Incisional Hernia

An incisional hernia develops when tissue or organs push through weakened abdominal muscles at the site of a previous surgery, creating a bulge near your surgical scar that may appear months or even years after the procedure.

Table of contents

• What is an Incisional Hernia?
• Why Incisional Hernias Develop
• Risk Factors
• Signs and Symptoms
• Possible Complications
• How Doctors Diagnose Incisional Hernias
• Treatment Options
• Preventing Incisional Hernias
• Recovery After Surgery

What is an Incisional Hernia?

An incisional hernia happens when a section of your intestine or abdominal tissue pushes through weakened muscles in your abdominal wall at the site where you had surgery. The surgery weakens your abdominal muscles, making it easier for sections of your intestine or abdominal fat to push through and create a hernia. The hernia creates a bulge or lump near your surgery scar.^[1]

Incisional hernias are common complications of abdominal surgery. Experts estimate that up to 20% of people who have a laparotomy (open abdominal surgery) develop one.^[1] According to other sources, this rate may be as high as 15% to 20%, and in some cases, up to 33% of people may develop an incisional hernia after abdominal surgery.^[3][4]

An incisional hernia is a type of ventral hernia, which refers to hernias that occur in the abdominal wall. These hernias can appear weeks, months, or even years after you have surgery.^[3][4]

Most incisional hernias are not serious medical issues. However, a large incisional hernia can cause serious complications. Treatment usually involves surgery to repair the hernia and strengthen weak spots in your abdominal muscles.^[1]

Why Incisional Hernias Develop

Incisional hernias develop because the abdominal wall fails to close properly after surgery. Despite advancements in surgical techniques, the rate of incisional hernias following abdominal surgery remains significant.^[3]

Most surgical wounds from abdominal surgery heal well, leaving the abdominal wall just as strong as it was before the operation. However, if the abdominal wall doesn’t grow back together tightly enough, it may be weakened near the scar. Then tissue or parts of organs might push through the gap that arises and bulge out.^[9]

Incisional hernias can occur after any abdominal surgical procedure where the abdominal wall is cut. They have also been reported after traumatic abdominal wall injuries. Midline incisional hernias, which occur along vertical incisions in the middle of the abdomen, are more common than hernias at other sites.^[3]

The hernia occurs when the surgical wound does not heal properly, causing a gap to develop in the abdominal wall. The weakened area cannot stay intact against the pressure of the abdomen, allowing abdominal tissue, intestines, or organs to push through and protrude.^[2]

Risk Factors

Several factors can slow healing time and increase your risk of developing an incisional hernia. These factors are related to the patient, the disease, and technical aspects of the surgery.^[3]

Patient-related factors that impair proper wound healing and affect the strength of new tissue include:^[1][3]

• Being very active soon after surgery
• Diabetes
• Obesity or morbid obesity
• Lung diseases like chronic obstructive pulmonary disease (COPD) that cause chronic coughing
• Long-term use of immunosuppressants or corticosteroids
• Smoking
• Malnutrition
• Renal failure
• Older age

Disease-related and surgical factors that increase risk include:^[2][3]

• Strenuous physical activity before adequate wound healing
• Gaining weight or becoming pregnant after surgery
• Straining during bowel movements
• Surgical site infections
• Hematoma (blood collection) at the wound site
• Abdominal swelling due to fluid accumulation
• Emergency surgeries
• Midline incisions
• Acute abdominal surgeries

Very overweight people are more likely to develop incisional hernias because the pressure inside the abdomen is greater, which puts more strain on the scar tissue.^[9] People who smoke get hernias at higher rates than nonsmokers, partly because chronic coughing can trigger a hernia and smoking interferes with collagen formation in the body, reducing tissue strength.^[15]

Signs and Symptoms

A small incisional hernia may not cause symptoms. A small hernia is about 2 inches (5 centimeters) wide or long. A large incisional hernia—one that measures more than 4 inches (10 cm)—may cause pain and create a bulge or lump near your surgery scar.^[1]

The most common symptom of an incisional hernia is a visible bulge formed at the surgical site. The hernia may sometimes be reducible, meaning its contents can slide back or be manually pushed back into the abdominal cavity.^[2]

Common symptoms include:^[1][2][4]

• A bulge near an old surgical incision
• Sharp pain and discomfort when straining, lifting, coughing, or sneezing
• Pain that can be sharp or a dull ache
• Aching, burning, or gurgling sensations
• Redness of the bulge
• Abdominal pain during physical activity
• Nausea and vomiting
• Diarrhea or constipation
• Thin stools

The bulge may be more noticeable when you stand up or put strain on your abdominal muscles. For example, you may notice a bulge if you are constipated and have to bear down to have a bowel movement.^[1] The lump appears when you cough or strain, and then may go away again.^[9]

