Incisional hernia: Difference between revisions

(Created page with "==Background== *An incisional hernia is a protrusion of abdominal contents through a defect in the abdominal wall fascia at the site of a previous surgical incision<ref name="statpearls">Incisional Hernia. In: ''StatPearls''. Treasure Island (FL): StatPearls Publishing; 2023. PMID 28613665.</ref> *Most common type of ventral hernia; occurs after '''10–23%''' of abdominal surgeries<ref name="statpearls"/> *Majority develop within the '''first 3 years''' after surgery, t...")
 
(Formatting: removed excessive bold)
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*Natural history is '''progressive enlargement''' over time
*Natural history is '''progressive enlargement''' over time
*The primary concern in the ED is '''incarceration''' and '''strangulation:'''<ref name="doble">Doble JA, Puthoff EM. Incarcerated and strangulated hernia. In: Docimo S, Pauli EM, eds. ''Clinical Algorithms in General Surgery''. Springer; 2019:865-868.</ref>
*The primary concern in the ED is '''incarceration''' and '''strangulation:'''<ref name="doble">Doble JA, Puthoff EM. Incarcerated and strangulated hernia. In: Docimo S, Pauli EM, eds. ''Clinical Algorithms in General Surgery''. Springer; 2019:865-868.</ref>
**'''Reducible:''' Hernia contents return to the abdominal cavity with manual pressure or spontaneously
**Reducible: Hernia contents return to the abdominal cavity with manual pressure or spontaneously
**'''Incarcerated:''' Contents cannot be reduced — may cause [[Small bowel obstruction|bowel obstruction]]; '''surgical emergency'''
**Incarcerated: Contents cannot be reduced — may cause [[Small bowel obstruction|bowel obstruction]]; '''surgical emergency'''
**'''Strangulated:''' Blood supply to the herniated contents is compromised → bowel ischemia, necrosis, perforation; '''life-threatening emergency'''
**Strangulated: Blood supply to the herniated contents is compromised → bowel ischemia, necrosis, perforation; '''life-threatening emergency'''
*Smaller hernia defects are at '''higher risk''' for incarceration/strangulation than large defects (narrow neck traps contents more readily)<ref name="statpearls"/>
*Smaller hernia defects are at '''higher risk''' for incarceration/strangulation than large defects (narrow neck traps contents more readily)<ref name="statpearls"/>
*Emergency hernia repair carries significantly higher morbidity (20%) and mortality (3%) compared to elective repair<ref name="newmanagement">Schlosser KA, Arnold MR, Otero J, et al. What's new in the management of incarcerated hernia. ''J Gastrointest Surg''. 2024;28(2):222-229. PMID 38101896.</ref>
*Emergency hernia repair carries significantly higher morbidity (20%) and mortality (3%) compared to elective repair<ref name="newmanagement">Schlosser KA, Arnold MR, Otero J, et al. What's new in the management of incarcerated hernia. ''J Gastrointest Surg''. 2024;28(2):222-229. PMID 38101896.</ref>
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===Incarcerated===
===Incarcerated===
*Bulge that '''cannot be reduced'''
*Bulge that '''cannot be reduced'''
*'''Increasing pain''' at the hernia site
*Increasing pain at the hernia site
*Nausea, vomiting (if bowel is obstructed)
*Nausea, vomiting (if bowel is obstructed)
*Abdominal distension, obstipation (if complete bowel obstruction)
*Abdominal distension, obstipation (if complete bowel obstruction)
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===Strangulated (surgical emergency)===
===Strangulated (surgical emergency)===
*'''Severe, constant pain''' at the hernia site — often out of proportion to exam early on<ref name="strangulated">Strangulated Hernia. In: ''StatPearls''. Treasure Island (FL): StatPearls Publishing; 2022. PMID 32644427.</ref>
*Severe, constant pain at the hernia site — often out of proportion to exam early on<ref name="strangulated">Strangulated Hernia. In: ''StatPearls''. Treasure Island (FL): StatPearls Publishing; 2022. PMID 32644427.</ref>
*'''Skin changes:''' Erythema, warmth, or '''dusky/violaceous discoloration''' overlying the hernia — highly concerning for vascular compromise
*Skin changes: Erythema, warmth, or '''dusky/violaceous discoloration''' overlying the hernia — highly concerning for vascular compromise
*Signs of systemic toxicity: '''fever, tachycardia, hypotension'''
*Signs of systemic toxicity: '''fever, tachycardia, hypotension'''
*Peritoneal signs (rebound, guarding) if bowel perforation has occurred
*Peritoneal signs (rebound, guarding) if bowel perforation has occurred
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===Key clinical pearl===
===Key clinical pearl===
*'''Do NOT attempt reduction''' if strangulation is suspected (skin changes, systemic toxicity, prolonged incarceration) — reducing necrotic bowel into the abdomen can lead to perforation, peritonitis, and sepsis<ref name="strangulated"/>
*'''Do NOT attempt reduction''' if strangulation is suspected (skin changes, systemic toxicity, prolonged incarceration) — reducing necrotic bowel into the abdomen can lead to perforation, peritonitis, and sepsis<ref name="strangulated"/>
*'''Richter hernia:''' Only the anti-mesenteric border of the bowel wall herniates — may strangulate '''without''' complete bowel obstruction; can be missed clinically because obstructive symptoms may be absent<ref name="statpearls"/>
*Richter hernia: Only the anti-mesenteric border of the bowel wall herniates — may strangulate '''without''' complete bowel obstruction; can be missed clinically because obstructive symptoms may be absent<ref name="statpearls"/>


