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Introduction: A hernia is the abnormal exit of tissues or
an organ through the wall of cavity in which it normally reside. In the modern
world with an increase in the number of surgeries performed, the incisional
hernias have emerged as an important concern in any post-surgical abdomen.
Overall, the incidence of the incisional hernia reported world-wide is 3% to
20%.
Materials and methods: The study was conducted in SMHS
Hospital of Government Medical College, Srinagar. All patients presenting form
2014 to 2018 in the surgical OPD of the hospital with Incisional hernia were
included in the study. A detailed enquiry of risk factors like obesity,
hypertension, diabetes mellitus and malignant disease, number of previous
surgeries and nature of previous abdominal surgery was recorded and the data
was systemically recorded and statistically analysed.
Results and observations: In a total of 300 patients
included in our study, 63 were males and 237 were females. While majority of
patients were in the age group between 30 and 60 years, the mean age was 48.5 ±
12.1 years. Majority of the patients had an incisional hernia following a
pelvic surgery by an infraumblical midline incision; LSCS in 65.8% of females
and abdominal hysterectomy in 12.6% of patients. Most common comorbidities in
our patients with incisional hernias were BMI>35 kg/m2 in 25.6%
of the patients followed by both diabetes and hypertension in 19% of the
patients and diabetes and hypertension in 12.3% and 17.6% of patients,
respectively.
Conclusion: We concluded that in patients with high risk
of incisional hernia a proper attention to the suture technique, i.e., mass and
continuous suture, use of non-absorbable suture material, closure by a senior
surgeon, better preparation of the operative field and scrupulous sterility
throughout the procedure in order to decrease the incidence of post-operative
wound infection should be followed strictly so as to minimize the occurrence of
this preventable post-surgical complication of the wound.
Keywords: Hernia, Incisional hernia, Laparoscopic
INTRODUCTION
A hernia is the abnormal exit of tissues or
an organ through the wall of cavity in which it normally reside (often
involving the intestine at a weak point in the abdominal wall). Abdominal wall
hernias occur only at sites where aponeurosis and fascia are not covered by
striated muscles. Groin hernias are most common type of hernia other hernias
include hiatus, incisional and umbilical. In the modern world with an increase
in the number of surgeries performed, the incisional hernias have emerged as an
important concern in any post-surgical abdomen. Incisional hernia develops in
the scar of a wound in the abdominal wall, which was inflicted during previous
surgery. Overall, the incidence of the incisional hernia reported world-wide is
3% to 20% [1,2]. However, different areas have different incidences. Till now,
there is very limited data available on the incidence of abdominal incisional
hernia in developing countries. We performed a study to assess the incidence of
this disease and the possible risk factors for the disease prevalent in this
part of the world.
MATERIALS AND
METHODS
The study was conducted in SMHS hospital of
Government medical College Srinagar. All patients presenting form 2014 to 2018
in the surgical OPD of the hospital with Incisional hernia were included in the
study. A detailed history and clinical examination of all patients was
obtained. A detailed
RESULTS AND
OBSERVATIONS
In a total of 300 patients included in our
study, 63 were males and 237 were females. Pie chart below shows the sex
distribution of patients in our study (Figure
1).
In our study, majority of patients were in
the age group between 30 and 60 years with a mean age of 48.5 ± 12.1 years. The
table shows the age distribution of patients in our study (Table 1).
In our study majority of the patients had an
incisional hernia following a pelvic surgery by an infraumblical midline
incision; LSCS in 65.8% of females and abdominal hysterectomy in 12.6% of
patients. Figure 2 below shows the
nature of the surgery leading to incisional hernias in our patients.
Figure below shows the co-morbidities noted
in the patients included in our study. Approximately 26.3% of patients in our
study had BMI more than 35 Kg/m2 (Figure 3).
DISCUSSION
Incisional hernia is one of the commonest
complications of abdominal surgery. Incisional hernia can develop at different
times from surgery, however, majority of Incisional hernias about 90% occur
during the first 3 year of surgery [3]. It varies between 11% and 20% in
uncomplicated wounds [4-6]. In this study, we studied the demography of
patients presenting with incisional hernia. In our study, majority of patients
were females. In a total of 300 patients, 79% were females and 21% were males.
Ellis et al. [7] also obtained an incidence of 64.6% of incisional hernia in
female population in their study of 383 patients. Malviya et al. [8] also had
incisional hernia in 34.42% of male and 65.57% of female patients with overall
M: F ratio 1:2 approx. confirming a female preponderance of incisional hernia
as noted in our study.
