Incisional hernia repair

Photo of an overweight man at the gym (PantherMedia / AndrewLozovyi) Incisional hernias can occur near or along surgical scars in the abdomen. Although they don’t usually cause any serious problems, they can be unpleasant. The treatment options for incisional hernias are open surgery or minimally invasive surgery. Minimally invasive surgery is also called “keyhole surgery,” or “laparoscopic” surgery if it is performed on the abdomen.

Incisional hernias may occur months or years after an abdominal operation. You can usually only see a small lump or swelling near the site of the scar at first. The lump appears when you cough or strain, and then goes away again. Over time, though, it might get bigger and start hurting.

Most incisional hernias don’t cause any serious problems. In rare cases, parts of the bowel might get trapped in the opening of the hernia, 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.

How do incisional hernias develop?

Most surgical wounds heal well, leaving the abdominal wall just as strong as it was before the operation. But if the cut that was made in the abdominal wall doesn’t grow back together tightly enough, the abdominal wall may be weakened in that area. If the scarred area can then no longer withstand the pressure in the abdomen, tissue or parts of organs might push through the gap that arises and bulge out.

The risk of incisional hernias is influenced by the following factors:

  • The type of scar and the sewing technique used: Most incisional hernias occur after open abdominal surgery, where a large incision (cut) was made across the middle of the abdomen.
  • Older age, other illnesses and wound healing problems: These can increase the risk too.
  • Being very overweight: Very overweight people are also more likely to develop incisional hernias because the pressure and strain on the scar tissue is greater.

Depending on what kind of operation was done, about 5 to 15 out of 100 people develop an incisional hernia after having abdominal surgery. Most incisional hernias occur in the first year after the surgery.

What can you do to prevent them?

To lower the risk of incisional hernias, people are advised to do the following:

  • Avoid straining your abdominal muscles too much in the first few months after surgery. But there is very little research on which kinds of strain are potentially harmful and which are not.
  • Lose weight. The pressure inside the abdomen goes down as a result.
  • Wounds are able to heal better in people who don’t smoke and who manage medical conditions like diabetes properly, so this also lowers the risk of incisional hernias.

Some people who have a major abdominal operation or incisional hernia surgery wear a special abdominal belt (corset) for a while afterwards, in order to help support their abdominal wall. But it isn’t clear whether abdominal belts actually help to prevent incisional hernias.

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.

What are the treatment options for incisional hernias?

The opening of the hernia is sewn shut and usually covered with a synthetic mesh. This helps strengthen the abdominal wall. The risk of having another incisional hernia is much greater if no mesh is used.

The surgery can be carried out in the following ways:

  • Open surgery: The abdomen is cut open, the opening of the hernia is closed from the outside, and a mesh is placed on it to strengthen it.
  • Laparoscopic (minimally invasive or keyhole) surgery: The doctor inserts surgical instruments and a fine tube with a camera attached to it (a laparoscope) through several small cuts. The cuts are about 5 to 10 mm long. The mesh is attached to the abdominal wall from the inside.

If an incisional hernia occurs within the first few weeks after an abdominal operation, the hernia isn’t repaired immediately. This gives the abdominal wall time to recover. Incisional hernias are generally only repaired several months after the surgery that led to them was carried out.

Is open surgery or laparoscopic surgery better?

These two approaches are equally well-suited to stabilize the abdominal wall. There is also no difference between them in terms of the risk of incisional hernias recurring, as long as synthetic mesh was used.

One advantage of keyhole surgery is that the surgical wounds are less likely to become infected afterwards. It also allows you to leave the hospital sooner.

But the risk of complications might be a little higher with keyhole surgery if the surgeon doesn’t have enough experience. This is because it is harder to learn how to perform keyhole surgery compared to open surgery. So the surgeon’s level of experience will probably play a bigger role than the type of surgery that is done.

To find out how much experience different hospitals in Germany have with a certain type of surgery, you can read their hospital quality reports.

What risks are associated with surgery?

Surgery can lead to injuries in the abdominal cavity. The wound may also become infected in the first few days after surgery. About 15 out of 100 people experience pain after surgery, but it often goes away after a few days or weeks. In some cases the pain becomes permanent, though. Possible causes of pain include nerves that were damaged, scar tissue sticking together, or the mesh being too tight.

Sometimes fluid builds up around the mesh after surgery. The fluid may have to be removed using a hollow needle (puncture aspiration).

About 5 out of 100 people develop another incisional hernia after having surgery to repair a hernia. People who have had keyhole surgery are advised to avoid lifting and carrying heavy objects in the first six weeks after the operation. Those who have had open surgery should avoid doing this for the first three months because the scar is bigger.

Do incisional hernias always have to be operated on?

If incisional hernias don’t cause any problems and there's a low risk of complications, surgery isn't always needed. But this type of hernia often gets bigger over time, and there's a small risk that part of the bowel might become pinched. There is currently not enough good research to be able to say what the pros and cons of not having surgery are.

When deciding whether or not to have surgery, the patient’s age and other medical conditions play a role too. It is best to discuss the advantages and disadvantages of having surgery with a doctor.

When are incisional hernias more difficult to treat?

Because large incisional hernias are often very unpleasant, many people who have them want to have treatment. But large hernias are a lot harder to operate on than small hernias.

Many people who have large incisional hernias are very overweight, have weak abdominal muscles and also have other medical conditions. This increases the risk of complications after surgery. The most suitable type of surgery will then depend on a range of individual factors. It can be a good idea for people in this situation to make an appointment at a specialized hernia center.

Women who would still like to have children are also in a special situation. Their abdominal muscles have to be able to stretch a lot during pregnancy to make room for the growing baby. Because synthetic mesh is less elastic than natural muscle tissue, doctors are concerned that women who become pregnant will have a greater risk of complications. Unfortunately there is very little scientific research in this area.

Most women who have an incisional hernia can put off the hernia surgery until they're sure they don’t want to have any (more) children. When hernia surgery is necessary in women who might still have children, doctors tend to recommend not using a mesh. But then the hernia often returns during pregnancy.