incisional hernia

Scar fracture: description

What is a scar break? When the scar is fractured, the scar tissue diverges and the contents of the abdomen protrude. This weakness is located in the incisor usually in the area of ​​the anterior abdominal wall. A scar fracture generally consists of a hernia, a hernial sac, and the contents of the hernia, which are palpable and visible especially in the presence of increased pressure in the abdomen.

Scar fracture: abdomen

Any surgery on the abdominal wall carries the risk of incisional hernia. About ten to twenty percent of patients develop a scar fracture following abdominal wall surgery. This makes the scar fracture the most common long-term complication after surgery. It is estimated that approximately 80,000 incisional hernias occur annually, and one-third of patients undergo surgery.

Usually, the scar fracture occurs after median incision surgery, a common surgical procedure in which the skin and abdominal wall layers are severed midway along the body axis. There is the so-called Linea alba, where various abdominal muscles begin. The muscle layers consist of the external oblique abdominal muscle (external oblique abdominis), the internal oblique abdominal muscle (abdominal internal obliquus), the transverse abdominal muscle (transversus abdominis muscle), and the rectus abdominis muscle (rectus abdominis muscle).

If a cut along the alba line is closed, the applied seams usually provide good grip despite high clamping forces.

Scar fracture: symptoms

Incisional fractures vary in size, location and size of the hernia sac. Symptoms range from complete absence of symptoms to pain that can result in complete incapacity to work. The pain usually occurs when the abdominal muscles are tense, for example, when coughing, lifting heavy loads or pressing.

In the case of a scar fracture, the doctor usually feels the first symptom as a protrusion in the area of ​​the scar. A small scar fracture is sometimes not visible at all and only becomes apparent with increasing pressure in the abdomen. If the size of the incisor increases, parts of the intestine may be in it. Chair irregularities or blood in the stool can be the result.

In addition to redness and pain at the hernia, which increase significantly when the hernia sack is pinched, the physical performance may decrease.

Scar-Broken Symptoms: Monstrous Hernia

Each scar fracture can expand into a so-called “monstrous” scar fracture, which then has a diameter of over ten to fifteen centimeters. In this incisional tear are always abdominal viscera, which must be pushed back into the abdominal cavity during surgery.

Incisional symptoms: entrapment

The smaller the fracture gap, the sooner the break can be pinched. Within a few hours severe, permanent or colicky abdominal pain can occur – usually in the area of ​​incisional hernia. The stomach is very sensitive to pressure. Severe abdominal pain, fever, nausea, and vomiting indicate that, for example, parts of the intestine have been pinched. An entrapment is always an emergency and must be operated on immediately.

Scar fracture: causes and risk factors

The cause of an abdominal wall fracture is a combination of increased internal pressure in the abdomen and a congenital or acquired weak spot of the connective tissue of the abdominal wall. The pressure in the abdomen can be increased by obesity, pregnancy, coughing, pressing or an ascites. For small fractures, only fatty tissue can be contained in the fracture bag, while in case of large fractures, small intestine or large intestine can also be found therein.

About half of the incisional hernias occur within the first six months after surgery – scarring is possible up to five years after surgery.

Scar fracture: risk factors

In addition to basic or concomitant diseases of the patient and also surgical-technical factors play a role. In summary, the following risk factors for a scar fracture apply:

Patient-dependent factors:

• overweight
• wound infection
• older age
• nicotine consumption
• Cortisone and medications that suppress the immune system
• Hereditary collagen diseases
• Concomitant diseases such as anemia, tumor disease, diabetes mellitus, abdominal aortic aneurysm

Surgical technical factors:

• incision
• sutures
• suture technique

Obesity from a body mass index of 25 is one of the most important risk factors for the development of incisional hernias. The main cause is the increased pressure in the abdomen. In addition, because of the increased amount of adipose tissue, the doctor is often less likely to suture the surgical wound in overweight individuals.

Decreased blood flow and thus oxygen supply to the scar tissue through anemia, shock or malnutrition influences wound healing just as negatively as smoking, collagen metabolism diseases, wound infections or cortisone therapy. Smokers have a fourfold increased risk of scarring.

Although incision fractures can not be prevented even by special incisions, so-called keyhole surgeries (laparoscopic surgeries), which are characterized by small incisions, show significantly less incisional hernias. Suture material and technique also play a role in the development of incisional hernia.

Scar fracture: examinations and diagnosis

In case of a scar fracture you should definitely consult a doctor. The doctor will record the medical history and perform a physical examination while lying or standing. He will also ask you to squeeze once to increase abdominal pressure. Possible questions of the doctor can be:

• When were you operated on?
• How many operations have already been performed?
• Since when do the complaints exist?

The doctor will grope the break ring with the protruding break bag – if the contents of the break bag can easily be pushed back into the abdominal cavity, the diagnosis can be easily made. With smaller incisors, a physical examination is often more difficult because the fracture ring is unremarkable and usually only a local pressure pain exists.

A scar fracture is characterized by the size of the hernia, whether the protrusion can be pushed back spontaneously, how far the fracture is from the costal arch, and its location – for example, in the upper or lower abdomen – characterized.

Scar fracture diagnosis: Imaging procedures

In overweight patients it is often difficult to diagnose a scar fracture. It is helpful to visualize internal organs and tissues using techniques such as ultrasound, computed tomography or magnetic resonance imaging. Even in patients with severe symptoms, in which no clear finding could be made by the pure physical examination, imaging techniques are used. Cancer patients are screened for any newly developed tumors.

Scar fracture: treatment

A scar fracture is usually always operated because it does not regress itself. Also, a small scar fracture should be operated, since the fracture bag can be pinched. In patients with a large incisional hernia, it makes sense to lose weight before the operation and to do regular breathing exercises.

A scar fracture surgery is not an urgent procedure in patients without discomfort. The muscle layers, however, diverge over time, so that the incisional hernia increases steadily.

A scar fracture surgery should take place at the earliest three months, until one year after the previous operation – only then the wound edges are stable enough. A scar fracture can be operated either open or with the so-called keyhole technique (laparoscopy).

Scar fracture surgery: open surgery

In the open scar fracture surgery, the surgeon opens the abdominal wall with a belly cut. Then he releases the bag and pushes it back into the abdominal cavity. Depending on the size of the bag and the health of the patient, there are various methods to close the abdominal wall again:

A very small scar fracture is usually closed with a direct suture. From a breaking size of three centimeters, a stabilizing plastic net is usually used. The mesh is used so that it overlaps the scar fracture on each side at least five centimeters. A distinction is made, depending on the abdominal wall layer in which the plastic mesh is used, the inlay, onlay, or sublaid technique.

For large incisors, so-called “bio-meshes” can be used. They are extracted from the small intestine of pigs and later degraded by the body after the affected tissue has been stabilized.

Scar fracture surgery: keyhole technique

The keyhole technique (laparoscopy) is operated on a small abdominal incision with a camera optics. This method is considered to be very gentle on the patient – repeated fractures and wound healing disorders are less common. Also, the use of painkillers and the length of stay in the hospital are lower.

Scar fracture: disease course and prognosis

A scar fracture can usually be operated without any problems and successfully treated. Becomes a incisional hernia not operated, he continues to expand. Complications such as bowel obstruction, pain and digestive problems can be the result. Due to new surgical procedures, plastic implants and standardized treatment steps, hernia surgery has continued to develop. Recent developments in plastic net technology reduce pain and foreign body sensation and allow for better abdominal wall mobility.