Clinical Case: Incisional Hernia Post-LSCS

1. Predisposing Factors of Hernia (1 mark)

• Obesity - this patient is obese (increases intra-abdominal pressure and impairs wound healing)
• Chronic cough - this patient has asthma, causing repeated bouts of coughing (elevated intra-abdominal pressure)
• Hypothyroidism - impairs wound healing and tissue repair
• Genetic collagen disorders
• Malnutrition / immunosuppression / steroid therapy
• Cancer
• Postpartum state (recent LSCS, 5 months ago - wound still maturing)

• Poor quality tissues
• Wound tension
• Wound infection (SSI is a major risk post-LSCS, especially in obese patients)

• Inappropriate suture material
• Poor closure technique
• Inadequate fascial bites (current evidence recommends 5 mm apart, 5-8 mm from wound edge)

2. Preoperative Preparation for Surgery (1.5 marks)

A. General Prehabilitation

• Weight loss - loss of 7% of total body weight achieves significant improvement in metabolic state; 5 kg of weight loss creates approximately 1 extra litre of space in the abdominal cavity, crucial for hernia reduction (Bailey and Love's)
• Fitness improvement and core strength exercises
• Multidisciplinary team (MDT) assessment - now considered standard of care for complex incisional hernia repair

B. For Obesity

• Target BMI reduction preoperatively
• Nutritional optimization
• Prophylactic anticoagulation planning (high DVT/PE risk in obese patients)
• Appropriate dosing of drugs, anaesthetic agents

C. For Asthma

• Ensure optimal bronchodilator control (step-up therapy if needed)
• Salbutamol/inhaled steroids should be continued perioperatively
• Pulmonary function tests (PFTs) / spirometry to assess baseline
• Anesthesia planning: regional/spinal anesthesia preferred over general where possible to avoid bronchospasm triggers
• Chest physiotherapy pre- and post-operatively
• Avoid NSAIDs perioperatively (aspirin-exacerbated respiratory disease risk)

D. For Hypothyroidism

• Check TFTs (TSH, Free T4) - surgery should be deferred until euthyroid state is achieved
• If on thyroxine replacement, continue it perioperatively (thyroxine has a long half-life, one missed dose is acceptable, but ensure regular dosing)
• Hypothyroidism increases risk of: adrenal insufficiency, prolonged ileus, poor wound healing, cardiovascular instability (bradycardia, hypotension)
• Alert anesthesia team: hypothyroid patients are sensitive to sedatives and opioids

E. Routine Preoperative Workup

• Full blood count, metabolic panel, coagulation profile
• Blood glucose (obesity + hypothyroidism - screen for T2DM)
• ECG (hypothyroid cardiovascular effects)
• Imaging: CT abdomen to assess hernia defect size and contents
• Cross-match blood
• Prophylactic antibiotics (especially high SSI risk in obese)
• VTE prophylaxis (LMWH + compression stockings)

3. What May Happen if the Patient is Left Untreated (1 mark)

1. Increase in size - incisional hernias tend to enlarge progressively over time; overlying skin may become thin and atrophic
2. Skin ulceration - local trauma and microvascular damage from stretched, thin overlying skin
3. Irreducibility - the hernia contents can no longer be pushed back, usually due to adhesions or increasing size
4. Intestinal obstruction - common because of coexisting internal adhesions; episodes of colicky abdominal pain, vomiting, and constipation
5. Strangulation - less frequent in incisional hernias (because most are wide-necked), but occurs when the fibrous defect is small relative to a large sac; leads to ischemia and bowel infarction - a surgical emergency
6. Death - from untreated strangulation and perforation leading to peritonitis and sepsis