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Incisional Hernia in Pregnancy

Article · January 2012

DOI: 10.4018/ijudh.2012100110

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 INTERNATIONAL MEDICAL JOURNAL OF STUDENTS’ RESEARCH

INCISIONAL HERNIA IN PREGNANCY : A REVIEW

AUTHOR: SUJOY DASGUPTA
VOLUME 2, ISSUE 1

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,
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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

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
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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
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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
VOLUME 2, ISSUE 1

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 C-
section 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
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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
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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
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(Continued from page 19)

hernia were 43% and 24%, respectively. The rates of second recurrence were 58% and 20%,
respectively.
VOLUME 2, ISSUE 1

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
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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
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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.
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(Continued from page 20)

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
VOLUME 2, ISSUE 1

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.
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References
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Correspondence:
dr.sujoydasgupta@gmail.com
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