Ventral and incisional hernias: Clinical sciences

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Introduction0:00–1:15

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.

Unstable Patient1:15–1:43

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.

Stable Patient1:43–1:58

There are a few findings you may notice here. Alright, first, the patient might be asymptomatic, with a possible history of prior abdominal surgery.

Asymptomatic Ventral/Incisional Hernia1:58–3:24

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.
Now, let’s go back to our history and physical examination and talk about symptomatic ventral and incisional hernias. Patients might report some localized fullness and sharp pain around the bulge, especially with increased activity.

Symptomatic Ventral/Incisional Hernia3:24–4:21

They might also have a history of prior abdominal surgery. On physical exam, you can expect to find a visible abdominal wall bulge on the anterior abdominal wall or the site of a prior surgical incision, which becomes more apparent when the patient performs a Valsalva maneuver.
Additionally, the hernia will be reducible. With these findings, you can make the diagnosis of a symptomatic ventral or incisional hernia.
The treatment of choice is an elective surgical repair, so be sure to call the surgical team for a consultation. In the meantime, you should counsel your patient to seek immediate medical attention if their pain worsens, or if they are suddenly unable to reduce their hernia.
Okay, let’s move on to patients with signs and symptoms of an incarcerated ventral or incisional hernia! In this case, history may reveal fullness and constant, sharp pain, especially with increased activity.

Incarcerated Ventral/Incisional Hernia4:21–5:45

The patient might complain of changes in bowel habits, such as constipation, and they might have a history of prior abdominal surgery.
On physical exam, you’ll notice a visible abdominal wall bulge in the same location as your patient’s pain, typically on the anterior abdominal wall or site of prior incision.
The skin over the bulge might be erythematous and tender to palpation. In addition, unlike asymptomatic or symptomatic ventral or incisional hernias, this type of hernia is not reducible.
If you see these findings, you are dealing with an incarcerated ventral or incisional hernia. Once you make the diagnosis, you will need to assess when the symptoms initially started.
If the symptoms developed acutely, meaning within hours of presentation, you can attempt to reduce the hernia to prevent it from becoming strangulated.
However if you are dealing with an incarcerated hernia, you likely won’t be able to reduce it, so call the surgical team for an urgent hernia repair.
On the other hand, if the symptoms are chronic and have been present for weeks, months, or even years, you are even less likely to be able to reduce it.
So, consult the surgical team for elective repair. Now that we have reviewed incarcerated ventral and incisional hernias, let’s focus on a more serious condition called a strangulated ventral or incisional hernia.
In this case, the blood supply of the contents contained within the hernia sac becomes compromised. If a loop of bowel is stuck in the hernia, the compromised blood supply causes ischemia and necrosis of the herniated bowel.

Strangulated Ventral/Incisional Hernia5:45–7:59

This can lead to bowel perforation, which is a surgical emergency. Patients with strangulated ventral or incisional hernias typically have a history of fever, severe, sharp pain, and signs of bowel obstruction, such as abdominal pain, nausea, vomiting, and constipation or obstipation.
Again, watch out for a history of prior abdominal surgery. The physical exam may show an abdominal wall bulge located on the anterior abdominal wall or at the site of a prior incision, with overlying skin that is erythematous, warm, and very tender on palpation.
If you see these findings, you are dealing with a strangulated ventral or incisional hernia. Here’s a clinical pearl!
Do not attempt to reduce the strangulated hernia, since the hernia sac may contain a necrotic bowel segment that can cause life-threatening abdominal sepsis.
Alright, now you’ve made your diagnosis - start the patient on IV fluids, broad-spectrum IV antibiotics, and place a nasogastric tube if the patient has any signs or symptoms of a bowel obstruction.
Once these treatment measures are implemented, you should also call the surgical team for an emergent repair of the strangulated hernia with resection of any necrotic contents.
One last clinical pearl! Although imaging such as CT of the abdomen and pelvis are usually not necessary to make a diagnosis, it might be appropriate in patients with obesity or very large hernias to better visualize the hernia and its contents.
Additionally, CT can provide information about the patient’s anatomy, which can help operative planning in complex cases.
Alright, as a quick recap… Patients with ventral or incisional hernias can present as with asymptomatic, symptomatic, incarcerated, or strangulated hernias.
Asymptomatic hernias can be observed for watchful waiting or electively repaired if there is risk of the hernia progressing.
Symptomatic hernias are often repaired electively by the surgical team. However, when it comes to incarcerated ventral or incisional hernias, call the surgical team for an urgent repair if the symptoms started acutely; or call the surgical team for an elective repair, for chronic hernias.

Review7:59–8:54

Lastly, if the hernia is strangulated, do not attempt to reduce it! Start the patient on IV fluids and broad-spectrum antibiotics and place a nasogastric tube if your patient is vomiting.
Then, call the surgical team for an emergent repair. If the symptoms started acutely or call the surgical team for an elective repair for chronic hernias Lastly if the hernia is strangulated do not attempt to reduce it Start the patient on IV fluids broad spectrum antibiotics and place a nasogastric tube If your patient is vomiting then call the surgical team for
Ventral and incisional hernias: Video and Causes | Osmosis