==Differential diagnosis==
==Differential diagnosis==
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==Evaluation==
==Evaluation==
===Workup===
===Workup===
*'''Physical examination''' is the primary diagnostic tool for external hernias
*Physical examination is the primary diagnostic tool for external hernias
**Examine with patient standing and supine
**Examine with patient standing and supine
**Ask patient to perform Valsalva maneuver / cough while palpating the incision site
**Ask patient to perform Valsalva maneuver / cough while palpating the incision site
**Assess reducibility — '''gently attempt reduction only if no signs of strangulation'''
**Assess reducibility — '''gently attempt reduction only if no signs of strangulation'''
**Note size of the defect, tenderness, skin changes, and whether contents are reducible
**Note size of the defect, tenderness, skin changes, and whether contents are reducible
*'''Labs (if incarceration or strangulation suspected):'''
*Labs (if incarceration or strangulation suspected):
**CBC (leukocytosis suggests strangulation/ischemia)
**CBC (leukocytosis suggests strangulation/ischemia)
**BMP (electrolytes, renal function — dehydration from vomiting)
**BMP (electrolytes, renal function — dehydration from vomiting)
**'''Lactate''' — elevated lactate raises concern for bowel ischemia, but '''a normal lactate does NOT exclude strangulation'''<ref name="newmanagement"/>
**Lactate — elevated lactate raises concern for bowel ischemia, but '''a normal lactate does NOT exclude strangulation'''<ref name="newmanagement"/>
**VBG/ABG if metabolic acidosis suspected
**VBG/ABG if metabolic acidosis suspected
**Type and screen (anticipate possible surgery)
**Type and screen (anticipate possible surgery)
*'''Imaging:'''
*Imaging:
**'''CT abdomen/pelvis with IV contrast''' — '''study of choice''' for complicated incisional hernias<ref name="statpearls"/>
**CT abdomen/pelvis with IV contrast — '''study of choice''' for complicated incisional hernias<ref name="statpearls"/>
***Identifies hernia contents (fat only vs. bowel), signs of obstruction, bowel wall thickening/enhancement (or lack thereof), free fluid, pneumoperitoneum
***Identifies hernia contents (fat only vs. bowel), signs of obstruction, bowel wall thickening/enhancement (or lack thereof), free fluid, pneumoperitoneum
***Determines defect size and relationship to surrounding structures
***Determines defect size and relationship to surrounding structures
***Can identify strangulation (non-enhancing bowel wall, mesenteric congestion, free fluid)
***Can identify strangulation (non-enhancing bowel wall, mesenteric congestion, free fluid)
**'''Abdominal XR (upright/supine):''' May show dilated loops and air-fluid levels consistent with [[Small bowel obstruction|SBO]]; insufficient alone to evaluate the hernia
**Abdominal XR (upright/supine): May show dilated loops and air-fluid levels consistent with [[Small bowel obstruction|SBO]]; insufficient alone to evaluate the hernia
**'''Ultrasound:''' Can identify hernia defect and contents at bedside; useful as initial evaluation in hemodynamically unstable patients or pregnant patients; operator-dependent
**Ultrasound: Can identify hernia defect and contents at bedside; useful as initial evaluation in hemodynamically unstable patients or pregnant patients; operator-dependent


