Incisional hernia

Introduction to incision Incisional hernia (incisional hernia) refers to the abdominal visceral organ or tissue protruding from the abdominal incision, is a common complication of laparotomy, the incidence of lower abdominal midline incision is higher, mostly occurs in the longitudinal incision area of the abdomen, seen in the incision, Infection, second-stage healing incision, a small number occurred in the absence of a slit rupture and appeared after a long time after surgery. The incidence is usually less than 1%, but the incidence of wound infection can reach 10%. basic knowledge The proportion of illness: the incidence rate of a specific population is 0.002%-0.003% Susceptible people: no specific population Mode of infection: non-infectious Complications: intestinal obstruction, abdominal pain, shock, blood in the stool

Incisional hernia

Causes

The incisional hernia is caused by the rupture or non-healing of the fascial layer deep in the surgical incision. It can be regarded as a delayed incision splitting or deep healing of the surface healing. Since the skin of the incision surface and the subcutaneous fat layer have healed, the tendon The membrane layer is cleaved. Under the action of intra-abdominal pressure, the viscera or tissue is exfoliated. The hernia sac may be the healed membrane that has healed, or it may be formed by gradual crawling after peritoneal rupture. The etiology and pathogenesis of incisional hernia The same as the slit split.

Age factor (20%):

Incisional hernia is more common in elderly patients, rarely occurs in young adults, the imbalance of protease and anti-protease ratio in the serum of the elderly, 1 anti-trypsin deficiency, tissue degeneration, especially long-term smokers, oxides in nicotine Oxygen free radicals can not only cause emphysema, but also accelerate, aggravate the fascia of the whole body, degeneration of the decidual tissue, the content of collagen and hydroxyproline in the degenerative tissue is significantly reduced, and the activity of oxidase is low, so that Is not hydroxylated to hydroxyproline, resulting in weak abdominal muscles, decidua and connective tissue, low ability to heal and resist intra-abdominal pressure, in addition, the role of obesity, malnutrition and high intra-abdominal pressure in the elderly It is also an important cause and predisposing factor for the high incidence of incisional hernia. There are many diseases in the elderly that cause increased intra-abdominal pressure, such as chronic cough, intractable constipation, enlarged prostate and huge intra-abdominal tumors. Sudden intra-abdominal pressure is as strong as violent. Coughing, forced bowel movements, etc. can cause the incision to split or partially split, or cause the formation of incisional hernia or aggravate the incisional hernia. Obesity not only affects wound healing, sometimes resulting in increased intra-abdominal pressure, one of the factors is the occurrence of incisional hernia.

Abdominal wall strength (10%):

Patients with weak abdominal wall are relatively prone to incisional hernia. When the incision is split and then sutured, it can be found that the suture has not broken or opened, but the fascia, the aponeurosis is cut by the suture, the incision is split and the incisional hernia occurs. The reason is that the incision fascia layer is not healed or the healing is delayed. The suture is caused by the fascia and the aponeurosis. The cutting force of the suture to the fascia and the aponeurosis is like the hanging line of the anal fistula. Cutting force, if the effect of healing at the cutting edge is not achieved, the cutting is completed, and the tissue is not healed, that is, the incision is split or the incisional hernia is formed, and the fascia and the diaphragm are too weak to be easily cut, and some fascia A weak incision, when the suture is sutured, the fascia can be cut with a little force. If the incision is not reduced, the incision will be split or the incision will be formed under the continuous intra-abdominal pressure. The obese patient is more likely to have an incision. Oh, it is also related to the lack of muscles and weak fascia.

Nutritional status (15%):

Malnutrition, such as anemia, hypoproteinemia, vitamin C deficiency, etc. can lead to incision edema, hypoxia, insufficient synthesis of procollagen, so that the incision or fascia does not heal and cause incision rupture or incisional hernia.

Abdominal primary disease (10%):

A large number of clinical observations have found that the primary intra-abdominal disease is closely related to the healing of the incision and the occurrence of incisional hernia. Especially, the incidence of elderly gastrointestinal malignant tumors is more, because the cancer directly affects digestion and absorption, and late bleeding, obstruction, ascites, etc. For systemic conditions, local healing ability has a greater impact, especially ascites spillover can directly hinder wound healing. The incidence of this disease is higher after intraoperative abdominal purulent diseases, such as acute appendicitis and incision incision after colon surgery. The incidence is higher, which is caused by bacterial growth in the abdominal wall incision, resulting in infection of the incision and affecting healing.

