An incisional hernia is a protrusion of tissue that forms at the site of a healing surgical scar. This is a type of ventral hernia and accounts for 15-20% of all abdominal hernias, occurring when improper healing from previous surgery further weakens abdominal muscles. The hernia appears as a bulge under the skin and can be painful or tender to the touch. The characteristic “bulge” of an incisional hernia can be identified when you are standing upright or are performing physical activity, such as heavy lifting. Incisional hernias do not heal on their own and require surgical treatment to repair.

Dr. Ford will look and feel for a bulge in your incision. He may ask you to lie down with your legs bent. He may also ask you to cough while standing up. You may need a CT scan to show the hernia.

Anatomy of Hernias

Causes of an Incisional Hernia

People who had abdominal surgery are at risk for developing incisional hernias. They are especially susceptible three to six months following the procedure when the tissues are healing from the incision. Incisional Hernias are more likely after emergency surgery or surgery that requires a large incision. If the edges of the wound aren’t properly aligned after surgery, the incision may not heal well, increasing the likelihood of a hernia. The sewing technique used to close the incision can also play a part.

Strenuous activity, substantial weight gain, or pregnancy can cause excessive stress on the healing abdominal tissue and should be avoided during this healing window.

Several things can prevent the surgical incision from healing properly, including:

  • Putting too much pressure on your abdomen
  • Becoming pregnant before the cut fully heals
  • Getting back into physical activities too soon after surgery

Several risk factors can increase the chances of a hernia developing after surgery, including:

  • Wound infection
  • Existing health conditions, such as renal failure, diabetes, or lung disease
  • Obesity
  • Smoking
  • Certain medications, including immunosuppressant drugs or steroids
Inguinal Hernia Casues

Symptoms of an Incisional Hernia

The most noticeable symptom of an incisional hernia is a bulge near the incision site. It’s often most visible when you strain your muscles, such as when you stand up, lift something, or cough.

Besides a visible bulge, incisional hernias might also cause:

  • Nausea and vomiting
  • Fever
  • Burning or aching near the hernia
  • Abdominal pain and discomfort, particularly around the hernia
  • Faster heartbeat than usual
  • Constipation
  • Diarrhea
  • Thin, narrow stool

While you’re most likely to develop a hernia between three and six months after your surgery, hernias can occur before or after this time frame. Hernias are often categorized as reducible or irreducible:

  • Reducible Hernias
    Reducible hernias can be pushed back in. They may also shrink when you lie down.
  • Irreducible Hernias
    Irreducible hernias happen when part of your intestine pushes into the hernia, making it hard to push the hernia back in. Irreducible hernias can lead to bowel obstruction, which can then lead to a strangulated hernia. This requires immediate treatment.
when an incisional hernia requires surgery

Incisional Hernia Treatment

To diagnose an Incisional Hernia, Dr. David W. Ford takes a thorough medical history and conducts a physical examination. The hernia is usually very apparent at or near an older surgical scar in the abdomen, however, if the bulge is not obvious, the patient may be asked to stand and cough so the doctor can see and feel the hernia as it protrudes from the abdominal wall. Dr. Ford checks to see if the hernia is reducible, and can be gently massaged back into its proper position in the abdomen. If not, surgery is the recommended course of treatment.

Patients most often only seek repair when Incisional Hernias cause symptoms of discomfort, pain, or cosmesis (disfiguring), with a wide variation in surgical techniques and strategies for repair. Because of this, recovery time varies depending on the size of the hernia, the technique used, and the age and health of the patient. Because large incisional hernias are often very unpleasant, many people who have them, want to have treatment. But large hernias are a lot harder to operate on than small hernias.

Women who would still like to have children are also in a special situation. Their abdominal muscles have to be able to stretch a lot during pregnancy to make room for the growing baby. Because the synthetic mesh is less elastic than natural muscle tissue, doctors are concerned that women who become pregnant will have a greater risk of complications. Unfortunately, there is very little scientific research in this area. Most women who have an incisional hernia can put off the hernia surgery until they're sure they don’t want to have any (more) children. When hernia surgery is necessary for women who might still have children, doctors tend to recommend not using mesh. But then the hernia often returns during pregnancy.