Possible Complications

While most incisional hernias are not serious, complications can occur in rare cases. Sometimes, scar tissue can develop causing an intestinal blockage.^[2]

An incarcerated incisional hernia happens when the intestine inside the hernia gets stuck in your abdominal wall. A strangulated incisional hernia is another complication that occurs when pressure on the hernia cuts off blood supply to the intestine in the hernia. The intestine can start to die, a condition called necrosis.^[1]

An incarcerated hernia that is fixed can become strangulated due to a lack of blood supply. This can lead to tissue damage due to necrosis or inflammation of the tissues involved in the hernia and is considered a medical emergency.^[2]

In rare cases, parts of the bowel might get trapped in the opening of the abdominal wall, blocking the passage of stool (obstruction) or cutting off the blood supply (strangulation). Large incisional hernias can also make it difficult for you to breathe or move normally.^[9]

Warning signs of serious complications include:^[1][2]

• Sudden, severe pain
• Changes in the color of the skin around the bulge (may become paler than usual and then turn darker than usual)
• Tender, painful, swollen, or discolored bulge
• Vomiting
• Fever
• Severe abdominal pain
• Unable to pass stools or gas
• Wound infection
• Intestinal blockage

You should go to the emergency room if you have these symptoms, as urgent or emergent surgery may be needed.^[1][11]

How Doctors Diagnose Incisional Hernias

A healthcare provider will do a physical examination. They may ask you to sit down and then stand up so they can see if the bulge in your abdomen comes and goes. You may be asked to stand and cough while your doctor examines the bulge in the abdomen.^[1][2]

Your doctor will review your medical and surgical history and carefully examine your abdominal area. They’ll ask about other symptoms to rule out the chance that you have an incarcerated incisional hernia.^[1][12]

Imaging tests may be ordered to view the abdominal or intestinal tissues and provide more details on the hernia’s location. These tests help determine the surgical strategy and can include:^[2][12]

• Ultrasound
• CT (computed tomography) scans
• MRI (magnetic resonance imaging) scans

Treatment Options

Treatment depends on your symptoms and the severity of the condition. For example, you may not need treatment if your hernia is small, not causing any problems, and has a low chance of causing complications.^[1][4]

If certain information is small and not causing any symptoms, a surgical repair may not be necessary. All surgery carries the risk of complications, so for some patients, watchful waiting is advised.^[17]

A hernia belt may be beneficial for some patients and can provide additional support to the abdominal wall. The belt is worn over the hernia site to prevent it from coming out. These belts are usually made-to-measure by a specialized appliance fitter. More modern elasticated support garments may provide an alternative for those who wish to avoid surgery or wear a belt, but there isn’t any good evidence that they will prevent hernias from enlarging.^[17]

A hernia repair is usually advised if a hernia becomes symptomatic—that is, if it starts enlarging, causing discomfort, or generally interfering with the activities of daily living. Severe cases may lead to strangulation where the blood supply to the tissues is blocked and is considered an emergency condition.^[2][17]

Treatment for an incisional hernia is surgery to repair the hernia and reinforce weak spots in your abdominal muscles. Incisional hernias can vary in size from very small to very large, and no single operation is suitable for all types of hernia.^[1][17]

Surgical Repair Methods

Most surgeons agree that repairing incisional hernias is best accomplished using mesh. The type of mesh used is often determined by the method of repair, size of the defect, the patient’s body habitus, and the manner in which a patient presents with the problem.^[7]

Operations can be done as open procedures or as keyhole (laparoscopic) procedures. Not all incisional hernias are suitable for a keyhole repair. Hernias are repaired using sutures or a combination of sutures and mesh reinforcement. Generally, sutured repairs are only suitable for smaller hernias, and large hernias nearly always need mesh reinforcement as well.^[17]

Open Incisional Hernia Repair: The procedure is performed under general anesthesia. Your surgeon will make an incision through your old scar. They will repair the weak tissue either with stitches only or using a synthetic mesh, which they will stitch to the muscles under your skin. For small hernias, the defect in the muscles may be sutured closed (herniorrhaphy). For larger defects, a natural or synthetic mesh is additionally placed over the defect to reinforce the closure (hernioplasty).^[2][6]

Your surgeon may need to form a flap of skin over the repair so that your skin closes properly. They will close your skin over the repair, and may place a drain to remove excess fluid.^[6]

Laparoscopic (Keyhole) Hernia Repair: This is a minimally invasive technique performed under general anesthesia. Your surgeon will make a few small incisions on the abdomen through which a laparoscope—a thin flexible tube with a light and a camera at its end—will be inserted along with other surgical instruments. The camera captures images that are displayed on a monitor to help your doctor carry out the procedure.^[2]

