Incisional hernia

　　Incisional hernia refers to a hernia that occurs at the site of an original abdominal surgical incision. Incisional hernia occurs due to poor incision healing and abnormal increase in abdominal pressure. Any factor that affects incision healing and any factor that can increase abdominal pressure can lead to the occurrence of incisional hernia. In addition to the basic elements of abdominal surgical incisions, it is also related to the following factors:

　　1. General factors

　　Old age, obesity, diabetes, malignant tumors, malnutrition, ascites, jaundice, systemic severe infection, shock, and the use of corticosteroid hormones can all affect incision healing.

　　2. Factors of increased abdominal pressure

　　Factors such as coughing, difficulty in defecation, difficulty in urination, and carrying loads can all increase abdominal pressure.

　　3. Local factors of the incision

　　The technique of closing and suturing incisions is very important. Incisional infection, gastrointestinal fistula, and other factors also affect incision healing. Incisional infection is the main cause of incisional hernia. After infection, the incision is secondary healing, with more scar tissue, and the abdominal wall has varying degrees of defects, with a significant decrease in the strength of the abdominal wall at the incision site. According to statistics, the incidence of incisional hernia after incisional infection is 5 to 10 times higher than that of primary healing incisions.

　　4. Other factors

　　Abdominal wall weakness or the presence of chronic diseases that increase intra-abdominal pressure is prone to induce incisional hernia, hence it is more common in elderly or obese patients. Other factors related to the original surgery include poor anesthetic effect during surgery, and the abdominal wall is not accurately matched during the process of forced approximation or suture.

　　Many factors can cause abnormal collagen metabolism in the body. Collagen is an important extracellular matrix that maintains the stability of the body's tissue structure. Recent studies abroad have shown that any factor that causes abnormal collagen metabolism will directly or indirectly affect the occurrence and development of abdominal wall hernia.

　　Since the contents of incisional hernia are usually intestines and omentum, their repeated friction with the hernia sac and each other is prone to adhesion, resulting in incomplete intestinal obstruction. During examination, a mass can be seen at the incision scar, with a diameter of a few centimeters for the smaller ones, and up to 10-20 cm or even larger for the larger ones. Instruct the patient to lie flat and insert fingers into the abdominal wall defect, then have the patient hold their breath to clearly palpate the hernia ring edge, understand the size of the defect and the strength of the edge tissue. Sometimes the hernia contents can reach the subcutaneous tissue. At this time, in the thinner parts of the skin, it is often possible to see intestinal patterns and intestinal peristaltic waves, and palpation can feel the gurgling sound of the intestinal tract. After the mass is复位, most can palpate the hernia ring edge formed by the abdominal muscle rupture. After the injury of the intercostal nerve of the abdominal wall, the abdominal muscle is weak due to relaxation, although there is local bulging, there is no clear mass edge, and there is no clear hernia ring that can be palpated. The hernia ring of incisional hernia is generally wide and large, and it rarely occurs with incarceration and strangulation.

　　Incisional hernia has no possibility of self-healing and has a significant impact on the overall condition. If not treated in time, most patients see the surrounding muscle, aponeurosis, fascia, and other tissues around the incision gradually weaken as the course of the disease progresses. The hernia ring enlarges, and the abdominal viscera increasingly protrude into the hernia sac outside the abdominal cavity, gradually developing into a large incisional hernia, which gradually reduces the actual abdominal cavity volume and makes the hernia sac become the 'second abdominal cavity' or 'extra-abdominal abdomen' to accommodate part of the abdominal viscera. In such cases, if tension repair is performed without adequate preparation, it may affect the respiratory and circulatory systems, especially in elderly patients with cardiovascular and pulmonary complications. Increased intra-abdominal pressure is one of the causes of incisional hernia. After the appearance of incisional hernia, the intra-abdominal pressure decreases. Once tension repair is performed, the intra-abdominal pressure may even increase even more than before, causing the diaphragm to elevate and leading to limited ventilation. At the same time, compression of the inferior vena cava may impede blood return, even leading to abdominal compartment syndrome and deep vein thrombosis.

