What type of hernia is most commonly seen in a patient with a prone belly, possibly with a history of abdominal surgery?

Incisional Hernia in Prune Belly Syndrome

The term "prune belly" refers to prune belly syndrome (also called Eagle-Barrett syndrome), a congenital condition characterized by absent or deficient abdominal wall musculature, and this condition does not inherently involve a specific "type" of hernia—rather, these patients are at extremely high risk for developing incisional hernias following any abdominal surgery due to their deficient abdominal wall.

However, if the question refers to a "prone belly" (meaning a patient positioned prone or with abdominal wall laxity), or if there is a history of abdominal surgery, the most relevant hernia type is incisional hernia.

Understanding Incisional Hernias

Incisional hernias represent the most common long-term complication following laparotomy, with incidence ranging from 2-40% across studies, and are defined as a late manifestation of abdominal fascia closure failure after surgical incisions. 1

Key Clinical Features

• Incisional hernias typically manifest within the first two years after surgery, with approximately half diagnosed within the first year following the initial operation 2
• These hernias can cause significant morbidity including pain, deformity, bowel obstruction, incarceration, strangulation, and necessity for reoperation with higher associated morbidity 1
• The estimated incidence following major abdominal surgery ranges from 2-40%, with emergency procedures carrying higher risk than elective operations 1

High-Risk Patient Populations

Patients with specific comorbidities face substantially elevated risk for incisional hernia development and should be identified early. 1

Risk Factors Include:

• Diabetes mellitus 1
• Chronic pulmonary disease 1
• Active smoking 1
• Obesity 1
• Immunosuppression 1
• Surgical site infection or contaminated surgical fields 1
• Previous abdominal surgery 1

Emergency Complications Requiring Urgent Intervention

When evaluating a patient with suspected incisional hernia, immediate assessment for complications is critical, as approximately 15% of incisional hernia repairs are performed emergently due to incarceration or strangulation. 2

Red Flag Signs:

• Irreducibility of the hernia 3
• Tenderness over the hernia site 3
• Erythema or overlying skin changes 3
• Systemic symptoms including fever, tachycardia, and leukocytosis 3
• Abdominal wall rigidity 3
• Signs of bowel obstruction 1

Laboratory Markers Predictive of Strangulation:

• Arterial lactate ≥2.0 mmol/L predicts non-viable bowel with significant accuracy 1, 3
• Elevated white blood cell count is moderately predictive of strangulation 1, 3
• Elevated creatinine phosphokinase and D-dimer levels suggest ischemic complications 3

Diagnostic Approach

Contrast-enhanced CT scanning is the study of choice for evaluating suspected complications of incisional hernias in the emergency setting. 1

• CT with contrast demonstrates 56% sensitivity and 94% specificity for predicting bowel strangulation based on reduced wall enhancement 1, 3
• CT helps identify bowel obstruction, perforation, and other intra-abdominal complications 1
• Point-of-care ultrasound can identify free fluid and intestinal distention 1

Special Consideration: Post-Bariatric Surgery

In patients with history of bariatric surgery (particularly Roux-en-Y gastric bypass), internal hernias must be distinguished from incisional hernias, as internal hernias present with persistent crampy epigastric pain and carry high risk of bowel ischemia. 1

• The triad of persistent epigastric pain, pregnancy, and history of laparoscopic Roux-en-Y gastric bypass should raise immediate suspicion for internal hernia 1
• Negative CT scan does not rule out internal hernia—40-60% of internal hernias may not show diagnostic CT findings 1
• Low threshold for diagnostic laparoscopy is recommended in post-bariatric patients with persistent abdominal pain 1

Critical Timing Considerations

Delayed treatment beyond 24 hours in cases of strangulated incisional hernia is associated with significantly higher mortality rates. 3

• Symptomatic periods lasting longer than 8 hours significantly affect morbidity rates 3
• Time from symptom onset to surgery is the most important prognostic factor 3
• Emergency hernia repair should be performed immediately when intestinal strangulation is suspected 3

Common Pitfalls to Avoid

• Do not delay surgical evaluation if any signs of incarceration or strangulation are present, even with equivocal imaging findings 1
• Do not rely solely on laboratory values—clinical assessment remains paramount, as WBC and lactate may be normal in early strangulation 1
• Do not assume all post-operative abdominal pain is benign—maintain high index of suspicion for incisional hernia complications, particularly in high-risk patients 1