What is an incisional hernia?
An incisional hernia is the protrusion of intra-abdominal contents through a defect in the abdominal wall created by a previous surgical incision. It develops in 10–20% of patients undergoing laparotomy, usually within the first 3 years after the operation, but may also appear after many years.
It is graded by size (small <4cm, medium 4–10cm, large >10cm), location (midline, lateral) and complexity (presence of skin defects, loss of domain). Modern treatment requires specialised evaluation and frequently uses advanced techniques such as TAR (Transversus Abdominis Release).
How common is it?
Incisional hernia is one of the most common late complications of abdominal surgery. The cumulative incidence over the first 3 years after laparotomy is 10–20%, while in high-risk groups (obesity, infections, emergency surgery) it can exceed 30%.
Approximately 350,000 incisional hernia repairs are performed annually in the United States, and tens of thousands in Greece. Their incidence is expected to rise due to the increasing rates of obesity and complex abdominal operations.
How does it present?
The main symptoms of incisional hernia include:
- Visible or palpable swelling along a previous surgical incision, more pronounced on standing or straining.
- Local discomfort, pain or burning sensation.
- Feeling of weight or pulling in the abdomen.
- Skin changes overlying the swelling, occasionally ulceration.
- Difficulty maintaining good abdominal posture.
- Severe pain, fixed swelling, redness or vomiting — incarceration or strangulation, requires emergency surgery.
How is it diagnosed?
Diagnosis is clinical, with imaging support for planning:
- Detailed history of the previous operation and time elapsed since.
- Clinical examination in supine and standing positions, with measurement of the defect.
- Abdominal CT — essential for accurately assessing the size, location and number of defects, as well as for evaluating "loss of domain".
- Evaluation of comorbid conditions (diabetes mellitus, obesity, smoking) which affect outcomes.
- Possible additional imaging (MRI) in complex cases.
Which factors increase risk?
Risk for incisional hernia depends on patient and technical factors. There is a hereditary component related to collagen synthesis, but acquired factors predominate.
- Obesity (BMI >30) — increases risk 2–3 fold.
- Smoking — impaired wound healing.
- Diabetes mellitus.
- Postoperative infection — the strongest single risk factor.
- Emergency surgery, contaminated procedure.
- Type of incision (midline incisions have higher risk than transverse).
- Suboptimal closure technique.
- Chronically raised intra-abdominal pressure.
- Connective tissue disorders, immunosuppression, chronic corticosteroid use.
Modern therapeutic options
Treatment of incisional hernia is highly individualised. The choice between open, laparoscopic and robotic technique depends on defect size, location, prior operations, comorbidities and patient preference.
Laparoscopic Repair (IPOM-Plus)
For small to medium hernias (<10cm), without skin damage. Performed through 3–4 small incisions, with primary closure of the defect and reinforcement with intra-abdominal mesh. Lower wound infection rate and faster recovery compared to open repair.
Robotic Repair (rTAR / rTAPP)
The leading-edge technique for complex hernias. The Da Vinci system allows transversus abdominis release (TAR) for restoration of normal anatomy with mesh placement in the retromuscular position. Excellent long-term outcomes even in very large hernias.
Open Repair with TAR
For very large hernias (>10cm), loss of domain or compromised tissues. The TAR technique allows complete reconstruction of the abdominal wall with sublay mesh placement. The most reliable technique in extreme cases.
Frequently asked questions
Can the hernia be repaired immediately or do I need preparation?
Preoperative optimisation is essential, especially in large hernias. We recommend smoking cessation 6 weeks earlier, weight reduction in obese patients, and tight glycemic control in diabetics. In very large hernias, special techniques (preoperative Botox, pneumoperitoneum) may be needed.
Is the hernia likely to recur after repair?
In primary incisional hernias treated with mesh, recurrence rate is 5–15%. In repeated recurrent hernias and very large hernias, recurrence may reach 20–30%. The TAR technique reduces recurrences significantly.
Is the operation painful?
Modern multimodal pain control protocols (TAP block, ERAS protocol) significantly reduce postoperative pain. Most patients have good pain control with simple analgesics within 48 hours.
When can I return to normal activities?
Light activity (walking) from the 2nd day. Driving in 10–14 days. Office work in 2–3 weeks. Strenuous activity and lifting only after 6–8 weeks, depending on the size of repair.