The abdominal cavity is inflated with a harmless gas to improve the visualization of the structures. The protruding tissues or organs are returned back to the abdomen, and the defect is closed with sutures or a mesh. The laparoscope and instruments are then removed, and the incisions are closed with stitches or surgical tape.^[2]

Robotic Hernia Repair: This procedure is similar to laparoscopic repair, but your surgeon uses robot-assisted technology to guide the movements of the surgical tools precisely. This allows for more precise movements during surgery.^[5][12]

Complex Ventral Hernia Repair: This involves separating the different layers of the abdominal wall to create a more durable repair. The key to repair is having wide coverage of the defect. This is best accomplished using one of the component separation techniques, which allows for the release of either the anterior or posterior components of the abdominal wall. This provides laxity to the muscles and allows for closure of larger defects.^[7][12]

The operation can take between 90 minutes and 3 hours, sometimes longer in more complicated cases.^[6]

Preventing Incisional Hernias

Giving your body time to heal is the best thing you can do to reduce your risk. You may need to hold off on strenuous activities. Ask your surgeon when you can start being more active.^[1]

To lower the risk of incisional hernias, people are advised to do the following:^[9][2][15]

• Avoid straining your abdominal muscles too much in the first few months after surgery
• Maintain a healthy weight—the pressure inside the abdomen goes down as a result
• Avoid straining during bowel movements
• Treat constipation (stool softeners may be recommended following abdominal surgery)
• Avoid strenuous activity and place pressure over the area for support while performing activities that may strain the abdominal area
• Use topical ointments for wound healing
• Control your blood sugar level if you are diabetic
• Quit smoking—wounds are able to heal better in people who don’t smoke
• Avoid heavy lifting wherever possible, using your legs and not your back to lift heavy objects if you need to

Regular exercise should help to prepare you for surgery, help you to recover, and improve your long-term health. Do not do exercises that involve heavy lifting or make your hernia painful. Before you start exercising, ask the healthcare team or your doctor for advice.^[6]

People who have a higher risk of incisional hernias can have a synthetic mesh put in their abdomen during abdominal surgery as a preventive measure. The mesh strengthens the abdominal wall and can greatly reduce the risk of incisional hernias, but it can also cause problems such as chronic pain.^[9]

Recovery After Surgery

After surgery to repair your hernia, you are likely to have pain for a few days. You may also feel tired and have less energy than normal. This is common. You should feel better after a few days and will probably feel much better in 7 days.^[16]

For several weeks you may feel discomfort or pulling in the hernia repair when you move. You may have some bruising around the area of the repair. This is normal.^[16]

Activity guidelines:^[16][19]

• Rest when you feel tired. Getting enough sleep will help you recover
• Try to walk each day. Start by walking a little more than you did the day before. Walking boosts blood flow and helps prevent pneumonia and constipation
• If your doctor gives you an abdominal binder to wear, use it as directed
• Avoid strenuous activities, such as biking, jogging, weight lifting, or aerobic exercise, until your doctor says it is okay
• Avoid lifting anything that would make you strain, including heavy grocery bags, a vacuum cleaner, or a child
• Most people are able to return to work within 1 to 2 weeks after surgery. But if your job requires heavy lifting or strenuous activity, you may need to take 4 to 6 weeks off from work
• You may shower 24 to 48 hours after surgery, if your doctor okays it. Pat the cut dry. Do not take a bath for the first 2 weeks
• Ask your doctor when it is okay for you to have sex

Diet recommendations:^[16][19]

• You can eat your normal diet. If your stomach is upset, try bland, low-fat foods like plain rice, broiled chicken, toast, and yogurt
• Drink plenty of fluids
• Focus on high-fiber foods to prevent constipation, which can strain your surgical site
• Stay well-hydrated by drinking plenty of water throughout the day
• Include protein-rich foods like lean meats, eggs, and legumes to support tissue healing
• Consider smaller, more frequent meals if you experience fullness or discomfort
• You may notice that your bowel movements are not regular right after your surgery. Avoid constipation and straining with bowel movements

Incision care:^[16]

• If you have strips of tape on the cut, leave the tape on for a week or until it falls off
• If you have staples closing the cut, you will need to visit your doctor in 1 to 2 weeks to have them removed
• Wash the area daily with warm, soapy water, and pat it dry. Don’t use hydrogen peroxide or alcohol, which can slow healing
• You may cover the area with a gauze bandage if it weeps or rubs against clothing. Change the bandage every day

Pain management:^[16]

• Take pain medicines exactly as directed
• Hold a pillow over your incision when you cough or take deep breaths. This will support your belly and decrease your pain
• Do breathing exercises at home as instructed by your doctor to help prevent pneumonia

Recovery timelines vary based on the surgical approach used. Laparoscopic procedures generally allow for quicker recovery compared to traditional open surgery, but individual healing rates differ.^[19]