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Types of Incisional Hernia Repair Surgeries

Dr. David W. Ford employs the 2 main types of surgery for hernias: Open Herniorrhaphy or Robotically-assisted laparoscopic Herniorrhaphy, both with or without a mesh (Hernioplasty). Although laparoscopic surgery, either robotically-assisted or not, is the preferred method, it does carry a higher probability of reoccurrence and often open surgery is suggested if scar tissue resectioning is involved.

Robotically-Assisted Incisional Herniorrhaphy or Hernioplasty
with The Da Vinci® Robotic Surgical System

Surgical robotics for minimally invasive surgery

As a Board-Certified General Surgeon, Dr. David W. Ford operates with a minimally invasive robotic system to repair ventral and inguinal hernias. Both minimally invasive approaches only requires a few small incisions that doctors use to insert surgical equipment and a camera for viewing.

Robotically-assisted Incisional Hernia surgery utilizes an advanced robotic platform that is not autonomous but is controlled by the surgeon who is seated in the operating room and operates via the Surgeon Console that controls the Patient Cart’s robotic devices, including various surgical instruments and a camera. The da Vinci Surgical System allows surgeons to perform minimally invasive hernia repairs with clinically supported precision and accuracy. Robotically assisted surgery uses a laparoscope (a thin lighted tube with a camera on the tip) that is inserted through one of several small incisions, made away from where the hernia has occurred. The images gathered from the laparoscope’s camera are magnified, high-definition 3D, which are sent to a monitor that Dr. David W. Ford uses to guide the surgical system during the operation. If needed, the abdomen can be inflated with a harmless gas (carbon dioxide), which creates space to allow the doctor to view the inside of the body.

For the Incisional Hernia Repair, the inner lining of the abdomen is cut to allow Dr. David W. Ford to see the weakness in the abdominal wall. The surgery can also cut into the peritoneum (the sac created around the old scar tissue) or it can repair and push fatty tissue, muscle and intestines back in without cutting the peritoneal sac. Reconstruction of the abdominal wall, removal of extraneous fat, tissues or scar tissue occurs at this time. Surgical mesh material is usually inserted to strengthen the weakened area and reconstruct the abdominal wall, although sometimes a suture-only repair is needed, especially in child-bearing women. After the procedure is completed, the small incisions in the abdomen are closed with a stitch or two or with surgical tape and a drain may be inserted at the incision site if needed. Dr. David W. Ford’s use of the state-of-the-art da Vinci Surgical System in his robotically assisted hernia repair surgeries has allowed him to set a very high standard of expertise that can combine this method with traditional Open Surgery if required.

Many robotically-assisted surgical systems are FDA approved and in use today. However, many are specially designed for specific organs, procedures, or conditions, such as lung or pulmonary surgeries or knee and other extremity replacement surgeries. The da Vinci Robotic Surgical System is the premier system specialized in hernia repair surgery. Dr. David W. Ford is not only an expert board-certified surgeon but also certified in the use of this leading-edge technology.

This robotic platform offers Dr. David W. Ford fully wristed instruments and a 3D high-definition camera with 10x magnification. As a result, the repair can be done with more precision, and complex hernias can be fixed with small incisions. Furthermore, the robot doesn’t get tired and Dr. Ford sits during surgery, so there is less surgeon fatigue. For the patient, this translates into quicker recovery, less pain, and fewer complications. This is the preferred approach for medium to large hernias and many inguinal hernias as it combines the best of open and laparoscopic surgeries. Also, Dr. Ford is more likely to be able to sandwich the mesh between layers of the abdominal wall to keep the mesh from coming into contact with the intestines.

Other benefits of robotic hernia surgery include:

  • Access to clear three-dimensional images (unlike laparoscopic surgery’s two-dimensional images) of the inside of the abdomen for more precise surgery.
  • Dr. Ford can easily use stitches to sew tissue and meshes into the inside of the abdomen.
  • The patient is left with smaller scars rather than one large incisional scar.
  • The possibility of much less pain, faster recovery, and quicker return to normal diet and activities after surgery are observed, compared to all other types of hernia repair surgery.