Diabetes (10%):

Diabetes can cause delayed healing of the incision, and the incision is relatively easy to infect and has the potential for incisional hernia, coagulopathy, respiratory failure, liver dysfunction, jaundice and uremia, due to weak tissue regeneration, wound healing Inadequate postoperative abdominal pressure caused by incisional hernia, chronic obstructive pulmonary disease or pulmonary infection may also be the cause of incisional hernia.

Other (5%):

Long-term application of adrenergic corticosteroids, immunosuppressive agents, anticoagulant drugs, etc., can cause the incision to heal due to poor healing of the incision.

Local factor

(1) Incision factors: lumbosacral origin occurred in longitudinal incision, but transverse incision was rare. Singleton statistically performed 3147 cases of transverse incision, 29 cases (0.92%) had incisional hernia, 6,000 cases of longitudinal incision, and incisional hernia in 131 cases (2.2 %), this is because: 1 there is an anatomical basis of the abdominal incision, that is, except for the rectus abdominis, the fibers of the abdominal wall and the fascia, the sheath and other tissues are mostly lateral, and the longitudinal incision of the abdomen is bound to Cutting these tissue fibers of the abdominal wall, when suturing these tissues, is affected by the lateral traction of the muscles, the sutures are easily slipped between the fibers, so the incision is prone to cracking, 2 the nutrient vessels and intercostal nerves near the incision are cut, and the incisions are made. The surrounding tissue loses nerve support and blood supply disorders, which reduces its strength, delays healing, and is prone to incisional hernia when abdominal pressure is increased.

In addition, some scholars believe that the location of the incision is also closely related to the occurrence of incisional hernia. Welsh (1966) counts 500 incisional hernias: 76% of the inferior incisional hernia (including 21% of the McDonald's incision), and 15% of the upper incisional hernia Other 9%, domestic Peng Jingsheng et al (2001) reported that 72 cases of incisional hernia, 86.11% occurred in the anterior abdominal wall longitudinal incision, 25% occurred in the right lower right median incision, 23.61% occurred in the right superior rectus abdominis incision, which may The posterior rectus sheath of the abdomen is incomplete, and the pressure in the abdomen is relatively high, which is easy to cause suture cutting, so it is easier to form an incisional hernia.

(2) Infection and drainage factors: Incision infection is one of the main causes of incisional hernia. After infection, the incision healed in the second stage, and there were many scar tissues. The abdominal wall may have different degrees of defects. The abdominal wall strength of the incision site was significantly reduced. According to statistics, the incision The incidence of incisional hernia after infection is 5 to 10 times that of the first-stage healing incision. The incisional hernia after the appendicitis in the Mc Burnry incision is almost caused by infection. Prevention of wound infection is an important measure to reduce the incidence of incisional hernia.

In addition, placing the drainage tube through the incision can affect the local healing, increase the chance of infection of the incision, and leave a weak point locally after the drainage tube is removed, which is easy to become a factor of incisional hernia formation.

(3) Technical factors: intraoperative aseptic operation is not strict, the operation method is rough and causes tissue damage, hemostasis caused by hemostasis, and poor suture technique can lead to incision infection and incisional hernia. We found that The low-grade physician's sutured abdominal wall incision has more incision splitting or incisional hernia. The reason is that the suture technique is an important factor. For example, the layers of the abdominal wall are not tightly aligned, and the local cavity is ineffective, which may cause infection or cracking of the incision. Open; needle spacing is too sparse or too dense, suture too dense to affect the local blood supply of the incision, thereby affecting healing, suture too sparse, in the case of the same incision tension, single needle suture is subjected to greater tension, easy to cut fascia, Moreover, when the suture is too sparse, the omentum is easy to protrude from the line, which not only affects the peritoneal healing, but also causes the small intestine and other internal organs to be ejected in the future; after surgery, the fascial tissue of the margin is prone to collagen decomposition and weakening. When the point and the needle point are too close to the fascia edge (marginal distance), the tensile strength is weakened, the space for the suture cutting fascia is reduced, and the fascia is more easily cut.

(4) Anesthetic factors: Abdominal surgery with epidural anesthesia may result in poor anesthesia. When closing the abdominal wall incision, it is necessary to forcibly suture the suture, and it is easy to cause tearing of the peritoneum and other tissues. the reason.

