Abdominal surgical incisional hernia is a common complication after abdominal surgery, and its development is often associated with incisional infection, improper surgical operation, increased intra-abdominal pressure and other systemic factors such as malnutrition, jaundice, obesity, and use of steroid hormones.
I. Classification of incisional hernia in abdominal surgery
The classification of abdominal surgical incisional hernia should include two parts: the size of the hernia ring defect and the site of the hernia ring defect.
According to the size of the hernia ring defect, it is classified as
(1) small incisional hernia: the maximum distance of the hernia ring < 3 cm
(2) Medium incisional hernia: the maximum distance of the hernia ring is 3 to 5 cm
(3) Large incisional hernia: the maximum distance of the hernia ring is 5 to 10 cm
(4) Giant incisional hernia: maximum distance of hernia ring ≥ 10 cm
According to the location of the hernia ring defect is divided into
(1) midline incisional hernia
(2) lateral abdominal wall incisional hernia (including subcostal incisional hernia, inguinal area incisional hernia and intercostal iliac incisional hernia).
Treatment of abdominal surgical incisional hernia
Abdominal surgical incisional hernia cannot heal by itself, and all of them need surgical treatment. For patients with poor general condition, cardiopulmonary insufficiency or other medical comorbidities, active preoperative preparation should be performed before choosing the timing of surgery.
1. Surgical timing selection.
For primary and recurrent incisional hernias without a history of incisional infection, repair surgery is recommended 3-6 months after incisional healing; for primary and recurrent incisional hernias with a history of incisional infection, repair surgery is recommended 1 year after infection control and incisional healing; for recurrent hernias with infection that have undergone repair surgery using repair materials, repair should be performed 1 year after incisional healing, and it is recommended that subcutaneous tissue from the original infected incision be taken for bacterial culture before reoperation. It is recommended to take the subcutaneous tissue of the original infected incision for bacterial culture before reoperation, and if it is negative, new material can be used for repair; if it is positive, antibiotics should be used for treatment, and surgery should be performed after the bacterial culture is negative. Abdominal surgical incisional hernias with contaminated wounds are repaired with direct sutures. If the defect is large, it can be repaired with autologous tissue graft or with absorbable artificial material. If the trauma is not heavily contaminated, it can be repaired with polypropylene mesh under adequate preoperative preparation, and repair with PTFE and its composite materials is not recommended. In principle, non-absorbable materials are not used simultaneously to repair abdominal surgical incisional hernias during emergency surgery.
2. Surgical method selection.
small incisional hernia: continuous sutures with 1-0 Prolene thread are recommended to close the hernia ring defect, and the ratio of the length of the sutures used to the length of the incision is preferably 4:1.
medium incisional hernias: direct sutures can be used, but repair with repair material is required when tension is present in the pulling together of the concomitant tissue
Large and giant incisional hernias: best repaired with repair material.
Perioperative treatment
1. Preoperative preparation.
Actively manage systemic diseases accompanying patients with incisional hernia of abdominal surgery. Closely detect respiratory function, including routine chest X-ray and determination of pulmonary function and blood gas analysis. For patients with respiratory insufficiency, adequate preoperative preparation should be performed: for patients with lung infection, preoperative antibiotic treatment should be applied, and surgery should be performed 1 week after infection control. Thoracic and diaphragmatic calcification by deep breathing. Smokers should stop smoking 2 weeks prior to surgery. For giant incisional hernia, preoperative abdominal dilation and abdominal muscle compliance training should be performed to prevent respiratory failure and abdominal compartment gap syndrome after the hernia contents are returned to the abdominal cavity. The hernia contents can be returned to the abdominal cavity 2 to 3 weeks before surgery, and the abdomen should be ligated with a lap band. During the initial period of ligature, the respiratory function of the patient should be closely observed to prevent sudden respiratory failure. In the first week, blood gas analysis should be performed every other day and lung function measurement should be performed once every 3 days. In the second 2 weeks, these tests can be extended according to the patient’s condition. After 2 to 3 weeks of preparation, the patient’s lung function and blood gas analysis results can be operated when they meet the aforementioned criteria.
2. Pre-operative prophylactic antibiotic use.
Prophylactic application of antibiotics can significantly reduce the rate of abdominal surgical incisional hernia infection, especially for patients of advanced age, diabetes mellitus, immunocompromised, huge or multiple re-incisional hernias, repair with large biomaterials and incisions that may suffer from gastrointestinal bacterial contamination, prophylactic antibiotics should be routinely administered.
3. Postoperative management.
(1) Postoperative antibiotics should be administered for 2 to 3 d, or according to the patient’s condition.
(2) To ensure the patency and sterility of the closed drainage. Drainage should be removed within 3 to 5 days after surgery according to the amount of drainage (less than 10 ml/ d). If the surgical wound is large and there is a lot of drainage, the extraction time can be extended appropriately. After the drainage is removed, attention should still be paid to the presence of local fluid and blood accumulation, and aspiration should be performed at any time when fluid and blood accumulation are found.
(3) Pay attention to the change of body temperature and check the wound frequently after surgery. If the body temperature still continues to rise and the wound is red and swollen after surgery, be alert to the occurrence of wound infection and give antibiotic treatment and pay attention to local treatment.
(4) In the early postoperative period, patients can move around in bed and walk on the ground after 2-3 days. The lap band should be applied with pressure for 2 weeks after surgery and continue to be used for 3 to 6 months. Strenuous activities and heavy physical labor are prohibited for 3-6 months after surgery.