Should robotically-assisted surgical laparoscopic surgery be recommended as part of treatment for your hernia repair, Dr. David W. Ford and his team will have the best state-of-the-art technology at their disposal to usher in your recovery.

How The Da Vinci® Robotic Surgical System works

Da Vinci surgical systems are comprised of three components: surgeon console, patient-side cart, and vision cart.

Surgeon Console

Surgeon Console

The surgeon console is where I sit during the procedure, have a crystal-clear 3DHD view of your anatomy, and controls the robotic instruments. Through a few small incisions, the tiny instruments are "wristed" and move like a human hand, but with a far greater range of motion.
Patient Cart

Patient Cart

The patient-side cart is positioned near the patient on the operating table. It is where the instruments used during the operation move in real time in response to your surgeon’s hand movements at the surgeon console.

A camera provides a high-definition, 3D magnified view inside your body. Every hand movement your surgeon makes is translated by the da Vinci system in real time to bend and rotate the instruments with precision.

Vision Cart

Vision Cart

The vision cart makes communication possible between the components of the system possible, and supports the 3D High Definition vision system.

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Robotic-Assisted Surgery

"The da Vinci Surgical System allows me to make smaller incisions, resulting in reduced risk of infection, minimize scarring, reduce pain, and accelerate recovery time, allowing my patients to return to normal activities more quickly."
David W. Ford, MD, FACS
da Vinci Surgical System

Open Incisional Herniorrhaphy

In open incisional hernia repair, also called herniorrhaphy, the patient is given general anesthesia as a sedative, and this is often augmented with epidural anesthesia to improve recovery time and pain control. Then Dr. David W. Ford makes an incision on the abdomen, releases scar tissue, moves the hernia contents (often bowel or fat) back into the abdomen, and reinforces the muscle wall with stitches.

Usually, the area of muscle weakness is reinforced with a synthetic or biologic mesh to provide additional support to reduce the likelihood of recurrence (Hernioplasty), however, the Open Incisional Hernia Repair can be done with or without the mesh insertion. A drain at the incision site may also be needed.

This surgical method generally takes about 3 hours, and one can expect to stay at the hospital for observation for 2-5 days.

Open incisional hernia surgery

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Mesh in Hernia Repair: Making an Informed Decision

Non-Surgical Options:

  • Conservative, watch & wait management is helpful for patients with minimal or no symptoms.
  • The hernia itself should not limit your ability to engage in your usual daily activities.

Surgical Options:

Hernia repair involves an operation, with overall one of two main approaches:

  1. Mesh repair – the use of mesh to enhance the repair & provide further reinforcement
  2. Non-mesh repair – closing the abdominal defect with stitches, creating some tension

Safety of Surgical Mesh:

  • There is a large volume of data on the outcome of various hernia operations and different types of mesh, and the use of mesh to repair the majority of hernias has been the preferred method in the US, UK, and worldwide for over 30 years.
  • When surgeons themselves have hernias that require surgery, they opt for mesh repairs.
  • Patient safety is a critical component, and therefore, different meshes used in surgery are tightly regulated in both the US and UK.

What is the “Gold Standard”?

  • Using mesh has become the gold standard in hernia repairs – and has a lower recurrence rate.
  • Many patients with hernias have tissue weakness and often do not hold stitches well, which may explain why non-mesh repairs have a higher failure/recurrence rate than with mesh.
  • For the vast majority of patients, mesh poses little if any additional risk.

Risks of Mesh:

  • Mesh is a foreign material, like synthetic implants, such as dentures, crowns, heart valves, etc.
  • It is possible for mesh to become infected, but this is rare.
  • Some patients develop chronic pain after surgery. There is no strong relationship with the use of mesh and chronic pain. Furthermore, non-mesh repairs can result in similar pain outcomes.
Mesh in Hernia Repair
Hernia Mesh diagram

Post-Operative Incisional Hernia Surgery Recovery

Post-operative Treatment of Incisional Hernias will vary due to the repair surgical procedure chosen, the severity of the hernia, its location, and any complexities in either surgery or comorbidities of the patient. Without any complications, a simple incisional hernia repair usually requires a hospital stay of 2-5 days. If internal stitches were substantial, additional observation may be required. At first, you may need to rest in bed with your upper body raised on pillows, to help you breathe easier and lessen post-surgery hernia pain. Both cold and heat can help lessen some types of post-op pain.

