Ventral and incisional hernias: Clinical sciences

A ventral hernia is a defect in the fascia of the anterior abdominal wall. The majority of ventral hernias are acquired commonly from trauma to the abdominal wall and weakening of the fascia from repeated weight loss and subsequent weight gain, as well as straining, and coughing due to respiratory disease. Rarely, ventral hernia can be congenital like in omphalocele and gastroschisis.

Incisional hernias, on the other hand, are defects of the anterior abdominal wall resulting from improper healing of previous abdominal surgeries. Large midline incisions, from an exploratory laparotomy for example, have the highest risk for incisional hernias.

Risk factors for developing incisional hernias include obesity, smoking, malnutrition, and immunosuppressive therapies as they impede normal wound healing.

Both ventral and incisional hernias can present as either asymptomatic, symptomatic, incarcerated, or strangulated.

Alright, when you encounter a patient with signs and symptoms suggestive of a ventral or incisional hernia, you should first perform an ABCDE assessment to determine whether the patient is unstable.

If the patient is unstable, you should stabilize their airway, breathing, and circulation. This means that you may need to intubate the patient, obtain IV access, and administer fluids before continuing with your assessment.

Let’s take a look at the different findings for stable patients. When it comes to stable patients, your first step is to obtain a focused history and physical examination. There are a few findings you may notice here.

Alright, first, the patient might be asymptomatic, with a possible history of prior abdominal surgery. On physical exam, you might find a small abdominal wall bulge that increases in size when the patient bears down or performs a Valsalva maneuver. To do this, tell your patient to breathe in and forcefully breathe out against closed glottis or closed mouth and pinched nose. The idea behind the Valsalva maneuver is to breathe out against a closed airway, which increases the intra-abdominal pressure, making the hernia pop out.

Alright, back to the physical. The bulge will likely be located on the anterior abdominal wall or at the site of a prior incision. On palpation, the bulge will be nontender and easily reducible. If these are your findings, then you can diagnose your patient with an asymptomatic ventral or incisional hernia. When it comes to treatment, these hernias are often managed with watchful waiting.

However, you can consider a surgical consultation for elective repair if the hernia becomes larger or symptomatic, which increases the risk of incarceration, pain, or poor cosmesis. If your patient wishes to wait, advise them to seek immediate medical attention if they have any new-onset or worsening pain at their hernia site, or if they are suddenly unable to reduce the hernia.