　　The main manifestations of abdominal wall incision hernia are prominent hernia masses at the incision site when standing, which are more obvious when coughing or exerting force. Usually, the hernia ring is large, and the hernia mass can be spontaneously retracted and disappear when lying flat. If the hernia mass is large with a large number of visceral and tissue protrusions, there may be discomfort such as abdominal dull pain and dragging descent. Instruct the patient to lie flat, insert fingers into the abdominal wall defect, and then ask the patient to hold their breath to clearly palpate the hernia ring edge, understand the size of the defect and the strength of the edge tissue. When the abdominal wall defect is only covered by skin, intestinal peristalsis can be seen.

　　Abdominal wall incision hernia refers to a hernia that occurs at the site of an abdominal surgical incision. This type of hernia does not have a true hernia sac. It is more common in the area of abdominal longitudinal incisions, especially median incisions or pararectus abdominal incisions. The incidence rate accounts for about 1.7% of hernias and rarely occurs in primary healing incisions. Prevention is better than treatment for abdominal wall incision hernia. What are the preventive measures for abdominal wall incision hernia? The following introduces the preventive measures for this disease.

　　1. Carefully design the incision

　　To avoid incision hernia, clinical doctors should carefully design the incision according to the treatment goal, minimize the use of transrectus abdominis and pararectus abdominal incisions, and replace them with transverse incisions, median incisions, and para-median incisions.

　　2. Improve healing ability

　　Strengthen the patient's nutritional support, correct anemia and hypoproteinemia, supplement vitamin C, K, etc., improve the patient's general condition, and enhance healing ability.

　　3. Actively treat complications or complications

　　For complications or complications such as diabetes, coagulation mechanism disorders, respiratory dysfunction, liver dysfunction, and kidney dysfunction that affect tissue healing, active treatment should be given. Elective surgery must wait until the above conditions are corrected or controlled before surgery is performed.

　　4. Actively deal with factors that increase abdominal pressure

　　Before surgery, actively treat diseases that increase intra-abdominal pressure, such as pulmonary infection, chronic obstructive pulmonary disease, large amounts of ascites, constipation, or difficulty in urination. Prevent and deal with factors that increase intra-abdominal pressure after surgery, such as bloating, vomiting, hiccups, coughing, and sneezing, and at the same time, use an abdominal binder.

　　5. Prevent incision infection

　　Before surgery, actively treat the patient's skin, nasopharynx, and gastrointestinal tract infections. Shaving the surgical area may damage the skin or cause minor skin incisions, so it should be replaced with hair cutting or depilation methods, and the time from skin preparation to surgery should be kept as short as possible.

　　6. Adhere strictly to the principles of surgical surgery during the operation

　　(1) Strictly implement sterile operation techniques, correctly treat suppurative foci and necrotic foci of abdominal viscera strangulation, etc., to prevent incision contamination.

　　(2) Avoid the excessive power of the electrocautery to prevent the liquefaction of the incisional fat, which may affect the healing of the incision.

　　(3) Avoid rough movements to prevent excessive tissue damage, which may affect the healing of the incision.

　　(4) Thorough hemostasis to avoid hematoma at the incision, which may hinder the healing of the incision.

　　(5) Properly align the tissue layers to prevent the formation of ineffective cavities; the suture thread should not be too thin, and the suture should not be too loose or too tight. The knot should not be too loose. When suturing the fascia, the entry and exit points should not be too close to the incision edge. In addition, continuous suturing has a strangulating effect on the local tissue, and once a break occurs, the entire line becomes loose, so it is best to choose interrupted suturing.

　　(6) Estimate the possibility of infection at the incision, and perform secondary suture if necessary.

　　(7) Avoid leaving drain materials at the incision. If it is necessary to leave a drain, it should be punctured out through a stab incision.

　　(8) The operation should be performed under good anesthesia, and it is forbidden to pull the peritoneum tightly during peritoneal suture to avoid excessive tearing of the peritoneum.

　　(9) If necessary, use tension-reducing suture.

　　7. Rational use of antibiotics.

　　The above are the preventive measures for incisional hernia of the abdominal wall, which are very helpful for understanding this disease. Active and scientific prevention will reduce the occurrence of this disease, and only by actively preventing diseases can we stay away from them.

　　Incisional hernia (incisional hernia) refers to the hernia that occurs at the site of abdominal surgery incision, which has no true hernia sac. Then, what kind of examination should be done for incisional hernia?

