Incisional hernia

1) Disease Description (Causes and Symptoms)

• Definition: An incisional hernia is a condition in which the abdominal wall muscles and fascia separate at the incision site from a previous abdominal surgery (laparotomy), allowing intra-abdominal organs (such as the intestines) to protrude through the gap.
• Pathophysiology: The sutured layers of the abdominal wall, particularly the muscle and fascial layers, may separate due to infection, tissue weakness, suture failure, or persistent increases in intra-abdominal pressure (such as coughing, constipation, or ascites) during or after surgery, forming a hernia sac. If an organ becomes trapped in the hernia opening, it may progress to obstruction or impaired blood flow (incarceration and necrosis).
• Main causes and risk factors: Surgical wound infection, improper suturing, obesity, chronic coughing or constipation, ascites, repeated abdominal surgery, smoking, diabetes, malnutrition, steroid use, and others.
• Main symptoms: Localized bulging at the surgical wound site (especially when standing or straining), dull pain or discomfort, abdominal distension, and gurgling sounds in the abdomen. Although uncommon, sudden severe pain, vomiting, or difficulty passing stool may suggest incarceration (intestinal adhesions or necrosis).

2) Treatment Methods

• Diagnosis: Mainly physical examination (checking for bulging when standing and lying down), ultrasonography, and abdominal CT (assessment of the size of the defect and whether the intestine is involved). Assessing the symptoms and urgency is most important.
• Non-surgical treatment: When there are few symptoms and the defect is small, observation or wearing an abdominal binder (inguinal support belt) may relieve symptoms, but there is a risk of recurrence or progression.
• Surgical treatment (standard):
  • Goal: Hernia repair and reinforcement of the defect to prevent recurrence.
  • Typical method: Closing the defect and reinforcing it with an artificial mesh (synthetic mesh), using either invasive open surgery or laparoscopic surgery. When the defect is large, reconstructive surgery such as component separation may be necessary.
  • Small early defects: A method using an artificial mesh plug or similar technique may be selected.
  • In cases of contamination or infection: Use of biological mesh instead of synthetic mesh or staged surgery may be considered.
  • Emergency surgery: If the intestine in the hernia is incarcerated, ischemic, or necrotic, immediate surgery and resection of the necrotic intestine are necessary.
• Medication and supportive treatment: Pain control (NSAIDs, acetaminophen, short-term opioids), antibiotics for wound infections, constipation prevention (keeping bowel movements soft), and breathing exercises (to prevent pulmonary complications).
• Preoperative optimization: Smoking cessation (to reduce delayed healing and the risk of recurrence), weight loss, blood glucose control, treatment of infections, improvement of nutritional status, and improvement of pulmonary function.
• Precautions (related to treatment):
  • Mesh reinforcement is recommended because closure with sutures alone has a high recurrence rate.
  • The type and method of mesh should be selected carefully according to the degree of contamination during surgery.
  • In the early postoperative period, avoid lifting heavy objects, severe coughing, and straining.

3) Checklist Before an Outpatient Visit (Including Items to Bring and Example Questions)

• Items to bring/submit:
  • List of current medications (including anticoagulants, antiplatelet drugs, and steroids)
  • Previous surgical records (if possible, the operative report and date of surgery), and copies of previous imaging tests (CT/ultrasound)
  • Record of when symptoms began, aggravating factors, and the nature of the pain (using a pain scale)
  • Recent weight changes, smoking and alcohol use, and history of chronic diseases (such as diabetes or lung disease)
  • Photographs of the hernia area when standing and lying down, if available, can help with diagnosis
• Important information to provide during the visit:
  • Whether the hernia reduces or cannot be pushed back in, and whether vomiting, difficulty passing stool, or high fever is present
  • Whether there has recently been a wound infection or other wound problems
• Things to do before the outpatient visit:
  • If there is severe pain, vomiting, fever, or the hernia is hard and cannot be reduced, visiting the emergency department is recommended
  • Patients taking anticoagulants should check in advance how to stop the prescription medication, in consultation with the treating physician
• Example questions (useful for patients to prepare their own answers):
  • When was the hernia first noticed? Is it steadily getting larger?
  • Is the pain constant, intermittent, or worsened by exercise?

4) Examples of General Questions to Ask the Doctor

• What are the recommended treatment options for this condition? (Non-surgical observation versus surgery)
• If surgery is performed, which method (open surgery with mesh, laparoscopy, plug, etc.) do you recommend? What are the advantages and disadvantages?
• During surgery, do you plan to use synthetic mesh or biological mesh? What are the differences in recurrence and infection rates?
• What lifestyle guidelines should I follow before and after surgery, and how long will the recovery period be?

5) Examples of Condition-Specific Questions

• Does my hernia currently require emergency surgery because incarceration is suspected? What symptoms should prompt me to go to the emergency department immediately?
• The abdominal wall is weak because of a previous surgical site (for example, an appendectomy or bowel resection). To reduce the risk of recurrence, which surgical method—laparoscopy or open surgery—is more suitable?