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INCISIONAL HERNIA IN PREGNANCY : A REVIEW AUTHOR: SUJOY DASGUPTA POST GRADUATE STUDENT, M.D.(OBSTETRICS & GYNECOLOGY) EDEN HOSPITAL, MEDICAL COLLEGE, KOLKATA, INDIA Background A postoperative ventral abdominal wall hernia, more commonly termed incisional hernia, is the result of a failure of fascial tissues to heal and close following laparotomy.1 Such hernias can occur after any type of abdominal wall incision, although the highest incidence is seen with midline and transverse incisions.2 Similarly, the remote complication of a caesarean section could be an incisional hernia due to defective abdominal wound healing and herniation of gravid uterus through the abdominal wall.15 Herniation of gravid uterus has been reported sporadically as incisional hernia and umbilical hernia of pregnancy. The importance of abdominal hernias in relation to pregnancy is perhaps not sufficiently understood because of their infrequent occurrence.16 They do, however, occasionally become a real obstetric problem, when complications like herniation of gravid uterus leading to incarceration, strangulation, or burst abdomen develop.20–23, 30 Herniation of gravid uterus is probably rare because of the fact that by the time the uterus reaches the level of hernial aperture, it is usually too large to enter the hernial sac.24 There may be potential complications like spontaneous abortion, preterm labor, accidental hemorrhage, intrauterine fetal death, and rupture of lower uterine segment during labor.20 –24, 17 An infrequent but more serious complication is incarceration of gravid uterus with or without strangulation along with ulceration and excoriation of the overlying skin and bleeding from the ulcerated area leading to shock.20–25, 32., Excessive stretching of the skin may cause this type of ulceration due to friction between the hernia sac and other parts of the patient’s body.26
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Incidence Modern rates of incisional hernia range from 2-11%.3-5 While it was once believed that the majority of incisional hernias presented within the first 12 months following laparotomy, longer-term data indicate that at least one-third of these hernias will present 5-10 years postoperatively.1 Multiple risk factors exist for the development of an incisional hernia. Some of these risks are under the control of the surgeon at the initial operation, while many others are patient-specific or related to postoperative complications. Patient-specific risks for postoperative ventral hernia include advanced age, malnutrition, presence of ascites, corticosteroid use, diabetes mellitus, cigarette smoking, and obesity.2-8 Emergency surgery is known to increase the risk of incisional hernia formation. Wound infection is believed to be one of the most significant prognostic risk factors for development of an incisional hernia.2,9 It is for this reason that many surgeons advocate aggressive and early opening of the skin closure to drain any potential infection at the fascial level. Postoperative sepsis has also been identified as a risk for subsequent incisional hernia.1 Technical aspects of wound closure likely contribute to incisional hernia formation. Wounds closed under excessive tension are prone to fascial closure disturbance. Therefore, a continuous closure is (Continued on page 19)
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advocated to disperse the tension throughout the length of the wound. In this way, 1-cm bites of fascia on either side of the incision are taken with each pass of the suture and the suture is advanced 1 cm at a time along the length of the incision. The type of incision may affect hernia formation. Studies have shown that transverse incisions are associated with a reduced incidence of incisional hernia compared to midline vertical laparotomies, although the data are far from conclusive.7,10 The remote complication of a caesarean section could be an incisional hernia due to defective abdominal wound healing and herniation of gravid uterus through the abdominal wall.16 Thus Csection accounted for most of the incisional hernia, accounting for 3.1% of all cesarean sections.33 The incidence of incisional hernia after CS was similarly influenced by midline vertical incision, the need for additional operative procedures, more potent and higher quantities of antibiotic administration, postoperative abdominal distension, intra-abdominal sepsis, residual intra-abdominal abscess, wound infection, wound dehiscence, postoperative fever, and abdominal incision of previous cesarean section healing with secondary intention.20,21,24,34 A search of the literature reveals only 15 reported cases of anterior abdominal wall hernias complicated by pregnancy, of which 8 developed incarceration with or without subsequent strangulation.20–23,25,27–29 Cases with variable onset of herniation at gestation ranging from 4 to 8 months have been reported in the literature.20,26,30,32 Incisional hernia in twin pregnancy has also been described in literature. 