　　The examination of incisional hernia of the abdominal wall mainly involves a careful physical examination of the patient. During the examination of incisional hernia, small masses at the scar of the incision can be a few centimeters in diameter, while larger ones can reach 10-20 cm, even more. Sometimes, the contents of the hernia can reach subcutaneous tissue, at this time, it is often seen that there are intestinal shapes or peristaltic waves, and touching it can feel the gurgling sound of the intestinal tract. After the mass is复位, most can feel the abdominal muscles. The incisional hernia caused by the abdominal wall rib intercostal nerve injury after the incision is weak, although there is local bulging, there is no clear mass edge, nor is there a clear hernia ring that can be touched. Since the hernia ring of incisional hernia is generally large and wide, it rarely occurs in incarcerated hernia.

　　Since the clinical symptoms of incisional hernia of the abdominal wall are relatively obvious, the diagnosis of the disease mainly depends on the patient's past surgical history. Most of the time, the diagnosis can be made through careful physical examination. If a more definite diagnosis is needed, it can be made through B-ultrasound examination, so that the results of the examination can be more clear.

　　Patients with incisional hernia of the abdominal wall should pay great attention to their diet and health care in their daily life. The method of food therapy can not only alleviate the pain of the patients but also supplement nutrition, strengthen the physical health of the patients, and enhance their immunity. Patients with incisional hernia should always remember the following dietary taboos and recommendations.

　　First, the foods that patients with incisional hernia of the abdominal wall should eat

　　1. To prevent infection and fever, green beans, rapeseed, toon, taro, earth ear, bitter melon, lily, crucian carp, malan head, and loach can be used.

　　2. Eat more grains, coarse grains, beans, and their products, fresh melons and fruits, vegetables, garlic, mushrooms, wood ear, onions, and fish, etc.

　　3. Eat more foods rich in vitamin A, B-group, and vitamin C, such as oranges, apples, tomatoes, and other fruits and vegetables.

　　Secondly, dietary taboos for patients with incisional hernia of the abdominal wall

　　1. Abstain from smoking, drinking, raw garlic, mustard greens, and other spicy foods.

　　2. In the early postoperative period when the gastrointestinal function has not fully recovered, try to eat less gas-producing foods such as milk and sugar to prevent intestinal bloating. If coffee-colored fluid is discharged, it indicates bleeding in the gastrointestinal tract, and temporary fasting or administration of ice slurry should be prohibited until bleeding stops before eating.

　　3. Avoid high-salt foods. To avoid hypertension caused by the retention of sodium ions in the body.

　　4. Eat less shellfish, bamboo shoots, taros, and other easily allergic 'mushrooms'.

　　5. Eat less drinks and snacks containing chemicals, preservatives, and additives.

　　6. Avoid overly acidic, spicy, salty, and stimulating substances such as tobacco and alcohol.

　　The above are the dietary taboos for patients with incisional hernia of the abdominal wall, which are very helpful for scientific and reasonable treatment and health. Scientific and reasonable diet can shorten the recovery time.

　　The conventional method of Western medicine for treating incisional hernia of the abdominal wall is mainly surgical treatment, but for the elderly and weak and patients with chronic diseases that increase intraperitoneal pressure, elastic abdominal bands are used to prevent the hernia from protruding. The main consideration of this method is the physical condition and tolerance of the patient.

　　Before the operation, the doctor should analyze the cause of the disease and its symptoms in detail in combination with the patient's condition. If the cause of the disease continues to exist, there is a possibility of recurrence after the operation. In addition, obese patients should lose weight before surgery. In clinical practice, the surgery for incisional hernia of the abdominal wall is mostly simple repair and suture, and less hernioplasty is performed. Simple repair and suture surgery is because the incisional hernia usually has no complete hernial sac, and the hernial contents often protrude through the defect in the abdominal wall and are adherent to the superficial tissue of the abdominal wall, even to the skin. Therefore, it is advisable to make a diamond-shaped incision at the normal abdominal wall at the edge of the original incision to avoid injury to the organs adherent under the incision. The operation mainly involves separating adhesions, retracting the hernial contents, resecting the hernial ring and its surrounding scar tissue, and suture the abdominal wall in layers without tension. Sometimes, the fascia can also be overlapped and sutured to strengthen the abdominal wall.

　　However, it is not commonly used for hernioplasty. If the patient has a large incisional hernia, with excessive defects in the abdominal wall that cannot be sutured, autologous fascia lata, silk, or other synthetic fiber meshes can be inserted to repair the defects. It seems that different patients have different situations, and the surgical method should be selected in combination with the actual situation.