Discussing hernia repair in obstetrics

Discussing hernia repair in obstetrics | Image Credit: © hin255 - © hin255 - stock.adobe.com.

A recent article published in the American Journal of Obstetrics & Gynecology, discussed the etymology, risk factors, and management of hernias.

Hernias, defined as abnormal protrusions of organs, are at risk of developing at the site of a surgical incision or through a defect in the underlying fascia. Hernia repair accounts for approximately 700,000 procedures performed in the United States per year. In women, the risks of epigastric hernias, incisional ventral hernias, and emergency repair of the hernia are higher compared to men. 

Emergency hernia repair is associated with increased rates of morbidity and mortality, making prevention, early diagnosis, and management vital. Improvement of minimally invasive surgery (MIS) techniques has been associated with reduced risks, with rates of ventral hernia formation after MIS as low as 0.5%.

Diagnosis of ventral hernias can often be accomplished through a physical examination. Symptoms include a bulge in the abdominal wall and associated pain. When a physical examination cannot diagnose hernias, imaging modalities may be considered.

Pregnancy is a potential risk factor of hernias, with the expansion of the uterus leading to increased intraabdominal pressure and displaced abdominal organs. Other factors increasing the risk of hernias include obesity, hypertension, smoking, postoperative wound complications, increasing age, and chronic steroid use. Cancer also increases the risk of hernias with a high disease burden.

Data has indicated reduced risk of hernias through continuous fascial suture closure. Hernia risk can also be significantly reduced using smaller bites when suturing fascia. 

In patients with metastatic cancer, exploratory laparotomies can be avoided using laparoscopy before open surgery to determine whether the disease is inoperable. MIS should also be considered for reducing postoperative hernia formation, as well as avoiding laparotomy. 

Hernia formation is more likely following open surgeries through a midline, making them a risk factor. However, the risk of hernia formation after surgery can be reduced through mesh placement.

There is little information on how to manage patients with a presenting hernia at the time of obstetrical or gynecological surgery. This requires clinicians to evaluate retrospective data, case reports, and individual experience when deciding how to proceed with these patients.

A recent study indicated hernia repairs concurrent with obstetrical surgeries do not increase hospitalization duration, postoperative pain, or recovery length. For gynecological surgeries, a preoperative consultation with a general or plastic surgery team for assistance with the repair is recommended. Repair with mesh also reduces recurrence rates compared to hernia repair with sutures.

Recommendations vary for how to treat a hernia which develops during pregnancy based on gestational age. However, emergency hernia repair is recommended in patients with skin ulceration, necrosis, or bowel incarceration.

Hernias which present later in pregnancy require a decision on whether emergency hernia repair should be conducted alongside cesarean delivery, or if cesarean delivery should be delayed until term. Patients receiving a planned cesarean delivery should have elective hernia repair conducted concurrently.

Data has indicated hernia repair should be conducted during delivery rather than be delayed. This removes the need for a second hospital visit with associated medical costs and recovery durations.

Patients with a hernia desiring future pregnancy should have repair completed before the beginning of pregnancy. While there is little information on how long after hernia repair pregnancy should be avoided but the current recommended duration is 12 months.

Recommendations for hernia repair are based on the approaches of a surgeon and the risk factors of a patient. Doctors should consider the best techniques, timing, and approach to follow.

Reference

Knochenhauer HE, Lim SL, Brown DA. An obstetrician-gynecologist’s review of hernias: risk factors, diagnosis, prevention, and repair. American Journal of Obstetrics & Gynecology. 2023;229(3). doi:10.1016/j.ajog.2023.04.024