Pathology

1. Incisional hernia:
   • Extrusion of abdominal contents (fat, omentum, bowel) through a weak sacr
   • Represents a partial wound dehiscence where the skin remains intact
2. Predisposing factors
   • Pre-operative: age, obesity, malignancy, abdominal distension
   • Operative: poor wound closure, too small bites, inappropriate suture material
   • Post-operative: wound haematoma, wound infection, early mobilisation, postoperative atelectasis and chest infection
3. Complications:
   • Obstruction
   • Incarceration
   • Skin exoriation
   • Persistent pain

Approach

• Begin by examining the hands
• Expose abdomen

1. Inspect
   • Patient may be overweight
   • Scar over abdominal wall - describe car, drain sites, old stomas
   • Ask patient to lift head off bed, note any bulges out of scar
   • Ask patient to cough / strain - tell examiner you have demonstrated a weakness associated with the scar
2. Palpate
   • Paplate patient's scar - note any tenderness
   • Note presence of any nodulatiry and feel for the presence of a defect under all or part of the incision
   • Ask patient to cough and feel weakness in scar
   • Determine whether defect is whole lenght or scar
   • Ask if patient is able to reduce the hernia
3. Percuss
4. Auscultate
   • Listen for bowel sounds if there is a large hernia

Completion

1. Examine rest of abdomen
2. ?

Treatment options in Managing incisional hernia

1. Non-surgical
   • Use of truss / corset
   • Weight loss
   • Management of risk factors (respiratory disease, nutrition)
2. Surgical
   • Dissection of hernia sac from surrounding tissues and definition of tissue bodering defect on all sides to 2-3cm
   • Closing of defect and then using mesh overlapping adequately over normal tissues to allow healing (about 3cm) - technique of choice
   • Layered closure technique