===Diagnosis===
===Diagnosis===
*'''Uncomplicated incisional hernia:''' Clinical diagnosis — reducible bulge at a surgical incision site with positive cough impulse; imaging usually not required
*Uncomplicated incisional hernia: Clinical diagnosis — reducible bulge at a surgical incision site with positive cough impulse; imaging usually not required
*'''Incarcerated/strangulated hernia:''' Clinical diagnosis confirmed by CT
*Incarcerated/strangulated hernia: Clinical diagnosis confirmed by CT
**CT findings concerning for strangulation: bowel wall thickening with decreased enhancement, mesenteric haziness/fat stranding, transition point at the hernia defect, free fluid, pneumoperitoneum (perforation)
**CT findings concerning for strangulation: bowel wall thickening with decreased enhancement, mesenteric haziness/fat stranding, transition point at the hernia defect, free fluid, pneumoperitoneum (perforation)
*'''Key distinction:''' Incarcerated hernia '''containing only omentum/fat''' (no bowel) is painful but NOT a time-critical surgical emergency (no risk of bowel ischemia); still typically requires surgical repair but can be semi-elective<ref name="newmanagement"/>
*Key distinction: Incarcerated hernia '''containing only omentum/fat''' (no bowel) is painful but NOT a time-critical surgical emergency (no risk of bowel ischemia); still typically requires surgical repair but can be semi-elective<ref name="newmanagement"/>


==Management==
==Management==
===Reducible hernia===
===Reducible hernia===
*'''Manual reduction''' if uncomplicated and no signs of strangulation:
*Manual reduction if uncomplicated and no signs of strangulation:
**Position patient supine (Trendelenburg may assist)
**Position patient supine (Trendelenburg may assist)
**Apply ice to the hernia to reduce edema
**Apply ice to the hernia to reduce edema
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===Incarcerated hernia (without signs of strangulation)===
===Incarcerated hernia (without signs of strangulation)===
*'''Attempt reduction''' with analgesia and sedation as above
*Attempt reduction with analgesia and sedation as above
*If '''reduction is successful:''' Observe in ED for 4–6 hours for signs of delayed ischemia → arrange urgent surgical follow-up
*If '''reduction is successful:''' Observe in ED for 4–6 hours for signs of delayed ischemia → arrange urgent surgical follow-up
*If '''reduction fails:''' '''Emergent surgical consultation''' for operative repair<ref name="newmanagement"/>
*If '''reduction fails:''' '''Emergent surgical consultation''' for operative repair<ref name="newmanagement"/>
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*'''Do NOT attempt reduction''' — risk of reducing necrotic bowel into the abdomen<ref name="strangulated"/>
*'''Do NOT attempt reduction''' — risk of reducing necrotic bowel into the abdomen<ref name="strangulated"/>
*'''Emergent surgical consultation''' — this is a '''time-critical surgical emergency'''
*'''Emergent surgical consultation''' — this is a '''time-critical surgical emergency'''
*'''Resuscitation:'''
*Resuscitation:
**Two large-bore IVs; aggressive crystalloid resuscitation
**Two large-bore IVs; aggressive crystalloid resuscitation
**NPO
**NPO
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**Broad-spectrum IV antibiotics (e.g. piperacillin-tazobactam or cefepime + metronidazole) — cover for gram-negative and anaerobic organisms in anticipation of ischemic/perforated bowel<ref name="strangulated"/>
**Broad-spectrum IV antibiotics (e.g. piperacillin-tazobactam or cefepime + metronidazole) — cover for gram-negative and anaerobic organisms in anticipation of ischemic/perforated bowel<ref name="strangulated"/>
**Correct electrolyte abnormalities
**Correct electrolyte abnormalities
*'''Surgery:''' Open or laparoscopic approach depending on surgeon preference and clinical stability; may require bowel resection if necrosis is found
*Surgery: Open or laparoscopic approach depending on surgeon preference and clinical stability; may require bowel resection if necrosis is found


