in the form of ultrasonography, CT or MRI scans may aid in the diagnosis of an incisional hernia

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

• What is an Incisional Hernia Repair procedure?
• Why is this procedure necessary? How will this procedure help?
• What does the procedure involve?
• How soon should I get it done? Is there an emergency?
• Who are the medical personnel involved in this procedure?
• What are the risks while performing the procedure?
• What are the possible complications that might take place, during recovery?
• How long will it take to recover? When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any lifestyle restrictions or modifications required, after the procedure is performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
• Is there any medication that needs to be taken for life, after the procedure?
• What are the costs involved?

During the Incisional Hernia Repair surgical procedure:

What kind of Anesthesia is given, during the Procedure?

General anesthesia (asleep and pain-free) is administered, prior to the Incisional Hernia Repair surgical procedure.

How much Blood will you lose, during the Procedure?

• If the Incisional Hernia Repair procedure is under laparoscopic (minimally-invasive) approach, there is little blood loss involved
• In open approach is used, the blood loss could be a little more, compared to a laparoscopic approach
• If complications arise during the procedure, it could lead to a further loss of blood

What are the possible Risks and Complications during the Incisional Hernia Repair surgical procedure?

There are general factors that increase the risk of getting complications during surgery and they include:

• Obesity: Generally greater the degree of obesity, greater is the surgical risk
• Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk
• Advancing age
• Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
• Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
• Poorly functioning liver, as evidenced by increased blood liver function tests
• Hypertension (increased blood pressure), especially if it is poorly controlled
• Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
• Poor lung function, as evidenced by abnormal lung function tests
• History of bleeding disorders
• Longstanding illness, such as autoimmune disorders, chronic infections
• Poor immune system due to a variety of causes

The possible risks or complications that may arise during the Incisional Hernia Repair surgery are:

• Infection
• Bleeding
• Injury to the neighboring structures
• Pain
• Discomfort
• Anesthetic complications
• Need for further procedures
• Pneumonia

What Post-Operative Care is needed at the Healthcare Facility after the Incisional Hernia Repair surgical procedure?

• At the healthcare facility, the patient is admitted to the general floor, after the procedure
• Pain is controlled with pain medications - the type, route, and dosage of pain medication, is dependent on the patient’s tolerance level
• Patient may initially kept NPO (nil per oral), till he/she resumes bowel functions (flatus or bowel movement)
• The diet is gradually advanced, as the patient recovers to tolerate it
• The patient is discharged, once the pain is controlled with oral pain medication, diet is tolerated well, the patient voids and ambulates well, with minimal or no assistance and once bowel function is regained (flatus or bowel movement)

After the Incisional Hernia Repair surgical procedure:

What are the possible Risks and Complications after the Incisional Hernia Repair surgical procedure?

Post Incisional Hernia Repair procedure, the following complications may arise:

• Excessive bleeding, resulting in blood clot accumulation at the surgery site (hematoma)
• Loss of bowel/bladder function
• Accidental damage to the intestinal tract, other neighboring structures
• Signs of an infection
• Recurrence of the hernia

What is the Prognosis after the Surgery?

• The outcome of an elective Incisional Hernia Repair is usually very good. The recurrence rate is very low
• Emergency repair carries a greater morbidity and mortality rate; this is directly proportional to the degree of bowel compromise
• Other co-existing medical conditions also influence the outcome

When do you need to call your Physician?

Do contact your physician if you notice any of the following symptoms, following an Incisional Hernia Repair:

• Worsening pain around the surgical wound
• Swelling and redness
• Bleeding or fluid drainage around the spot
• Fever
• Dizziness
• Any signs of infection

What Post-Operative Care is needed at Home after the Incisional Hernia Repair surgical procedure?

At home, the following post-operative care is recommended, after an Incisional Hernia Repair procedure:

• Avoid strenuous physical activities for a certain period of time, before slowly getting back to your regular daily routine
• Keep incision wounds clean and dry
• Complete the prescribed course of medications
• Avoid taking any pain-killers, unless they are prescribed by your physician
• Take stool softeners to prevent constipation, under advice by the physician
• Take antibiotic medication to help combat or prevent infection, under advice by the physician

How long does it normally take to fully recover, from the Procedure?

It may take anywhere between 4 to 6 weeks, to recover completely from the Incisional Hernia Repair surgical procedure.

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

The tissue is taken for further examination and later disposed, as per the standard medical procedure.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

• The tissue removed is processed in the laboratory under a pathologist's supervision
• The slide(s) are prepared once the tissue is processed, and this is examined by a pathologist and a pathology report issued
• Depending on the complexity of the case, issue of the report may take anywhere between 72 hours to a week's time

Who will you receive a Bill from, after the Incisional Hernia Repair surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The outpatient facility or hospital
• A general surgeon
• An anesthesiologist (if anesthesia was administered)
• A pathologist (if the tissue was sent for analysis)

Individuals are advised to inquire and confirm the type of billing, before the Repair of Incisional Hernia surgical procedure is performed.

Thanks and Gratitude:

We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.

Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA