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Incisional hernias and trocar hernias

hernienzentrum Dr.Med.Enrico Pöschmann
hernienzentrum 13-Oct. 2022

Incisional hernias and trocar hernias as late consequences of operations in the abdominal and thoracic region

For successful treatment, it is important that these are quickly closed surgically before internal organs become trapped or the weak spot can open up further.

Vizeral surgery, especially abdominal wall surgery, always involves a certain risk. In about 10 to 20 % of cases, scar hernias can develop at the suture points inside the abdomen in the months or years that follow. This is caused by sutures that have never healed properly. This is particularly common with sutures on the enveloping layer of the muscles. Over time, these sutures can open partially or even completely and lead to weaknesses in the abdominal wall. In addition, the scar tissue does not have the same strength and elasticity as the regular tissue and the risk is greater there that a hernial orifice can form at these points. The peritoneum and internal organs can then be pushed out of the abdominal cavity through the weak spot in the abdominal wall. Because these bridges occur in the area of scars from a previous operation, they are called incisional hernias.

What promotes incisional hernias?

The surgeon's cutting technique, the suturing technique and the suture material used all have an influence on the development of incisional hernias. Far more important factors, however, come from the patient. A high proportion of fatty tissue makes it more difficult for the surgeon to suture the wounds accurately, and severe obesity increases the pressure in the abdominal cavity, so that scar hernias develop more quickly. Diseases such as diabetes, wound healing disorders, collagen disorders or disorders in connective tissue metabolism also have a negative effect on scar healing. Smoking even increases the risk of scar hernias fourfold. In most cases, an incisional hernia does not pose a great risk to the patient, as long as it is treated immediately. However, if organs and intestines become trapped in the hernia, it can lead to intestinal obstruction, which can be life-threatening if not treated immediately.

Trocar hernias as a result of laparoscopic surgery

In the past, trocar hernias were much more common after major abdominal and thoracic surgery, because open surgery was usually performed. In the age of minimally invasive surgery, this has become much less common. However, laparoscopic surgery can cause so-called trocar hernias. Trocars are pin-shaped puncture instruments used to give the surgeon access to the body cavity. Surgical instruments or cameras can be inserted through the trocars, a kind of access tunnel into the abdomen or chest cavity. The risk of developing a trocar hernia is about 1 %, which is much smaller than that of an incisional hernia. But even these small openings can eventually cause scars in the tissue or weak points in the fascia. Tissue from the abdominal cavity can become trapped at these points and cause pain. Trocar hernias usually occur in the area of the navel or in the pit of the stomach, i.e. between the lower ribcage and the navel.

Bowel obstruction as a result of an incisional hernia

Large scars are much more dangerous than trocar accesses, because parts of the intestine can get stuck there, which in the worst case could lead to an intestinal obstruction. It is also possible that other internal organs will gradually be pushed through the weak points. If the corrective surgery is performed too late, it may even be difficult to close the abdomen properly again. It is especially important to recognise an incisional hernia at an early stage. If the patient has a corresponding protrusion in the area of a former surgical scar or pain at this point, he or she should have this clarified by a specialist immediately. Especially in the case of a possible intestinal obstruction, quick action is essential.

Procedure for the examination and treatment of incisional hernias

An ultrasound examination can be used to detect exactly where the scar has broken through and opened and how large the resulting gap is. In addition, a computer tomography may be necessary, during which the so-called Valsalva manoeuvre is performed. Here the patient presses lightly during the examination so that the entire extent of the hernia, i.e. the incisional hernia, becomes visible. How the operation is then performed in detail depends on the size of the incisional hernia and its contents, as well as the stage of acuteness and, of course, the patient's existing previous operations. Whenever possible, visceral surgery tries to correct the incisional hernia minimally invasively. In the case of large hernias, however, it is often necessary to open the old scar completely and aim for a complete new closure. In most cases, reinforcement by implanting a permanent or dissolvable plastic mesh is also necessary. Following this operation, the Hernia Centre usually advises a six-week rest period to relieve the abdominal muscles. After the stay in the clinic, the muscles must be built up and strengthened to achieve lasting stability. Do you possibly suffer from a trocar hernia or an incisional hernia? Or do you have problems with hernias? Contact the Hernia Centre - we will advise you competently and professionally.

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