===General principles===
===General principles===
*'''Pain control:''' IV opioid analgesia; do not withhold despite the need for serial abdominal exams — pain control facilitates reduction and improves cooperation
*Pain control: IV opioid analgesia; do not withhold despite the need for serial abdominal exams — pain control facilitates reduction and improves cooperation
*'''Abdominal binder:''' May provide symptomatic comfort for chronic, reducible hernias while awaiting elective repair; does NOT prevent incarceration
*Abdominal binder: May provide symptomatic comfort for chronic, reducible hernias while awaiting elective repair; does NOT prevent incarceration


==Disposition==
==Disposition==
*'''Discharge home:'''
*Discharge home:
**Asymptomatic or mildly symptomatic reducible hernia with no signs of incarceration or strangulation
**Asymptomatic or mildly symptomatic reducible hernia with no signs of incarceration or strangulation
**Successful reduction with observation period showing no signs of bowel compromise
**Successful reduction with observation period showing no signs of bowel compromise
**Arrange '''general surgery follow-up''' within 1–2 weeks for discussion of elective repair
**Arrange '''general surgery follow-up''' within 1–2 weeks for discussion of elective repair
**Provide strict return precautions: irreducible bulge, increasing pain, vomiting, inability to pass stool/gas, skin changes overlying the hernia, fever
**Provide strict return precautions: irreducible bulge, increasing pain, vomiting, inability to pass stool/gas, skin changes overlying the hernia, fever
*'''Admit:'''
*Admit:
**Failed reduction (incarcerated, requires operative repair)
**Failed reduction (incarcerated, requires operative repair)
**Successful reduction but with persistent pain, concerning exam, or laboratory abnormalities suggesting bowel compromise
**Successful reduction but with persistent pain, concerning exam, or laboratory abnormalities suggesting bowel compromise
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**Incarcerated hernia with bowel obstruction that cannot be reduced
**Incarcerated hernia with bowel obstruction that cannot be reduced
**Evidence of perforation on imaging
**Evidence of perforation on imaging
*'''Post-reduction observation pearl:'''
*Post-reduction observation pearl:
**Even after successful reduction of an incarcerated hernia, patients should be observed for '''delayed ischemia''' — bowel that appeared viable during reduction may declare itself as ischemic hours later; worsening pain, tachycardia, or peritoneal signs after reduction warrant urgent re-evaluation and possible surgical exploration<ref name="doble"/>
**Even after successful reduction of an incarcerated hernia, patients should be observed for '''delayed ischemia''' — bowel that appeared viable during reduction may declare itself as ischemic hours later; worsening pain, tachycardia, or peritoneal signs after reduction warrant urgent re-evaluation and possible surgical exploration<ref name="doble"/>