40 Diagnosis Diagnosis of a gravid uterus in an incisional hernia is made by the history of hernia between pregnancies, presence of an unusual bulge of the abdomen with stretched skin,24,28 and easily palpable uterus and fetal parts.26,31 Imaging studies like ultrasound and magnetic resonance imaging can also assist in diagnosis.26,23 possible factors associated with incarceration and strangulation are advancing age of gestation, polyhydramnios, and twin pregnancy.21 If there is incarceration, the uterus would be irreducible without any other symptoms; if there is strangulation, the patient can have severe abdominal pain and vomiting.21,22 Management The treatment of ventral incisional hernia is operative repair.1 The major sequel from operative repair of the incisional hernia is hernia recurrence, and there are convincing data that placement of mesh to repair the hernia defect has decreased the high recurrence rate historically associated with primary suture repair to less than 25%.11,12 The use of sheets of non-absorbable prosthetic mesh placed across the incisional hernia defect and sutured to the abdominal wall is routinely employed in the modern era. It is associated with a low incidence of perioperative complications and lower rates of recurrence than open, non-mesh repairs. Unfortunately, even with mesh repair, hernia recurrence remains a significant complication. In one multicenter trial, for example, 200 patients were randomly assigned to suture or mesh repair of a primary hernia or a first recurrence of hernia at the site of a vertical midline incision.13 The 3-year cumulative rates of recurrence among patients who had suture or mesh for repair of a primary (Continued on page 20)
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hernia were 43% and 24%, respectively. The rates of second recurrence were 58% and 20%, respectively. Many variations of mesh repair for the incisional hernia have been described. The mesh is cut to the shape of the hernia defect with a margin added circumferentially around the mesh to suture to healthy surrounding fascia. The mesh is sutured to the fascial layer either deep to the peritoneum or between the peritoneum and the abdominal wall. Alternative techniques have been described that suture pieces of mesh to fascia from both intra- and extra peritoneal planes.1 The evolution of ventral hernia repair has advanced from open mesh repair to the application of mesh repair to the laparoscopic approach. In this technique, the defect is repaired posteriorly and no dissection within the scarred layer of anterior fascia is required. The laparoscopic approach may also allow for identification of additional hernia defects in the anterior abdominal wall during the repair.14 Incisional hernia in pregnancy is also notorious for recurrence after surgical repair. Recurrence of hernia in subsequent pregnancies has also been described in 1 patient, in whom 3 consecutive pregnancies were managed successfully with use of abdominal binder but the fourth pregnancy was complicated by incarceration, strangulation, and ulceration of the overlying skin, culminating in cesarean section.22 The management of these pregnant patients with incisional hernia poses a dilemma as no consensus approach has been described. A conservative approach, including manual reduction of hernia and use of an abdominal binder during the antenatal period and labor, has been applied with varying success.20,22,24,32 Surgical intervention in the form of antenatal hernial repair in the second and third trimesters has also been undertaken in 2 patients by carrying the pregnancy to term and allowing for normal vaginal delivery.21,22 This approach, however, is associated with a significant risk of anesthesia and surgical intervention during pregnancy. Moreover, the enlarged