Successful management of strangulated incisional hernia in pregnancy — A case report

Abstract

Introduction

Abdominal hernias, including incisional hernias, can occur due to weakness in the abdominal wall. Incisional hernias commonly occur following surgical incisions, and factors such as poor closure technique and patient-related factors can contribute to their development.

Case presentation

In this case, the patient was presented with a painful, irreducible lump over a previous laparotomy scar, along with bowel obstruction symptoms. The diagnosis was supported by ultrasound findings showing obstructed bowel loop in the hernial sac. Emergency open surgical reduction and mesh repair were performed to treat the strangulated hernia and ensure the mother and fetus's safety. The patient had an uneventful postoperative period and was discharged after three days.

Discussion

Incisional hernias can be diagnosed through clinical evaluation, and imaging studies may be necessary in complex cases. However, imaging techniques such as X-rays and Computed Tomography scans are limited in pregnant women due to the radiation risks. Ultrasonography (USS) is preferred in pregnant women for its safety and non-invasiveness, although it may have reduced sensitivity in obese patients. Complicated hernias should be treated with emergency surgical repair, while elective surgery can be considered for asymptomatic or non-complicated hernias. Laparoscopic surgery offers advantages such as shorter hospital stays and fewer complications. Mesh repair reduces the recurrence risk in subsequent pregnancies (relate the discussion with the case).

Conclusion

Overall, surgical management of hernias in pregnancy requires careful consideration of individual circumstances and the use of appropriate techniques to ensure the safety of both the mother and fetus.

Highlights

• •A pregnant woman presented with strangulated incisional hernia.
• •Hernias are uncommon in pregnancy and should be evaluated to decide on the timing, approach, and techniques of surgical management.
• •Emergency surgery should be performed on a patient with complicated hernias like incarcerated, strangulated or obstructed hernias regardless of pregnancy status.

1. Introduction

Abdominal hernias occur due to congenital or acquirer weakness in the musculofascial layer of the abdominal wall [1]. Intra-abdominal contents tend to protrude through this weak point of the abdominal wall. Hernias are common worldwide surgical problems, and 20 million herniorrhaphy are performed annually. Though hernias are common in the abdominal wall, it is not always confined to the abdominal wall, and they can also occur in other areas such as the perineum, and diaphragm, and in the form of internal herniation [2]. Several risk factors are associated with the development of hernias, including smoking, obesity, history of hernia, male sex, older age, previous surgery, collagen disease, and pregnancy [3,4]. The hernias are fairly uncommon during pregnancy but when it is present, it can be a challenge to a surgeon and the patient [2] as it can affect the pregnancy outcome. The hormonal changes that can occur in pregnancy and increased intra-abdominal pressure due to a gravid uterus may play a significant role in developing hernia in pregnancy [3,5].

An abdominal wall hernia at the site of a previous surgical incision is called an incisional hernia. It is usually common following midline incision surgery but can occur in any abdominal surgical incision. It can be a definite hernia with all the components of the hernia (defect, sac, and contents), or a weak point with a shallow sac with occasional bulging of contents [6]. It has been reported that incisional hernia can occur following traumatic abdominal wall injuries [7] and failure in proper abdominal wall closure following surgery [8]. Around 15 % to 20 % of incisional hernias occur following laparotomy, even after the current advancement of surgical techniques [9].

Failure in proper abdominal wall closure is due to several factors, including patient-related, disease-related, and technical factors [10,11]. Several patient-related factors, including chronic illnesses such as diabetic mellitus, obesity, chronic renal failure, chronic constipation, chronic cough and malnutrition, and long-term usage of medications such as steroids and immune suppressive agents, can affect wound healing, ultimately leaving a weak point in the abdominal wall. Socioeconomic factors such as smoking habits and heavy manual work also can predispose to form a hernia. Disease-related factors, including surgical site, timing, the urgency of the procedure, complications, and underlying diseases, have an important role in forming an incisional hernia. Emergency surgeries [12], midline incisions, infection [13], and acute abdominal surgeries are associated with a higher incidence of incisional hernia development. Wound infection following surgery is commonly associated with incisional hernia formation. Technical factors are also important in developing an incisional hernia, poor surgical technique leading to acute wound dehiscence or failure in delayed healing leading to an incisional hernia. Appropriate suture material with adequate strength and length for side-to-side approximation of the abdominal wall is important to prevent incisional hernias [2,14].