Revision as of 16:08, 19 March 2026

Background

  • An incisional hernia is a protrusion of abdominal contents through a defect in the abdominal wall fascia at the site of a previous surgical incision[1]
  • Most common type of ventral hernia; occurs after 10–23% of abdominal surgeries[1]
  • Majority develop within the first 3 years after surgery, though they may appear years to decades later
  • Midline incisions carry the highest risk; non-midline (lateral, subcostal, Pfannenstiel, trocar site) hernias are less common but do occur
  • Risk factors for development:[1]
    • Surgical: midline incision, wound infection, emergency surgery, re-operation, improper fascial closure technique
    • Patient: obesity, smoking, chronic cough/COPD, diabetes, malnutrition, corticosteroid use, connective tissue disorders, immunosuppression, increased intra-abdominal pressure (ascites, pregnancy)
  • Natural history is progressive enlargement over time
  • The primary concern in the ED is incarceration and strangulation:[2]
    • Reducible: Hernia contents return to the abdominal cavity with manual pressure or spontaneously
    • Incarcerated: Contents cannot be reduced — may cause bowel obstruction; surgical emergency
    • Strangulated: Blood supply to the herniated contents is compromised → bowel ischemia, necrosis, perforation; life-threatening emergency
  • Smaller hernia defects are at higher risk for incarceration/strangulation than large defects (narrow neck traps contents more readily)[1]
  • Emergency hernia repair carries significantly higher morbidity (20%) and mortality (3%) compared to elective repair[3]

Clinical features

Uncomplicated (reducible)

  • Visible or palpable bulge at the incision site — more prominent with Valsalva, coughing, standing
  • May be asymptomatic or cause mild discomfort, pulling sensation, or intermittent pain
  • Positive cough impulse on palpation
  • Bulge reduces spontaneously or with gentle pressure when supine

Incarcerated

  • Bulge that cannot be reduced
  • Increasing pain at the hernia site
  • Nausea, vomiting (if bowel is obstructed)
  • Abdominal distension, obstipation (if complete bowel obstruction)
  • The hernia may be firm, tender, and slightly swollen

Strangulated (surgical emergency)

  • Severe, constant pain at the hernia site — often out of proportion to exam early on[4]
  • Skin changes: Erythema, warmth, or dusky/violaceous discoloration overlying the hernia — highly concerning for vascular compromise
  • Signs of systemic toxicity: fever, tachycardia, hypotension
  • Peritoneal signs (rebound, guarding) if bowel perforation has occurred
  • Leukocytosis, elevated lactate
  • Obstipation and complete absence of flatus

Key clinical pearl

  • Do NOT attempt reduction if strangulation is suspected (skin changes, systemic toxicity, prolonged incarceration) — reducing necrotic bowel into the abdomen can lead to perforation, peritonitis, and sepsis[4]
  • Richter hernia: Only the anti-mesenteric border of the bowel wall herniates — may strangulate without complete bowel obstruction; can be missed clinically because obstructive symptoms may be absent[1]

Differential diagnosis

Evaluation

Workup

  • Physical examination is the primary diagnostic tool for external hernias
    • Examine with patient standing and supine
    • Ask patient to perform Valsalva maneuver / cough while palpating the incision site
    • Assess reducibility — gently attempt reduction only if no signs of strangulation
    • Note size of the defect, tenderness, skin changes, and whether contents are reducible
  • Labs (if incarceration or strangulation suspected):
    • CBC (leukocytosis suggests strangulation/ischemia)
    • BMP (electrolytes, renal function — dehydration from vomiting)
    • Lactate — elevated lactate raises concern for bowel ischemia, but a normal lactate does NOT exclude strangulation[3]
    • VBG/ABG if metabolic acidosis suspected
    • Type and screen (anticipate possible surgery)
  • Imaging:
    • CT abdomen/pelvis with IV contrast — study of choice for complicated incisional hernias[1]
      • Identifies hernia contents (fat only vs. bowel), signs of obstruction, bowel wall thickening/enhancement (or lack thereof), free fluid, pneumoperitoneum
      • Determines defect size and relationship to surrounding structures
      • Can identify strangulation (non-enhancing bowel wall, mesenteric congestion, free fluid)
    • Abdominal XR (upright/supine): May show dilated loops and air-fluid levels consistent with SBO; insufficient alone to evaluate the hernia
    • Ultrasound: Can identify hernia defect and contents at bedside; useful as initial evaluation in hemodynamically unstable patients or pregnant patients; operator-dependent

