INCISIONAL HERNIA

INCISIONAL HERNIA

DEFINITION

• Incisional hernia refers to a hernia that occurs through a previously made surgical incision in the abdominal wall which has failed to heal properly.

• In Ayurvedic context, it may be correlated with Cchidra or Vidradhijanya Viddha Vrana Vikara depending on the doshic involvement and anatomical location.

AETIOPATHOGENESIS

MODERN PERSPECTIVE:

• It occurs due to inadequate healing of surgical wounds in the abdominal wall.

• Contributing factors include:

  • Wound infection

  • Poor surgical technique

  • Obesity

  • Increased intra-abdominal pressure (chronic cough, constipation, ascites, pregnancy)

  • Diabetes mellitus

  • Smoking

  • Steroid therapy

  • Malnutrition

  • Emergency surgery

  • Use of absorbable sutures in muscle layers

AYURVEDIC PERSPECTIVE:

• Improper management of Vrana or post-surgical wounds (Atyayika Karma) leads to Dushta Vrana.

• स्नायवसिरसन्धिषु मार्गे विगुणतां गते।
  गात्रविच्छेदपद्मेषु दोषास्तत्र प्रवर्तते॥
  (Su. Su. 24/7)

• Vitiated Vata and Kapha obstruct the channels and weaken the tissues at the surgical site.

• Dhatukshaya and Agnimandya also contribute to improper wound healing.

CLASSIFICATION

MODERN CLASSIFICATION:

1. Based on Size:

   • Small: <2 cm

   • Medium: 2–4 cm

   • Large: >4 cm

2. Based on Location:

   • Midline

   • Paramedian

   • Transverse

   • Subcostal

3. Based on Reducibility:

   • Reducible

   • Irreducible

   • Obstructed

   • Strangulated

4. Based on Time of Onset:

   • Early onset: <1 year post-surgery

   • Late onset: >1 year post-surgery

AYURVEDIC CLASSIFICATION (CORRELATIVE):

• Not classified directly, but can be correlated based on:

  • Dosha predominance

  • Vrana sthana (location)

  • Avastha (acute/chronic, suppurated/non-suppurated)

CLINICAL FEATURES

• Presence of swelling over previous surgical scar

• Swelling becomes prominent on standing, straining, or coughing

• Dull aching pain or dragging sensation

• Swelling may be reducible on lying down

• In obstructed or strangulated hernia:

  • Severe pain

  • Vomiting

  • Abdominal distension

  • Non-reducibility and tenderness over hernia site

AYURVEDIC CORRELATIVE FEATURES:

• शोथः, स्फोटः, वेदना, च जलप्रस्रवणम्।

• Chronic Dushta Vrana features:

  • गन्धो विष्टिवदुग्रश्च शोणितं पूयपिच्चिलम्॥
    (Su. Su. 21/6)

EXAMINATIONS

• Inspection and palpation of the hernia site

• Cough impulse test

• Reducibility test

• Ring occlusion test

• Auscultation for bowel sounds

• Assessment of previous scar integrity

INVESTIGATIONS & DIAGNOSIS

MODERN INVESTIGATIONS:

• Ultrasonography (USG): Confirms hernia and its content

• CT Scan Abdomen: Detailed anatomy, especially in obese patients or recurrence

• X-Ray Abdomen: In obstructed/strangulated cases

• Blood Tests: CBC, blood sugar, renal profile for surgical fitness

• MRI Abdomen: In complicated or recurrent cases

DIAGNOSIS:

• Based on history of previous surgery and examination findings

• Differentiated from:

  • Lipoma

  • Suture granuloma

  • Hematoma

AYURVEDIC DIAGNOSTIC APPROACH:

• Darshana, Sparshana, Prashna Pariksha (Tri-fold examination)

• Involvement of Dosha, Dhatu, and Srotas is assessed

COMPLICATIONS

• Obstruction

• Strangulation of bowel

• Recurrence after repair

• Infection of surgical wound

• Adhesions and bowel injury

• Respiratory distress in large hernias

MANAGEMENT

MODERN MANAGEMENT:

1. CONSERVATIVE:

• For unfit or asymptomatic patients:

  • Abdominal binder

  • Lifestyle modifications: weight loss, avoid straining

2. SURGICAL TREATMENT:

• Herniorrhaphy (Suture Repair): For small defects without tension

• Hernioplasty (Mesh Repair):

  • Open mesh repair: Onlay, inlay, sublay

  • Laparoscopic mesh repair: IPOM (Intraperitoneal Onlay Mesh), TEP, TAPP

• Component separation techniques for large defects

Pre-operative Optimization:

• Control of diabetes

• Smoking cessation

• Weight reduction

• Nutritional improvement

AYURVEDIC MANAGEMENT:

1. VRANA SHODHANA & ROPANA:

• Shodhana Dravyas:

  • Panchavalkala Kashaya, Triphala Kashaya for local wound wash

• Ropana Dravyas:

  • Jatyadi Taila, Madhu, Ghee based lepas

2. INTERNAL MEDICINES:

• Triphala Guggulu, Kaishora Guggulu – for shotha and granthi

• Gandhaka Rasayana, Rasa Parpati – for wound healing and immunity

• Punarnava Mandoora, Navayas Lauha – in associated anemia

3. BASTI CHIKITSA:

• Erandamooladi Niruha Basti, Dashamoola Niruha – for balancing vata and removing srotorodha

• Matrabasti with Bala Taila or Ksheerabala Taila

4. SHASTRA CHIKITSA (SURGERY):

• In complicated hernia cases (obstruction, necrosis), surgical intervention is mandated.

• Post-surgical Ayurvedic therapies:

  • Raktasthambhaka, Vrana Ropaka herbs and diet

  • Abhyanga and Swedana after recovery for muscle tone restoration

SUSHRUTA’S PRINCIPLE:

• शस्त्रं दाराणि कुर्वीत सूत्रं तत्र प्रयोजयेत् ।
  पुनः पुनस्तथा चोत्थं च्छिद्रं छिनत्ति बुद्धिमान्॥
  (Su. Chi. 17/23)

• Emphasizes use of Shastra Karma and Sutra Karma in managing wound-related defects.

PREVENTION

• Adequate post-operative care

• Aseptic surgical techniques

• Avoidance of strain during post-operative recovery

• Early management of respiratory and abdominal conditions

• Proper nutrition and lifestyle regulation