An incisional hernia is a type of hernia that develops at the site of a previous abdominal surgery where the abdominal wall was cut. This hernia develops due to improper closure of the abdominal wall. It is a common complication after laparotomy, with incisional hernia rates ranging from 15% to 20%. Among all abdominal wall hernias, incisional hernias make up a significant portion and are often regarded as among the most challenging to treat, thus considered a global public health concern.
Patient-related factors: Chronic diseases, such as diabetes, obesity, and renal failure; smoking; chronic constipation; cough; and medications such as immunosuppressants and steroids increase the risk for incisional hernia. For example, obesity increases abdominal wall tension and hinders the healing process. Any factor that increases intra-abdominal pressure contributes to impaired healing.
Disease-related factors: The occurrence of incisional hernia increases with factors such as incision site infection, emergency surgery, complications, and acute abdominal surgery.
Technical factors: Factors, such as suture material and the surgical technique employed, can lead to the reopening of the surgical incision due to poor healing. Studies have shown that midline vertical incisions have the highest hernia rate. If the cut fascial edges are not brought together properly to facilitate healing, either due to improper suture material or closing under tension can increase the risk of incisional hernia.
Some incisional hernias are asymptomatic for a long period of time and are accidentally diagnosed during a routine physical examination or imaging studies done for other purposes. If symptomatic, patients may experience the following:
If left untreated, complications such as incarceration (the herniated content cannot be pushed back), bowel obstruction, or strangulation (compromised blood supply) can arise, leading to severe pain, bowel dysfunction, and ischemia.
Diagnosis begins by obtaining a careful patient history, such as information about prior surgeries, onset of swelling or bulge, potential triggers (standing, straining, lifting), pain, reducibility, and complications.
Physical examination involves the clinician palpating the abdomen to assess for a mass and its location relative to the past surgical scar. Occasionally, the edges of the hernial defect can also be palpated, and the size of the hernia can also be determined.
Imaging is crucial in patients with obesity, large or recurrent hernias, or when the diagnosis is not confirmed via physical examination. Computed tomography scan of the abdomen is the preferred imaging modality, allowing detailed evaluation of the hernial defect size, condition of the abdominal wall (e.g., muscles, connective tissue, or condition of a previous mesh), hernia content (e.g., bowel, fat, etc.), and any complications (e.g., strangulation).
A recent diagnostic and preoperative planning tool called HEDI (Hernia Evaluation, Detection, and Imaging) uses computed tomography imaging to obtain two images (one at rest and another during Valsalva maneuver [forced exhalation against a closed airway]) to determine the hernia defect size/volume and abdominal‑wall instability (tissue elasticity, muscle activation, wall distension). A 3D model of the abdomen can highlight weak areas that strain under pressure.
Thus, modern incisional hernia management involves modifying the repair technique to the hernia (size, complexity, previous surgeries), the patient (risk factors or comorbidities), and the surgical environment (availability, expertise, contamination risk), aiming for a durable, tension-free repair with minimal morbidity.
The decision to repair an incisional hernia depends on several factors, including hernia size, fascial defect, pain or discomfort, risk of future complications, comorbidities, and patient preference.
The primary goals of repair are preventing recurrence, restoring abdominal wall integrity, minimizing post-operative complications, restoring quality of life (e.g., mobility, comfort, etc.), and promoting the return to normal activities.
Surgical techniques have evolved from traditional approaches (e.g., simple suturing) to mesh-based repair, laparoscopic repair, and tissue reconstruction.
Traditionally, small incisional hernias were repaired by simply suturing the fascial edges. However, due to high recurrence rates (approximately 43% in some studies), this approach is now outdated. These high recurrence rates have reserved suture-only repair, with caution, for small defects, good tissue quality, and minimal tension.
Mesh-based Open Repair: Onlay, Sublay (Preperitoneal/Retromuscular), Inlay -H3
Polypropylene meshes have revolutionized incisional hernia repair. They reinforce the defect, distribute tension, and provide long-term abdominal wall strength.
Onlay mesh repair: In this method, the mesh is placed over the anterior fascia, under subcutaneous tissue. The disadvantages of this method are wound complications (e.g. infection), large soft tissue dissection, and prolonged recovery.
Sublay (retromuscular/preperitoneal) mesh repair: The mesh is placed deep, between the peritoneum and the rectus muscle. This method has shown lower recurrence and fewer complications compared to onlay repairs.
Inlay mesh repair: The mesh is placed directly on the defect and secured to the fascia with sutures. This method is associated with high recurrence rates.
Open mesh repair is associated with extensive soft tissue dissection, larger wounds, with risk of wound infection, prolonged hospitalization, and delayed return to normal activity.