Diagnosis

  • Uncomplicated incisional hernia: Clinical diagnosis — reducible bulge at a surgical incision site with positive cough impulse; imaging usually not required
  • Incarcerated/strangulated hernia: Clinical diagnosis confirmed by CT
    • CT findings concerning for strangulation: bowel wall thickening with decreased enhancement, mesenteric haziness/fat stranding, transition point at the hernia defect, free fluid, pneumoperitoneum (perforation)
  • Key distinction: Incarcerated hernia containing only omentum/fat (no bowel) is painful but NOT a time-critical surgical emergency (no risk of bowel ischemia); still typically requires surgical repair but can be semi-elective[3]

Management

Reducible hernia

  • Manual reduction if uncomplicated and no signs of strangulation:
    • Position patient supine (Trendelenburg may assist)
    • Apply ice to the hernia to reduce edema
    • Provide analgesia; procedural sedation may be necessary to relax the abdominal wall
    • Apply steady, gentle pressure to the hernia, directing contents back through the defect
  • After successful reduction: observe for signs of bowel compromise (pain, peritoneal signs, tachycardia)
  • Arrange elective surgical referral for definitive repair

Incarcerated hernia (without signs of strangulation)

  • Attempt reduction with analgesia and sedation as above
  • If reduction is successful: Observe in ED for 4–6 hours for signs of delayed ischemia → arrange urgent surgical follow-up
  • If reduction fails: Emergent surgical consultation for operative repair[3]

Strangulated hernia

  • Do NOT attempt reduction — risk of reducing necrotic bowel into the abdomen[4]
  • Emergent surgical consultation — this is a time-critical surgical emergency
  • Resuscitation:
    • Two large-bore IVs; aggressive crystalloid resuscitation
    • NPO
    • Nasogastric tube for decompression if bowel obstruction
    • Broad-spectrum IV antibiotics (e.g. piperacillin-tazobactam or cefepime + metronidazole) — cover for gram-negative and anaerobic organisms in anticipation of ischemic/perforated bowel[4]
    • Correct electrolyte abnormalities
  • Surgery: Open or laparoscopic approach depending on surgeon preference and clinical stability; may require bowel resection if necrosis is found

General principles

  • Pain control: IV opioid analgesia; do not withhold despite the need for serial abdominal exams — pain control facilitates reduction and improves cooperation
  • Abdominal binder: May provide symptomatic comfort for chronic, reducible hernias while awaiting elective repair; does NOT prevent incarceration

Disposition

  • Discharge home:
    • Asymptomatic or mildly symptomatic reducible hernia with no signs of incarceration or strangulation
    • Successful reduction with observation period showing no signs of bowel compromise
    • Arrange general surgery follow-up within 1–2 weeks for discussion of elective repair
    • Provide strict return precautions: irreducible bulge, increasing pain, vomiting, inability to pass stool/gas, skin changes overlying the hernia, fever
  • Admit:
    • Failed reduction (incarcerated, requires operative repair)
    • Successful reduction but with persistent pain, concerning exam, or laboratory abnormalities suggesting bowel compromise
    • Bowel obstruction requiring decompression and observation
  • Emergent surgery:
    • Strangulated hernia (skin changes, systemic toxicity, elevated lactate, peritoneal signs)
    • Incarcerated hernia with bowel obstruction that cannot be reduced
    • Evidence of perforation on imaging
  • Post-reduction observation pearl:
    • Even after successful reduction of an incarcerated hernia, patients should be observed for delayed ischemia — bowel that appeared viable during reduction may declare itself as ischemic hours later; worsening pain, tachycardia, or peritoneal signs after reduction warrant urgent re-evaluation and possible surgical exploration[2]

See also

External links

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Incisional Hernia. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023. PMID 28613665.
  2. ↑ 2.0 2.1 Doble JA, Puthoff EM. Incarcerated and strangulated hernia. In: Docimo S, Pauli EM, eds. Clinical Algorithms in General Surgery. Springer; 2019:865-868.
  3. ↑ 3.0 3.1 3.2 3.3 Schlosser KA, Arnold MR, Otero J, et al. What's new in the management of incarcerated hernia. J Gastrointest Surg. 2024;28(2):222-229. PMID 38101896.
  4. ↑ 4.0 4.1 4.2 4.3 Strangulated Hernia. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022. PMID 32644427.
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