Once the pregnant woman presents with a hernia, careful clinical assessment should be performed to decide the timing, approach, and surgical technique to treat the patient. The severity of symptoms and signs and complications of hernias at presentation and pregnancy status will play a crucial role in those decision makings [14]. In general, complicated hernias like incarcerated or strangulated or obstructed hernias can manage with open emergency surgical repair regardless of pregnancy status, but uncomplicated or asymptomatic hernias can be managed with elective surgeries. It must be considered to offer laparoscopic surgery whenever possible [14,15].

We present a case of a pregnant woman who presented with a strangulated incisional hernia in the second trimester, successfully managed with emergency open surgery with mesh repair in a tertiary care hospital. Our case report has been written according to the SCARE criteria (16).

2. Case history

A 36-year-old pregnant woman G4P3C3, with no comorbidities, was referred to a tertiary care hospital from the local hospital at the gestational age of 20 weeks and three days for further surgical management. She is a mother of three children, all of whom were delivered via normal vaginal birth. She was presented to a local hospital with a painful, irreducible lump in her lower abdomen over the previous lower midline laparotomy surgical scar. It was associated with worsening intermittent colicky abdominal pain, three episodes of vomiting, and constipation for the last two days. She underwent lower midline laparotomy and appendicectomy for complicated appendicitis ten years back. She noticed an asymptomatic reducible lump over the midline surgical scar for the last nine years, which was not evaluated earlier. Still, the size of the lump was gradually enlarging in size without affecting her day-to-day activities until she developed rapidly worsening pain over the last two days. She didn't develop a fever associated with these symptoms. Her clinical examination revealed an irreducible tender lump over the past surgical scar with sluggish bowel sounds; the rest of the abdominal findings were insignificant. Her fetal well-being was normal. She didn't have any features suggestive of sepsis.

After detailed history and examination, we strongly suspected a strangulated incisional hernia during pregnancy. The diagnosis was supported by an Ultrasound scan (USS) abdomen performed at the local hospital, which shows obstructed bowel loop into the incisional hernial sac and normal fetal growth (Fig. 1). We decided for emergency open incisional hernia repair to safeguard the life of both mother and the fetus after an emergency Multi-Disciplinary Team meeting with obstetricians and surgeons. She underwent emergency surgery and successfully reduced strangulated bowel loops into the peritoneal cavity after confirming the viability of the small bowel content and mesh repair, as no contamination was noted during surgery (Fig. 2, Fig. 3). The immediate postoperative period was uneventful, and the patient was discharged from the hospital on postoperative day three.

Fig. 1.

Strangulated incisional hernia at the incisional site.

Fig. 2.

Intraoperative finding of strangulated small bowel loop with dark colouration.

Fig. 3.

a) Intraoperative finding after releasing tight band of neck of the hernial sac. b) Strangulated bowel loop getting back to its normal colour.

3. Discussion

Patients with an incisional hernia can classically present with positive cough impulses at the site of the surgical scar. These patients also have an increased risk of developing hernia-related complications such as irreducibility, obstruction, and strangulation.

Almost all incisional hernias are diagnosed with a thorough history and clinical examination during the first visit. Only a few instances, like in the early stages of a hernia, obese patients or complex cases may need imaging investigation such as USS, X-rays, Computed Tomography (CT), and Magnetic Resonance Imaging (MRI) [17]. Complete evaluations with imaging studies help confirm the diagnosis, assess the size of the defect, identify the herniated content and its vascularity, and assess the abdominal cavity to plan for surgical management. Sometimes incisional hernias are identified intraoperatively when the patient is undergoing some other surgery.

As in the normal population, most incisional hernias can be diagnosed with clinical evaluation in pregnant women. But in gravid women, both the diagnosis and treatment of hernias are challenging to the surgeon and the patient for diagnosis and treatment. Especially in complicated hernias like incarcerated, strangulated, or obstructed hernias are more challenging to make a clinical judgment as important clinical findings such as pain, nausea, vomiting, and leukocytosis are common in pregnancy. Imaging studies may become mandatory for further assessment and management in these situations. Due to the risk of radiation exposure during pregnancy, X-rays and CT are limited use. At the same time, the availability of MRI in the institution is also an issue. Considering these limitations in other imaging techniques, transabdominal USS is the modality of choice in complicated hernias in pregnant women when there is clinical confusion in diagnosis. USS has advantages in pregnancy as it does not carry the risk of radiation, is noninvasive, and can help exclude the other possible etiologies and the fetal status. Still, it also has some disadvantages as it is entirely operator dependent and has reduced sensitivity in obese and pregnant patients [14,15].