After recovery, you can usually return to work or school within a week. You will not be able to lift anything over 10 pounds, climb, or do strenuous activity up to 4 to 6 weeks following surgical repair of an Incisional Hernia. Always wash your hands before and after touching near your incision site. A truss or belt to help alleviate pressure at the incision site may be prescribed.

Losing weight relieves excess pressure on the abdomen, which can prevent a hernia from developing, improve hernia symptoms, and avoid complications such as strangulation. High fiber foods are recommended to avoid straining during bowel movements during healing in the first weeks to months after surgery.

You may call or email with any problems, questions, or concerns below:

Prescription Refill Hours:
Monday – Thursday 8:30 AM – 4:30 PM
Friday before 2:00 PM

Please call if you experience any of the following:
  • Temperature greater than 101 degrees
  • Incisions with increasing areas of redness, thick or colored discharge, worsening tenderness
  • Nausea and vomiting or an inability to tolerate anything by mouth
  • Progressively worsening pain

Pain

Acetaminophen (Tylenol)
  • 650mg to 1000mg every 6 – 8 hours for first 3 days, scheduled
  • After 3 days, may continue as needed for pain
  • Do not exceed 4000mg in 24 hours
  • Avoid if history of hepatic (liver) impairment, alcohol abuse
Non-Steroidal Anti-Inflammatories (NSAIDs), choose one:
  • Ibuprofen (Advil, Motrin) 400mg by mouth every 6 – 8 hours, as needed
  • Naproxen (Aleve) 440mg by mouth every 12 hours, as needed. Avoid if history of renal (kidney) impairment, or a history of coronary artery disease (CAD), hypertension. Avoid multiple NSAIDs at once (e.g. Ibuprofen + Naproxen)
Narcotics and Opioids
  • Oxycodone, Hydrocodone & combo pills are for severe breakthrough pain ONLY
  • If a combo pill (e.g. Percocet, Lortab, Vicodin, Norco), do NOT take with Tylenol.
  • Do not drive or operate machinery while taking narcotic pain medication.
  • Narcotics can be habit-forming, have addiction potential, and cause constipation, so be careful – and use sparingly.
Tramadol
  • Tramadol (Ultram) is for severe breakthrough pain & often used in place of opioids
  • It is not a true narcotic but can be habit-forming with long-term use.
  • Avoid if history of seizures
Simethicone
  • Simethicone (GasX) 40 to 125 mg every 8 hours as needed for gas pain & bloating
  • Do not exceed 500mg in 24 hours; this is sold over-the-counter

Hygiene

  • You may shower and use soap and water on surgical site incisions, the day after surgery
  • Keep dressing clean and dry for 24 hours, you may replace as needed for drainage
  • Do not swim or soak; no hot tub, pool, beach, lake, etc. for at least 7 days

Constipation

  • Post-operatively & within 2 days, should be having regular, soft bowel movements (BMs)
  • Hydrate & drink plenty of water (8 –10 glasses per day)
  • PEG 3350 (Miralax) 17g by mouth each day for BMs each day

Other alternative recommendations, as needed – Use at least one if have not had a BM for 2 days:

  • Magnesium Hydroxide (Milk of Magnesia) 15 – 30 mL by mouth once a day, as needed
  • Magnesium Citrate 200 – 300 mL by mouth once a day, as needed
  • Docusate (Colace) 100mg by mouth twice a day, as needed

Activity

  • Ambulate and increase activity as tolerated post-operatively
  • Simply walking often improves mentation, decreases pain & bloating, and improves BMs
  • Avoid heavy lifting (greater than 20 pounds) until follow-up after laparoscopic and open surgeries
  • Avoid prolonged straining and strenuous activity until follow-up
  • Wear your abdominal binder after hernia repair
  • Resume all home medication as directed

Wound Care

  • The raised, firm area called a healing ridge is normal, and should resolve over time
  • Remove your dressings/bandages 2 days after surgery, unless told otherwise by Dr. Ford himself
  • You may shower and use soap & water on surgical site incisions, the day after surgery