In our study, we observed that incisional
hernia was particularly common in 41 to 50 year age group followed by 51 to 60
year and 31-40 year age groups with an incidence of 32.33%, 24% and 22.67% of
incisional hernias respectively. Malviya A et al in their study on incisional
hernia also observed that the incidence of incisional hernia was maximum in the
age group of 31-60 years (67.21%) [8]. The mean age of patients in our study
was 48.5 ± 12.1 years. This is in accordance with the study of Ellis, Gajraj
and George who also noticed a mean age of 49.4 years in their study on
Incisional hernias [7].
In our study we noticed that while incisional
hernia was more common in females than males. Majority of females had an
incisional hernia following LSCS (65.8%) and abdominal hysterectomy (12.5%)
through an infra-umbilical midline incision. Emergency laparotomy accounted for
about 20.6% cases of incisional hernias. Open cholecystectomy and appendectomy
accounted for 3.6% to 4.6% Incisional hernias. In our study, we also noted 4
port site hernias following laparoscopic procedures. All such cases occurred
through the umbilical port. Malviya et al. [8] in their study on incisional hernia
also noted that approximately 50% of the patient with incisional hernia had
undergone a gynaecological procedure, among which caesarean section the
commonest operation was followed by abdominal hysterectomy. Mingoli et al. [9]
also in their study noted 18.1% incidence of incisional hernia following
emergency laparotomies. Purushothaman et al. [10] in their study on incisional
hernias also noted a very low incidence of incisional hernias after elective
surgeries and open appendectomies (8.1%). Julie et al. [11] in their study
noted the incidence of port site hernias via extended 5 mm ports to be around
0.1 to 5% which is comparable with our results of 1.3% incidence via 10 mm port
sites.
In our study, we observed that the most
common comorbidities in our patients with incisional hernias were BMI>35
kg/m2 in 25.6% of the patients followed by both diabetes and
hypertension in 19% of the patients and diabetes and hypertension in 12.3% and
17.6% of patients, respectively. Sidhu et al. [12] also observed in their study
that diabetes, hypertension (HTN) and body mass index (BMI) had persistent
significant positive associations with the development of an incisional hernia.
CONCLUSION
From this study, we concluded that the rate
of incisional hernia is higher after an emergency midline laparotomy than after
elective procedures. And the risk is particularly high in females undergoing
pelvic surgeries with comorbidities like BMI>35 kg/m2, Diabetes
mellitus and hypertension. Therefore from the observations of this study, we
suggest that in such patients a proper attention to the suture technique, i.e.
mass and continuous suture, use of non-absorbable suture material, closure by a
senior surgeon, better preparation of the operative field and scrupulous
sterility throughout the procedure in order to decrease the incidence of
post-operative wound infection should be followed strictly so as to minimize
the occurrence of this preventable post-surgical complication of the wound.
1.
Adesunkanmi AR,
Faleyimu B (2003) Incidence and aetiological factors of incisional hernia in
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Brown SR, Goodfellow PB
(2005) Transverse verses midline incisions for abdominal surgery. Cochrane
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Mudge M, Hughes LE
(1985) Incisional hernia: A 10 year prospective study of incidence and
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incisional hernia. J Visc Surg 149: e3-14.
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Reines HD, DeMaria EJ, Newsome HH, et al. (1996) Greater risk of incisional
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with prefascial polypropylene mesh. Am J Surg 171: 80-84.
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Müller-Riemenschneider
F, Roll S, Friedrich M, Zieren J, Reinhold T, et al. (2007) Medical
effectiveness and safety of conventional compared to laparoscopic incisional
hernia repair: A systematic review. Surg Endosc 21: 2127-2136.
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Ellis H, Gajraj H,
George CD (1983) Incisional hernias - When do they occur? Br J Surg 70: 290.
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Ajay M, Arvind P,
Girish B, Hitesh PB, Vivek S (2017) A comprehensive study on the incidence and
management of incisional hernia Int Surg J 4: 2303-2307.
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Mingoli A, Puggioni A,
Sgarzini G, Luciani G, Corzani F, et al. (1999) Incidence of incisional hernia
following emergency abdominal surgery. Ital J Gastroenterol Hepatol 31:
449-453.
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Rubby S, Emmanuel Stephen J (2016) Clinical study of incidence and surgical
management of incisional hernia. Int Surg J 3: 1875-1878.
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Julie LH, Jeffery SC,
James G, Dermot H, Sean MJ, et al. (2016) Incidence of port-site hernias: A
survey and literature review. Surgical Laparoscopy, Endoscopy &
Percutaneous Techniques 26: 425-430.
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Sidhu A, Siedler D,
Turner R (2017) Factors affecting the development of ventral incisional hernia
post abdominal surgery: a retrospective cohort study. Int Surg J 4: 3225-3227.
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