Incisional hernia: preliminary observations at a new institute

INTRODUCTION

The term “hernia” is derived from the Greek word hernios, which means “budding”. The term ventral hernia is used to describe any protrusion of abdominal viscera, most often a part of intestine, through the anterior abdominal wall. Ventral hernia can be divided into two categories: spontaneous (or primary) hernia and incisional (or secondary) hernia. European Hernia Society (EHS) introduced an elaborate classification of ventral hernias.² To avoid confusion, parastomal hernias were excluded from this classication, and were classified separately.³ Incisional hernia account for almost 80% of the ventral hernias.⁴ Their incidence following laparotomy ranges from 2% to 11% in different studies.⁵ Technical factors, such as slippage of knots, suture fractures, excessive tension, or rapidly absorbable sutures, can result in increased rate of incisional hernia.⁶ A surgical-site infection at the time of initial surgery has been reported to double the risk of herniation.⁷ Van’t Riet showed that any type of wound dehiscence led to an incisional hernia in 63% of patients at 4-years of follow-up.⁸

Many hernia repair methods have been described. Traditional primary repair entails a laparotomy with suture approximation of strong fascial tissue on each side of the defect. However, recurrence rates after this procedure is as high as 41 to 52% during long term follow-up.^1,9,10 Hernioplasties in which large prosthetic meshes are implanted appear to have lower recurrence rates (12 to 24%), but the required dissection of wide areas of soft tissue contributes to an increased incidence of wound infections and wound related complications (12% or higher).^9,11,12

The laparoscopic repair technique is based on the principles of Rives-Stoppa operation and involves placement of a large prosthetic mesh in a retro-muscular, intraperitoneal location.^9,13,14 The mesh overlaps the margins of the hernia by several centimeters, and is secured by multiple, interrupted, transabdominal sutures placed along the edge of the mesh. Placement of a large mesh in this intraperitoneal or preperitoneal location allows an even distribution of forces along the surface area of the mesh, which may account for the strength of the repair and the decreased recurrence rates associated with it. Additionally, minimally invasive procedure allows for lesser length of hospital stay, early return to work, and less surgical site infection. The aim of this study was to study the age-sex distribution in patients with incisional hernia, their past operative history, the site and size of defect, and the operative modality used.

METHODS

This is a prospective study done in the Department of General Surgery at All India Institute of Medical Sciences, Rishikesh

Inclusion Criteria

First 20 cases of incisional hernia presenting to the outpatient unit of this institute.

Exclusion Criteria

Intestinal obstruction, peritonitis, and defect size above 15 cm.

Prior operative history was obtained. Any comorbid condition, if present, was noted. Site and dimensions of the hernial defect was noted. Patients were preferentially treated by laparoscopic ventral hernia repair. Few patients could not be operated during same admission, either due to their unwillingness for surgery despite adequate counselling, or lack of fitness for anaesthesia.

RESULTS

Age and sex distribution

12 out of 20 patients were female (60%). Average age of the patient was 41.9±11.9 years. There was a stark difference in the age distribution between the two genders. Average age of a female patient was 36 years, and only 1 patient was above 50 years of age (8.33%). In contrast, average age of the male patient was 50.75 years, and 5 out of 8 patients were above 50 years of age (62.5%) (Table 2).

Operative history

Exploratory laparotomy accounted for 5 out of 8 cases amongst male patients (62.5%). Caesarian section was the commonest preceding operative procedure associated with incisional hernia (7 out of 12 females; 58.33%). One male patient had umbilical port-site hernia with prior history of laparoscopic appendicectomy*.

4 cases had recurrence of hernia following prior repair. Amongst those 4, one male patient had recurrence following repair of primary (i.e. spontaneous) epigastric hernia (Table 3)**.

Site of hernial defect

Infraumbilical incisional hernia was the commonest type (n=9; 45%), followed by umbilical incisional hernia (n=7; 35%). 8 out of 9 cases of infraumbilical hernia were females (88.9%), while 5 out of 7 cases of umbilical hernia were males (71.4%). Odds ratio was 20 (Table 4).

Size of defect

Average size of the defect was 6.2×5.6 cm.

There was no gender difference observed. Average area of the defect was 35.63 cm² (Table 5).

Comorbidities

Comorbid conditions were more commonly seen in men (3 out of 8; 37.5%). One female had past history of pulmonary tuberculosis and ATT, and another had bronchial asthma (total 2 out of 12; 16.7%) (Table 6).

Treatment

Laparoscopic ventral hernia repair (LVHR) using intraperitoneal composite mesh was the most common surgery performed (9 out of 13 treated patients; 69.2%). Open repair using underlay prolene mesh was done in one male patient, who had history of ischemic heart disease. Other methods used were open repair with suture approximation, IPOM and component separation technique (Table 7).

DISCUSSION

This was a prospective study which included the first 20 patients with incisional hernia presenting to the outpatient unit at our institute.

12 out of 20 patients included in the study were women (60%). This was not different from what Carlson MA et al had found, while reviewing 6266 published cases of minimally invasive ventral hernia surgery extracted from electronic databases (PubMed).¹⁵ Out of 5223 procedures in which sex was reported, 3031 of the patients (58%) were female.

Average age of the patient in our study was 41.9 years. Average age in female patients was 36 years, which was lower as compared to average age of male patients, i.e. 50.75 years. Carlson MA et al, in the above mentioned meta-analysis, observed the mean age of 55 years.¹⁵ Singh AP et al, reviewed 3266 cases from 34 studies extracted from electronic databases, and found the average age of the patient to be 55.34 years.¹⁶

History of preceding gynecological surgery was obtained in 7 out of 12 female patients (58.3%), and thus accounted for 35% of cases. Infraumbilical hernia was the commonest type, and was seen in 9 patients (45%; 8 women, 1 man). Qadri SJ et al in a study of 80 cases of incisional ventral hernia repair at a single centre between December 2005 and December 2009, observed that obstetrical or gynecological procedure was the most common index surgery leading to incisional hernia, and lower midline incision was the most common site of hernia.¹⁷ Average size of the defect was 6.2×5.6 cm, and mean area was 35.63 cm². Subramanian A et al in their study also found similar results. Average area of the defect in secondary or incisional hernia observed was 37.9±4.9 cm².¹⁸

LVHR was attempted in 9 patients, and none were converted to open repair (conversion rate = 0%). Bedi Ap et al in their meta-analysis of 34 studies comprising 3266 LVHR, found that 74 cases (2.26%) were converted to open procedure.¹⁶

CONCLUSION

Incisional ventral hernia is a commonly encountered condition, and is more common in females. Female patients are more likely to be younger compared to their male counterparts. Most common site is infraumbilical and gynecological operation the common index surgery associated with the condition.

Laparoscopic ventral hernia repair using intraperitoneal mesh is being increasingly used as the preferred modality of treatment, and has very low conversion rate to open procedure.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

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