uterus itself may hinder optimal herniorrhaphy, and further enlargement with advancing gestation may disrupt the hernia repair.24 Herniorrhaphy can be performed during pregnancy if there is evidence of morbid incarceration, strangulation or the skin is necrosed.18, 21,32 Strangulation at or near term appears to be a genuine indication for early hospitalization and elective cesarean section, possibly combined with hernial repair, which has successfully been applied in 2 patients.22,24 Normal vaginal delivery has been accomplished in pregnant patients with uterus lying in a hernia.21,32 However, some are of view that Caesarean section should be performed and herniorrhaphy can be performed during the caesarean section.16 Other people are of view that Incisional hernia during pregnancy is not an indication for cesarean section per se.19 It may not be feasible to perform LSCS in some patients due to unusual shape and contour of the uterus and an inapproachable lower segment; for these patients, a classic approach may be easier.22,23 Great care must be taken to avoid injuring any vital structures during incision of the abdomen, such as the small or large bowel, as it can be contained in the hernial sac, and the skin and peritoneum covering it may be very thin.35 Many studies in the literature have focused on the role of type of repair, mesh repair v/s suture repair (without mesh), in patients with hernias. Among patients with midline abdominal incisional hernias, mesh repair is superior to suture repair in preventing recurrence of hernia, regardless of the size of the hernia.36,37 The role of abdominal binder during the postoperative period is not known. (Continued on page 21)
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The component separation technique (CST) has proven to be effective for the treatment of those giant abdominal hernias in which prosthetic material utilization is not indicated. We report the case of a woman who presented at 38 weeks of gestation with non-reducible herniation of the pregnant uterus through an anterior abdominal wall incisional hernia treated with CST immediately after caesarean section. 40 Conclusion It is noted that a reduction of the frequency of occurrence of incisional hernia and its complications in female patients can be achieved through a combination of health education and sound surgical technique with good wound care.38 Conservative management until term is recommended, and herniorrhaphy should be postponed until after the delivery as optimum repair is not possible during the antenatal period because of gravid uterus. But if strangulation of the uterus occurs at or near term, emergency laparotomy cesarean delivery followed by repair of hernia may be the best option.19 Thus, the management of pregnant patients with uterus lying in incisional hernia needs to be individualized depending upon the severity of complications and the gestational age at presentation and successful treatment needs multidisciplinary approach. References 1. Michael J Zinner, Stanley W Ashley. Maingot’s Abdominal Operation. 11th Edition. Part IIAbdominal wall. Chapter 5- Hernias. 2. Bucknall TE, Cox PJ, Ellis H. Burst abdomen and incisional hernia: a prospective study of 1129 major laparotomies. Br Med J 1982;284:931 [PubMed: 6279229] 3. Santora TA, Rosalyn JJ. Incisional hernia. Surg Clin North Am 1993;73:557 [PubMed: 8497803] 4. Mudge M, Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg 1985;72:70 [PubMed: 3155634] 5. Regnard JF, Hay JM, Rea S. Ventral incisional hernias: incidence, date of recurrence, localization, and risk factors. Ital J Surg Sci 1988;3:259 6. Read RC, Yoder G. Recent trends in the management of incisional herniation. Arch Surg 1989;124:485 [PubMed: 2649047] 7. Greenall MJ, Evans M, Pollack AV. Midline or transverse laparotomy? A random controlled clinical trial. Part I: influence on healing. Br J Surg 1980;67:188 [PubMed: 6988033] 8. Makela JT, Kiviniemi H, Juvonen T, et al. Factors influencing wound dehiscence after midline laparotomy. Am J Surg 1995;170:387 [PubMed: 7573734] 9. Gys T, Hubens A. A prospective comparative clinical study between monofilament absorbable and non-absorbable sutures for abdominal wall closure Acta Chir Belg 1989;89:265 [PubMed: 2530745] 10. Carlson MA, Ludwig KA, Condon RE. Ventral hernia and other complications of 1,000 midline incisions. South Med J 1995;88:450 [PubMed: 7716599] 11. Millikan KW, Baptisa M, Amin B, et al. Intraperitoneal underlay ventral hernia repair utilizing bilayer ePTFE and polypropylene mesh. Am Surg 2003;69:258 12. McLanahan D, King LT, Weems C, et al. Retrorectus prosthetic mesh repair of midline abdominal hernia. Am J Surg 1997;173:445 [PubMed: 9168086] 13. Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 2000;343:292 (Continued on page 22)