Laparoscopic repair is a minimally invasive technique and is favored for incisional hernia treatment, especially in centers with appropriate expertise. The key advantages include small incisions, reduced soft tissue dissection, shorter duration of hospitalization, reduced postoperative pain and rate of complications, and early return to normal activities. Laparoscopic repair has some complications: not ideal for large hernias, dense adhesions, or previous complicated surgeries. Chances of recurrence increased if the mesh is not secured properly, lack of coverage, or inadequate overlap. It is the preferred method of choice for recurrent incisional hernias, although it requires a general surgeon with extensive expertise.
Advanced abdominal wall reconstruction techniques may be required for large, recurrent, and complex hernias, particularly those with poor tissue quality and large defects.
Component Separation Technique (CST): In this technique, the abdominal wall musculofascial layers are separated and mobilized to promote tension-free closure of the defect. A synthetic mesh may be used in addition to the repair to provide support and lower the recurrence rates. Studies have shown that without the mesh, CST suffers from high recurrence rates and complications. Thus, surgeons prefer to use CST along with mesh reinforcement.
Intraoperative Fascial Traction (IFT): This technique is used for hernias larger than 10 cm. Sutures are placed on either side of the hernia defect and into the fascia. The sutures are connected to a device that applies controlled tension, which stretches and elongates the fascial layer, enabling the defect to be closed.
Incisional hernia continues to be the most common and challenging complication following abdominal surgery. However, years of surgical advancements have significantly evolved its management—from traditional suture repairs to mesh-based, tension-free repairs, minimally invasive laparoscopic approaches, and now patient‑specific repair strategies comprising abdominal wall reconstruction.
Mesh-based repair seems to be the best option for balancing safety, recovery, and durability. For large, complex, or recurrent hernias, abdominal wall reconstructive techniques with component separation and mesh reinforcement continue to be the standard procedure.
Preoperative planning tools have shown promise in improving patient outcomes, reducing recurrence, and personalizing surgery. However, challenges, such as patient biology variability, wound healing capacity, surgical expertise, and long-term data in complex hernias, remain. Thus, general surgeons need to perform careful preoperative assessment and surgical planning, optimize comorbidities, and set realistic expectations. The goal is not only to repair hernias but also to restore abdominal wall function, reduce morbidity, and enhance quality of life.
If you notice a swelling or discomfort near a previous surgical scar, timely medical attention can help prevent serious complications. Kauvery Hospital, with experienced surgical teams across Chennai, Hosur, Salem, Tirunelveli, and Trichy, provides advanced imaging, minimally invasive techniques, and personalized care for effective incisional hernia treatment and long-term recovery.
What is an incisional hernia?
An incisional hernia is a bulge that develops at the site of a previous abdominal surgery where the surgical incision did not heal properly, allowing internal tissues or bowel to push through the weakened abdominal wall.
Why does an incisional hernia occur after surgery?
It occurs when the abdominal wall fails to heal strongly after surgery. Risk factors include obesity, diabetes, infection at the incision site, chronic cough, constipation, smoking, steroid use, and increased abdominal pressure.
What are the symptoms of an incisional hernia?
Common symptoms include a visible bulge near a surgical scar, swelling that increases while coughing or standing, discomfort or pain during lifting or straining, and a bulge that reduces when lying down.
Can an incisional hernia become dangerous?
Yes. If untreated, it can lead to incarceration (trapped tissue), bowel obstruction, or strangulation, which cuts off blood supply and requires emergency surgery.
How is an incisional hernia diagnosed?
Diagnosis involves medical history, physical examination, and imaging such as a CT scan. Imaging helps assess defect size, hernia contents, and possible complications.
Is surgery always required for an incisional hernia?
Most incisional hernias require surgical repair because they do not heal on their own and may enlarge over time. The timing depends on symptoms, size, and patient health.
What is the best treatment for incisional hernia?
Mesh-based repair is considered the standard treatment. It reinforces the abdominal wall and reduces recurrence compared to simple suturing.
What is the difference between open and laparoscopic hernia repair?
Open repair involves a larger incision and direct mesh placement, while laparoscopic repair uses small incisions and a camera, resulting in less pain, shorter recovery, and smaller scars.
Can an incisional hernia come back after surgery?
Yes. Recurrence can occur, especially in large or complex hernias, obesity, infection, or if proper mesh reinforcement is not used.
How long does recovery take after incisional hernia surgery?
Recovery varies by technique. Laparoscopic repair often allows return to light activities within 2–3 weeks, while open or complex reconstruction may require longer recovery.
Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai (Alwarpet, Radial Road & Vadapalani), Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and paediatric trauma care.
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