(5) Abdominal pressure factors: intestinal obstruction, massive ascites, difficulty in urinary defecation, and postoperative pulmonary infection or cough caused by chronic obstructive pulmonary disease can increase intra-abdominal pressure, increase the incision tension of the abdominal wall, and cause the incision inner layer The incision is caused by tearing.

Pathogenesis

1. Pathophysiology Abdominal incision Ankle ring is generally large, and there are few chances of incarceration and strangulation. The early hernia sac is incomplete. Over time, the peritoneum can crawl to form a complete hernia sac. Generally, the intestine and/or the omentum often form a difficult refractory sputum due to adhesion, and the peritoneum is healed and the fascia is split, and the peritoneal bulge forms a sac.

There is no possibility of self-healing in the incision, which has a great influence on the general condition. If not treated in time, most patients gradually increase with the disease course. The muscles around the incision, the diaphragm, the fascia and other tissues become weaker and the ankle ring increases. The intra-abdominal organs are more and more prominent in the hernia sac outside the abdominal cavity, and gradually develop into a huge incisional hernia, so that the true abdominal cavity volume is gradually reduced, and the hernia sac becomes a "second abdominal cavity" or "accommodating part of the abdominal organs." Abdominal abdomen", in this case, if the tension is not adequately prepared, it may affect the respiratory circulatory system, especially in elderly patients with cardiopulmonary complications. Increased intra-abdominal pressure is one of the causes of incisional hernia. After the incisional hernia appeared, the intra-abdominal pressure decreased. Once the tension was repaired, the intra-abdominal pressure increased even higher than the original, causing the diaphragm to rise, resulting in limited ventilation. At the same time, the inferior vena cava was compressed, the reflux was blocked, and even the abdominal cavity was caused. Gap syndrome and deep vein thrombosis.

2. Pathological classification There are three main types of incisional hernias: common incisional hernia, incisional hernia after laparoscopic puncture and temporary closure of the abdomen, the latter mostly occurring in cases of abdominal compartment syndrome, such as intestine In patients with rupture of the incision after the external hemorrhoid, due to the inability to suture in the second phase in time, the skin crawling covered the incision of the intestine and healed.

3. Degree classification: According to the size of the ankle ring, the abdominal wall incision can generally be divided into 3 types: 1 giant: diameter > 10cm. 2 medium: diameter 5 ~ 10cm. 3 small: diameter <5cm.

Incisional hernia prevention

1. Careful design of the incision In order to avoid the occurrence of incisional hernia, the clinician should carefully design the incision according to the purpose of treatment, and use the transabdominal rectus and rectus abdominis incision as much as possible, and replace it with a transverse incision, a median incision and a median incision.

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

3. Active treatment of complications or complications of diabetes, coagulopathy, respiratory dysfunction, liver dysfunction, renal dysfunction and other complications or complications that affect tissue healing, should be actively treated, elective surgery must be corrected Or control, and then perform surgery.

4. Actively deal with the factors that cause increased abdominal pressure. Preoperative treatment of pulmonary infection, chronic obstructive pulmonary disease, massive ascites, constipation or dysuria, etc., which cause increased intra-abdominal pressure, prevent and treat bloating and vomiting after surgery. Hiccups, coughing, sneezing, etc. cause increased intra-abdominal pressure, while using the abdominal band.

5. Prevent infection of the incision Before the operation, actively treat the patient's skin, nasopharynx, gastrointestinal tract infection, shaving in the operation area may damage the skin or cause tiny skin wounds. Shaping or hair removal should be used instead of shaving. It may shorten the time from preparation to surgery.

6. Strict surgical principles during surgery

(1) Strictly implement aseptic technique to correctly treat lesions such as suppurative lesions and abdominal necrosis of the abdominal organs to prevent contamination of the incision.

(2) Avoiding the power of the electric knife to substantially liquefy the incision fat and affect the healing of the incision.

(3) Avoid rough movements, prevent excessive tissue damage, and affect wound healing.

(4) Completely stop bleeding to avoid incision hematoma and prevent the incision from healing.

(5) Correctly align the organization level to prevent the formation of invalid cavity; the suture should not be too thin, the suture should not be too sparse or too dense, and the ligation should not be too loose; when suturing the fascia, the needle insertion point and the needle exit point should not be too close to the cutting edge. In addition, continuous suture has a strangulation effect on the local tissue, and a fracture causes the whole line to become loose, so try to choose intermittent suture.

(6) It is estimated that the incision may be infected, and a second-stage suture is required.

(7) Avoid indwelling the drainage material, and when it is necessary to keep the drainage, it should be pierced.