Surgical management of hernia in pregnancy is under debate regarding the timing, the approach, and the surgical technique. The timing of treatment significantly depends on clinical symptoms and signs at presentation and pregnancy status at diagnosis. If the patient presented with an incarcerated or strangulated hernia, she should be treated with emergency surgical repair regardless of her gestational age [14]. If the hernia is symptomatic but not complicated on clinical evaluation, it should be offered with elective surgery. It is better to delay the surgery until after delivery or after the last delivery in a pregnant woman if the hernia is small and asymptomatic [17]. Suppose the hernia is symptomatic but not complicated. In that case, surgical repair can be offered during the second trimester or postponed to the post-delivery period if no complication develops [2]. In the pre-pregnancy period, if the patient presents with a large and symptomatic hernia, it is better to offer elective laparoscopic or open surgery one or two years before the next pregnancy. If the hernia is small and less symptomatic, it can be treated after delivery, as pregnancy plays a significant role in the recurrence of hernia [14].

When considering the surgical approach and techniques, laparoscopic surgery may be safe in all trimesters in pregnancy and should be offered whenever possible. It is a complex decision to choose the laparoscopic or open approach to treat hernias, and it depends on the patient's age, sex, Body mass index (BMI), hernia size, comorbidities, surgeon's experience, previous surgery, available instruments, and patient preference. The outcome of surgery may significantly vary with these factors. The laparoscopic approach is generally considered superior to the open approach [18,19]. Furthermore, fetal outcomes have shown no significant difference in both laparoscopic and open approaches to treat hernias [20], and the laparoscopic approach is associated with less hospital stay, less postoperative pain, early return to work, and fewer complications [21]. Therefore, the laparoscopic approach should be considered over the open approach in pregnant women with no complicated cases. Therefore, laparoscopic mesh repair should be offered whenever possible, whereas the open approach may be preferred in complicated cases.

Once the timing and approach for ventral hernia repair are sorted out, whether to go for mesh repair or suture repair should be decided. Mesh repair might be better than suture repair as the mesh repair has reduced the recurrence rate during the next pregnancy. However, both suture and mesh repair can cause pain in the third trimester of the next pregnancy [15]. Suture repair may be suitable in the pre-pregnancy period for small hernias and emergencuy surgeries with contamination, but this technique has a higher chance of recurrence. Mesh repair may increase the risk of infection in emergency surgeries, but it is accepted and safe to do emergency mesh repair for incarcerated hernias [14]. With all available literature, mesh repair is the preferred, commonly used, and safer technique with no significant effect on pregnancy and labour course [[14], [15], [16], [17]].

As it is an emergency and complicated case, we offered open surgical repair. Intraoperatively we have found early ischemic changes in small bowel loops within the incisional hernial sac at the previous lower midline laparotomy surgical site with a tightening band at the neck of the hernia. However, we have witnessed that the bowel loop was viable and reversed back to its normal (pink) colour from bluish, and there was no contamination. We have chosen mesh repair after successfully reducing strangulated incisional hernia as it is a safer technique with no significant effect on pregnancy and labour course. Although mesh repair is traditionally not preferred for strangulated hernias, we chose a prosthetic mesh repair because anatomical repair would not effectively handle the increasing intra-abdominal pressure as the pregnancy progresses. Additionally, using antibiotics will help reduce the risk of infection and seroma formation associated with prosthetic mesh repair compared to anatomical repair. The immediate postoperative period was uneventful; eventually, our patient was discharged from the hospital on postoperative day three. She was followed up in our clinic, and no complications were noted. All the sutures were removed on day 14, discharged from our follow-up and referred back to the Antenatal clinic follow-up.

4. Conclusion

Hernias are uncommon in pregnancy and should be evaluated to determine the timing, approach, and surgical management techniques. Emergency surgery should be performed on a patient with complicated hernias like irreducible, strangulated or obstructed hernias, regardless of pregnancy status. Open surgeries are superior to laparoscopic surgery in emergencies. In this case, a pregnant woman with strangulated incisional hernia was treated successfully with open emergency surgery.

CRediT authorship contribution statement

Study concept – S. J. T. Dias, S. Gobishangar.

Data collection – S. J. T. Dias.

Interpretation - S. J. T. Dias, S. Gobishangar.

Manuscript preparing - S. J. T. Dias, S. Gobishangar, K. Heerthikan.

Registration of Research Studies.

N/A

Guarantor

S.J Thayalan Dias. University Surgical Unit, Teaching Hospital, Jaffna Sri Lanka. sjthayalan@gmail.com

Statement of informed consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethical Review Committee of the Tertiary care Hospital does not require ethical approval for reporting individual cases or case series.

Funding

None.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.