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Abdominal Wall

Pfannenstiel Incision

Maylard Incision


Incisional Hernia

Abdominal Wound
Dehiscence and

Massive Closure
of the Abdominal
Wall With a One-Knot
Loop Suture

Hemorrhage Control Following Laceration
of Inferior Upper
Epigastric Vessels

Incisional Hernia Repair

Although improved suture materials (stainless steel wire, monofilament nylon, Prolene, etc.), in addition to improved techniques in closing the rectus fascia, have significantly reduced the incidence of incisional hernia, such hernias do occasionally occur.

They are, interestingly, rarely seen with the lower transverse Pfannenstiel-type incision. The etiology of incisional hernia can range from wound infection and subfascial hematoma to a disruption of the suture line secondary to coughing during the immediate postoperative period.

The purpose of the operation is to close the hernia and reinforce the fascia to reduce recurrence.

Physiologic Changes. The overall comfort of a patient is increased by eliminating the incisional hernia. Although the incidence of bowel obstruction is small, it can occur. The traditional physiologic principles of hernia repair apply equally to incisional hernias and inguinal hernias (i.e., high ligation and excision of the hernial sac and double reinforcement of the rectus fascia).

Points of Caution. Care must be exercised in making the initial incision to avoid lacerating a loop of bowel adherent in the hernial sac.

Adequate mobilization of both fascia and subcutaneous tissue should be made to allow tissues to come together without tension.


The patient is placed on the operating table in a supine position. Palpation of the abdomen reveals the hernia. No attempt is made to excise the cutaneous portion of the hernial sac. A midline incision is made over the hernial area, excising the previous scar.

The incision is carried down to the hernial sac, which generally represents the peritoneum or attenuated rectus fascia. The hernial sac is located, a small hole is made, the sac is completely explored with the finger, the peritoneal incision is extended, and all contents are removed from the sac. The margins of the sac itself are identified and excised with scissors. The margins of the rectus fascia are then identified, and the skin and subcutaneous fat overlying the rectus fascia are sufficiently mobilized to allow the rectus fascia to be developed as two overlying flaps similar to a double-breasted coat. This is initiated by placing a retractor under the skin margin, applying two Kocher clamps to the margin of the rectus fascia, and dissecting the skin and subcutaneous tissue from the rectus fascia with sharp dissection. The same procedure is carried out on the opposite side. The peritoneum is closed with a running 0 synthetic absorbable suture.

A row of 28-gauge stainless steel wire or 0 nylon sutures is placed in the base of one flap and through the margin of the opposite flap as interrupted mattress sutures. These are tied in progression. The margin of the overlying flap is elevated by traction with small hemostats.

The line of sutures from the inner flap is completed. The outer layer of rectus fascia is pulled over the inner layer and sutured with interrupted 28-gauge wire or 0 nylon mattress sutures.

Any existing scar tissue in the skin and subcutaneous incision is surgically excised.

The subcutaneous tissue is closed with interrupted 2-0 synthetic absorbable suture, and the skin is closed with a subcutaneous 3-0 Dexon suture.

Copyright - all rights reserved / Clifford R. Wheeless, Jr., M.D. and Marcella L. Roenneburg, M.D.
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