Incisional hernia - Revision history

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Ostermayer: 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 incisionIncisional Hernia. In: ''StatPearls''. Treasure Island (FL): StatPearls Publishing; 2023. PMID 28613665. Most common type of ventral hernia; occurs after '''10–23%''' of abdominal surgeries *Majority develop within the '''first 3 years''' after surgery, t..."

2026-03-13T22:32:28Z

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..."

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==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, 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:<ref name="statpearls"/>
**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:'''<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
**'''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'''
*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>

==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<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
*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<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"/>

==Differential diagnosis==
*Seroma or hematoma at the incision site
*Wound infection / [[Abscess|incisional abscess]]
*Rectus sheath hematoma
*Other ventral hernias ([[Umbilical hernia]], [[Epigastric hernia]], [[Spigelian hernia]])
*[[Inguinal hernia]]
*[[Small bowel obstruction]] from other causes (adhesions, [[Internal hernia]])
*Desmoid tumor or other abdominal wall mass
*Incarcerated inguinal hernia
*Abdominal wall endometriosis (at Pfannenstiel scar)

==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'''<ref name="newmanagement"/>
**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<ref name="statpearls"/>
***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 [[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

===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<ref name="newmanagement"/>

==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<ref name="newmanagement"/>

===Strangulated hernia===
*'''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'''
*'''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<ref name="strangulated"/>
**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<ref name="doble"/>

==See also==
*[[Small bowel obstruction]]
*[[Inguinal hernia]]
*[[Umbilical hernia]]
*[[Femoral hernia]]
*[[Internal hernia]]
*[[Strangulated hernia]]
*[[Bariatric surgery complications]]

==External links==
*[https://www.ncbi.nlm.nih.gov/books/NBK435995/ Incisional Hernia - StatPearls]
*[https://www.ncbi.nlm.nih.gov/books/NBK555972/ Strangulated Hernia - StatPearls]
*[https://pmc.ncbi.nlm.nih.gov/articles/PMC8917417/ Risk of incarceration during nonoperative management of incisional hernias - Ann Surg 2022]
*[https://pubmed.ncbi.nlm.nih.gov/38101896/ What's new in the management of incarcerated hernia - J Gastrointest Surg 2024]

==References==
<references/>

[[Category:GI]] [[Category:Surgery]]

← Older revision		Revision as of 09:29, 22 March 2026
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	*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>		*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"/>		*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, though they may appear years to decades later		*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		*Midline incisions carry the highest risk; non-midline (lateral, subcostal, Pfannenstiel, trocar site) hernias are less common but do occur
	*Risk factors for development:<ref name="statpearls"/>		*Risk factors for development:<ref name="statpearls"/>
	**Surgical: midline incision, wound infection, emergency surgery, re-operation, improper fascial closure technique		**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)		**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		*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'''
Line 17:		Line 17:
	==Clinical features==		==Clinical features==
	===Uncomplicated (reducible)===		===Uncomplicated (reducible)===
	*Visible or palpable ~~'''~~bulge at the incision site~~'''~~ — more prominent with Valsalva, coughing, standing		*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		*May be asymptomatic or cause mild discomfort, pulling sensation, or intermittent pain
	*Positive ~~'''~~cough impulse~~'''~~ on palpation		*Positive cough impulse on palpation
	*Bulge reduces spontaneously or with gentle pressure when supine		*Bulge reduces spontaneously or with gentle pressure when supine

	===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)
Line 31:		Line 31:
	===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
	*Leukocytosis, elevated lactate		*Leukocytosis, elevated lactate
Line 57:		Line 57:
	**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)
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	**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
	**Provide analgesia; ~~'''~~procedural sedation~~'''~~ may be necessary to relax the abdominal wall		**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		**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)		*After successful reduction: observe for signs of bowel compromise (pain, peritoneal signs, tachycardia)
	*Arrange ~~'''~~elective surgical referral~~'''~~ for definitive repair		*Arrange elective surgical referral for definitive repair

	===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"/>

	===Strangulated hernia===		===Strangulated hernia===
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	**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:
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	**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
	**Bowel obstruction requiring decompression and observation		**Bowel obstruction requiring decompression and observation
	*~~'''~~Emergent surgery:~~'''~~		*Emergent surgery:
	**Strangulated hernia (skin changes, systemic toxicity, elevated lactate, peritoneal signs)		**Strangulated hernia (skin changes, systemic toxicity, elevated lactate, peritoneal signs)
	**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"/>

	==See also==		==See also==