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14. Thoman DS, Phillips ES. Current status of laparoscopic ventral hernia repair. Surg Endosc 2002;16:939 [PubMed: 12163959] 15. Chaudhuri S , Mitra S N , Daga A , Bandopadhyay D. Gravid uterus in an anterior abdominal wall hernia and successful repair at the time of Caesarean Section.www.bjmp.org › BJMP Dec 2009 Volume 2 Number 4 16. Malhotra M,Sharma J B, Wadhwa L,Arora R. Successful pregnancy outcome after cesarean section in a case of gravid uterus growing in an incisional hernia of the anterior abdominal wall. Ind J Med Sci 2003,57: 501-03 17. Dare F O, Makinde OO, Lalwal OO. Gravid uterus in an anterior abdominal wall hernia of a Nigerian woman Int J Gynecol Obstet 1990;32:377-9 18. Deka D, Banerjee N, Takkar D. Incarcerated pregnant uterus in an incisional hernia. Int J Gynaecol Obstet 2000;70:377-9 19. Saha P K, Rohilla M,. Prasad G.RV.,. Dhaliwal L K, Gupta I,. Herniation of Gravid Uterus: Report of 2 Cases: Discussion- www.medscape.com/viewarticle/545167_4 20. Dare FO, Makinde OO, Lawal OO. Gravid uterus in abdominal wall hernia of a Nigerian woman. Int J Obstet Gynecol. 1990;32:377–379. 21. Fullman PM. Incisional hernia containing an incarcerated twin pregnant uterus. Am J Obstet Gynecol. 1971;111:308–309. [PubMed] 22. Boys CE. Strangulated hernia containing pregnant uterus at term. Am J Obstet Gynecol. 1945;50:450–452. 23. Wolfe WR. Egley CC, Saad EJ, Cusack T. Prefascial marsupialization of the pregnant uterus. Obstet Gynecol. 1988;71:1021–1023. 24. Banerjee N, Deka D, Sinha A, Prasrad R, Takkar D. Gravid uterus in an incisional hernia. J Obstet Gynaecol Res. 2001;27:77–79. [PubMed] 25. Thomson SW. Two unusual complications of umbilical hernia in pregnancy. Br Med J. 1962;2:1586. [PMC free article] [PubMed] 26. Malhotra M, Sharma JB, Wadhwa L, Arora R. Successful pregnancy outcome of cesarean section in a case of gravid uterus growing in an incisional hernia of the anterior abdominal wall. Indian J Med Sci. 2003;57:501–503. [PubMed] 27. Hassim AM, Khurana KM. Gravid uterus in an umbilical hernia. Cent Afr J Med. 1967;13:260–261. [PubMed] 28. Adetoro OO, Komolafe F. Gravid uterus in an umbilical hernia - report of two cases. Cent Afr J Med. 1986;32:248–251. [PubMed] 29. Awojobi OA, Itayemi SO. Abdominal incisional hernia in Ibadan. Trop Doc. 1983;13:112–114. 30. Ray KK, Aggarwal S, Banerjee K, Karan S, Charu C. Gravid uterus in an incisional hernia leading to burst abdomen. Internet J Gynecol Obstet. 2005;5:2–5. 31. Rao Radha S, Shankara Gowa HS. A case of herniated gravid uterus through a laparotomy scar. Indian J Med Sci. 2006;60:154–157. [PubMed] 32. Nagpal M, Kaur S. Herniated pregnant uterus with bleeding from previous abdominal scar. J Obstet Gynaecol India. 2003;53:283. 33. Sahu L, Bupathy A. Evisceration of pregnant uterus through the incisional hernia site. J Obstet Gynaecol Res. 2006;32:338–340. [PubMed] 34. Adesunkanmi ARK, Faleyimu B. Incidence and aetiological factor of incisional hernia in past cesarean operations in a Nigerian hospital. J Obstet Gynecol. 2003;23:25–26. 35. Kingsnorth A, LeBlanc KA. 3rd ed. London/New York: Arnold Press; 2003. Management of (Continued on page 23)
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Abdominal Hernias; pp. 262–279. 36. Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med. 2000;343:392–398. [PubMed] 37. Israelsson LA, Smedberg S, Montgomery A, Nordin P, Spangen L. Incisional hernia repair in Sweden. Hernia. 2006;10:258–261. [PubMed] 38. Dare FO, Lawal OO. Experience with 29 cases of female ventral incisional hernias in Ile-Ife, Nigeria. PubMed 1683298 39 Palazzo F, Ragazzi S, Ferrara D, Piazza D. Herniated gravid uterus through an incisional hernia treated with the component separation technique. Pubmed- 19436952 40. Fullman PM. An incisional hernia containing an incarcerated twin pregnant uterus. Pubmed 5098603 41. Augustin G, Matosevic P, Kekez T, Majerovic M, Delmis J. Abdominal hernias in pregnancy. J Obstet Gynaecol Res. 2009 Apr; 35(2):203-11.
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