(8) The operation should be performed under good anesthesia. When the peritoneal suture is used, it should not be forcibly pulled to avoid the peritoneal tear.

(9) Use suture stitching if necessary.

7. Rational use of antibiotics.

Incisional hernia complications Complications, intestinal obstruction, abdominal pain, blood in the stool

(1) Intestinal incarceration: Under normal circumstances, the contents of the sputum (usually the intestine) can enter the sac through the ankle ring under the pressure of the abdominal cavity, and can be returned to the abdominal cavity by itself (or by external force). When various reasons (such as friction, adhesion, etc.) make the content of the reversible sputum suddenly unable to return, when the local lumps increase, it indicates that the intestinal incarceration is complicated, which is called incarcerated sputum, after the intestine is incarcerated The main clinical manifestations of intestinal obstruction,

(2) Intestinal tube strangulation: If the incarcerated sputum persists and cannot be treated and treated in time, the contents of the sputum (mainly the intestinal tract) have blood circulation disorders, intestinal obstruction, intestinal necrosis, and even intestinal perforation. , and concurrent with the strangulated hernia, the clinical manifestations of intestinal narrowing are:

1 paroxysmal, persistent, severe abdominal pain.

2 pulse increased, shortness of breath, increased white blood cell count and other shock performance.

2 peritoneal irritation (local tenderness, rebound tenderness, muscle tension, etc.), bowel sounds from hyperthyroidism to weakened or disappeared, can smell "gas over water", hematemesis (or bloody fluid), blood in the stool, the abdomen can be touched Swelling, bulging and mass, X-ray examination showed that the isolated intestine or small intestine with swelling and swelling in the abdomen changed, the intestinal lumen was widened, and the peritoneal effusion was obtained. The hemorrhagic fluid could be taken by abdominal puncture.

Incisional hernia symptoms Common symptoms Loss of appetite, abdominal wall incision, swelling, nausea and anxiety

Symptom

Abdominal wall protrusion at the incision of the abdominal wall is the main symptom. It is prominent or obvious when standing and exerting. It shrinks or disappears when lying down. When there are more organs and tissues protruding, the abdomen may have pain in the abdomen. Feelings and other discomforts, some patients may be accompanied by loss of appetite, nausea, anxiety, etc. Most of the contents of the incisional hernia may adhere to the extraperitoneal abdominal wall tissue and become difficult to relapse, sometimes with incomplete intestinal obstruction, a small number of ankle rings The patient can have an incarceration.

2. Physical examination

The incision scar is the same as the incision. Most of the incision is equal to the incision. The incisional hernia is smaller than the incision area. The content of the incision can reach the subcutaneous area. The subcutaneous fat layer is thin. The intestinal type or peristaltic wave can be seen. The paralyzed patient is lying flat and the tumor is reset. Use your fingers to reach the defect in the abdominal wall, and then let the patient hold your breath clearly and lick the edge of the ankle ring to understand the size of the defect and the strength of the edge tissue.

Incisional hernia examination

At the time of examination, the incision scar can be seen. The smaller ones are several cm in diameter, and the larger ones can reach 10-20 cm or even larger. Sometimes the contents of the sputum can reach the subcutaneous area. At this time, intestinal type or peristaltic waves are often seen, and the intestines can be felt. Sound, after the tumor is restored, most of them can touch the edge of the ankle ring formed by the splitting of the abdominal muscles. The abdominal wall of the abdominal wall is weakened by the abdominal muscles. Although there is local bulging, there is no clear lumps, and there is no clear. The ankle ring is accessible, and the ankle ring of the incision is generally wide and rarely incarcerates.

Abdominal incisional hernia generally does not require special examination, sometimes when the need to assess the primary disease before surgery, imaging can see the contents of the sputum, especially CT, can clearly see the continuity of the anterior abdominal wall, content Outcrop.

Incisional hernia diagnosis

Diagnostic criteria

History

Incisional hernia patients have a history of recent abdominal surgery, often with wound infection, splitting and so on. Or the patient's general condition is poor; or have a history of preoperative smoking and a history of chronic disease.

2. Clinical features

There is a reversible mass in the incision, and the physical examination can lick the ankle ring boundary formed by the abdominal muscle splitting. Auxiliary inspection can be seen in the image of the contents.

Differential diagnosis

And other types of small intestines such as sputum, oblique sputum, femoral hernia, umbilical hernia, white sputum, incarcerated sputum, stenosis and so on.

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