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An incisional hernia is a defect of the fascia of the abdominal wall following any incision, most commonly surgical incision.  It is a type of ventral hernia which is any hernia on the ventral abdominal wall. Ventral hernias may include primary (umbilical, epigastric, spigelian, or lumbar hernias not related to prior incisions) or incisional (following surgery including prior primary ventral hernia repair and trauma) subtypes. 
Epidemiology and Pathophysiology
Each year in the United States, nearly 5 million abdominal surgeries are performed and up to 20% of patients will develop a ventral incisional hernia. [2,3] It is estimated that this year in the United States, nearly 400,000 ventral hernias will be repaired of which one-fourth will be ventral incisional hernias. [2,3]
Incisional hernias are believed to develop due to three main reasons: (1) increased intra-abdominal pressure, (2) weakened abdominal wall, and (3) surgical technique. Increased intra-abdominal pressure is most commonly due to obesity in developed countries. Over two-thirds of Americans are overweight and/or obese, fueling the "obesity epidemic".  Obesity increases pressure on the abdominal wall and may affect the abdominal wall dynamics by changing the shape and thus directional forces. Other common causes of increased intra-abdominal pressure include extreme exertion from activity, chronic cough (due to smoking or chronic obstructive pulmonary disease), constipation, urinary obstruction, pregnancy, or ascites. [3,5] Abdominal wall weakness may related to genetics including underlying collagen vascular disorders, smoking, infections (e.g. surgical site infection), or incisions. [3,5,6] Finally, technical issues may contribute to the development of ventral incisional hernias. The incision (length, location, direction), suturing technique, and surgeon skill-level may all impact the rate of incisional hernia formation. [3,5,7] All of the technical issues may result in surgical site infections and/or poor healing of the incision.
Signs and symptoms
Clinically, incisional hernias present as a bulge or protrusion at or near the area of a surgical incision. Virtually any prior abdominal operation can develop an incisional hernia at the scar area (provided adequate healing does not occur due to infection), including large abdominal procedures such as intestinal or vascular surgery, and small incisions, such as (appendix removal or abdominal exploratory surgery). While hernias can occur at any incision, they tend to occur more commonly along a straight line from the xiphoid process of the sternum straight down to the pubis, and are more complex in this region. Hernias in this area have a high rate of recurrence if repaired via a simple suture technique under tension. For this reason, it is especially advised that these be repaired via a tension free repair method using a synthetic mesh.
Traditional "open" repair of incisional hernias can be quite difficult and complicated. The weakened tissue of the abdominal wall is re-incised and a repair is reinforced using a prosthetic mesh. Complications, particularly infection of the incision, frequently occur because of the large size of the incision required to perform this surgery. A mesh infection after this type of hernia repair most frequently requires a complete removal of the mesh and ultimately results in surgical failure. In addition, large incisions required for open repair are commonly associated with significant postoperative pain. Reported recurrence rates after open repair are up to 20% and influenced by mesh size and fixation type.
Laparoscopic incisional hernia repair is a new method of surgery for this condition. The operation is performed using surgical microscopes and specialized instruments. The surgical mesh is placed into the abdomen underneath the abdominal muscles through small incisions to the side of the hernia. In this manner, the weakened tissue of the original hernia is never re-incised to perform the repair, and one can minimize the potential for wound complications such as infections. In addition, performance of the operation through smaller incisions can make the operation less painful and speed recovery. Laparoscopic repair has been demonstrated to be safe and a more resilient repair than open incisional hernia repair.
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- Nguyen, SQ; Divino, CM; Buch, KE; Schnur, J; Weber, KJ; Katz, LB; Reiner, MA; Aldoroty, RA; Herron, DM (2008). "Postoperative Pain After Laparoscopic Ventral Hernia Repair: a Prospective Comparison of Sutures Versus Tacks". Journal of Society of Laparoendoscopic Surgery 12 (2): 113–6. PMC 3016187. PMID 18435881.
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