Incisional Hernia Surgery​ - Types, Benefits, Procedure

The choice of incisional hernia surgery depends on the hernia size and location of the hernia, the condition of the abdominal wall, previous abdominal operations, the presence of recurrent or complex hernias, the patient's overall health, and the surgeon's clinical assessment. The main types of incisional hernia surgery include: 

Types Based on Surgical Approach

• Open Incisional Hernia Repair
• Laparoscopic Incisional Hernia Repair
• Robotic-Assisted Incisional Hernia Repair

Types Based on Repair Technique

• Primary Suture Repair
• Mesh Repair
• Component Separation Technique
• Abdominal Wall Reconstruction
  
  

Types Based on Surgical Approach

Open Incisional Hernia Repair

Open incisional hernia repair is performed through an incision made over the hernia site. The protruding abdominal contents are returned to their normal position, the abdominal wall defect is repaired, and the weakened area is commonly reinforced with surgical mesh. This approach is often preferred for large, complex, or recurrent incisional hernias.

Laparoscopic Incisional Hernia Repair

Laparoscopic incisional hernia repair is a minimally invasive procedure performed through several small incisions using a laparoscope and specialised surgical instruments. The hernia defect is repaired from inside the abdominal cavity, and mesh is typically placed to strengthen the abdominal wall. 

Robotic-Assisted Incisional Hernia Repair

Robotic-assisted incisional hernia repair is an advanced minimally invasive technique in which the surgeon performs the operation using a robotic surgical system. The robotic platform provides enhanced visualisation, precision, and instrument control, which may be beneficial for selected patients with complex abdominal wall defects. Similar to other repair methods, surgical mesh is commonly used to reinforce the repair and reduce the likelihood of hernia recurrence.

Types Based on Repair Technique

Primary Suture Repair

Primary suture repair corrects the hernia by stitching the edges of the abdominal wall defect together without using a surgical mesh. This surgical technique is generally suitable for small defects where the tissues can be approximated without excessive tension.

Mesh Repair

Mesh repair reinforces the weak abdominal wall by inserting a synthetic or biological mesh over or within the hernia defect area. It is the most popular procedure for repairing incisional hernias.

Component Separation Technique

When an abdominal wall defect is too large to be repaired directly, the component separation approach is utilized. This approach brings the abdominal wall together with less tension while keeping its function by gently moving certain muscle layers.

Abdominal Wall Reconstruction

Abdominal wall reconstruction is used to repair large, recurring, or complex incisional hernias with major abdominal wall abnormalities. This approach combines advanced reconstructive surgical techniques, often with mesh reinforcement (supportive medical patch - synthetic or biological), to restore abdominal wall integrity and stability while improving patient's overall quality of life.

Indications for Incisional Hernia Surgery

Incisional hernia surgery is recommended when a hernia develops at the site of a prior abdominal incision and produces symptoms, progressively enlarges or bulges, or raises the risk of serious complications affecting normal life of an individual causing severe discomfort. The common indications for incisional hernia surgery include:

• Symptomatic incisional hernia
• Progressive enlargement of the hernia
• Recurrent incisional hernia
• Large or complex abdominal wall defects
• Incarcerated incisional hernia
• Strangulated incisional hernia
• Impaired quality of life
• Skin changes over the hernia
  
  

Symptomatic incisional hernia

Incisional hernia surgery is commonly recommended when the hernia causes persistent pain, discomfort, abdominal heaviness, or a visible bulge that interferes with daily routine activities. Surgical repair may help relieve symptoms and restore abdominal wall support.

Progressive enlargement of the hernia

An incisional hernia that gradually increases in size may weaken the abdominal wall further and become more difficult to repair. Early surgical treatment may help prevent progression and reduce the likelihood of future complications.

Recurrent incisional hernia

A hernia that recurs after a previous operation may necessitate further surgery, especially if it is accompanied by symptoms or expansion. The surgical method is determined by the cause of recurrence and the state of the abdominal wall that causes the hernia.

Large or complex abdominal wall defects

Large incisional hernias or those with substantial muscle separation in the abdominal wall may require surgical intervention to restore abdominal wall integrity and improve functional support. When necessary, advanced reconstructive procedures may be used.

Incarcerated incisional hernia

An incarcerated incisional hernia occurs when the herniated abdominal contents become trapped and cannot be returned to the abdominal cavity. Urgent surgical treatment is generally recommended to prevent further complications.

Strangulated incisional hernia

A strangulated incisional hernia develops when the blood supply to the trapped tissue becomes compromised. This condition is considered a surgical emergency that requires urgent operative management to prevent bowel damage and other serious complications.

Impaired quality of life

Persistent discomfort, decreased physical activity, limits at work or exercise, or difficulties completing regular daily activities as a result of the hernia may warrant surgical treatment. The treatment seeks to improve abdominal wall function and quality of life.

Skin changes over the hernia

Long-standing incisional hernias can cause the underlying skin to strain or ulcerate. Surgical correction may be required to avoid skin breakdown and successfully treat the abdominal wall defect.

Contraindications for Incisional Hernia Surgery

Incisional hernia surgery may not be appropriate for all patients, particularly if the risks outweigh the benefits or if pre-existing medical issues must be treated before proceeding with hernia surgery. Some of the common contraindications for elective incisional hernia surgery include:

• Uncontrolled medical conditions or comorbidities
• Severe cardiopulmonary disease
• Active local or systemic infection
• Uncorrected bleeding disorders
• Morbid obesity requiring optimization
• Advanced liver disease with uncontrolled ascites
• Pregnancy
• Limited life expectancy or poor functional status

Uncontrolled medical conditions or comorbidities

Elective incisional hernia surgery may be postponed in patients with poorly controlled conditions such as diabetes mellitus, severe hypertension, chronic obstructive pulmonary disease (COPD) or other systemic illnesses until adequate medical optimisation is achieved. Improving overall health before surgery helps reduce the risk of postoperative complications.

Severe cardiopulmonary disease

Patients with advanced heart or lung disease who are unable to safely tolerate anaesthesia or major abdominal surgery may not be suitable candidates for elective hernia repair until their medical condition is stabilised.

Active local or systemic infection

Surgery is generally deferred in the presence of an active abdominal wall infection, infected surgical wound, or systemic infection. Treating the infection before hernia repair helps minimise wound-related complications and reduces the risk of mesh infection when mesh reinforcement is planned.

Uncorrected bleeding disorders

Patients with uncontrolled coagulation disorders or those at a high risk of bleeding may require correction of the underlying abnormality before surgery. Appropriate perioperative management helps reduce the risk of excessive bleeding and postoperative hematoma formation.

Morbid obesity requiring optimisation

Severe obesity or overweight is associated with an increased risk of wound complications, surgical site infection, and chances of hernia recurrence. In selected patients, weight reduction may be advised before elective hernia surgery for incisional hernia to improve surgical outcomes.

Advanced liver disease with uncontrolled ascites

Patients with decompensated cirrhosis and chronic ascites are at a higher risk for wound complications and hernia recurrence. Prior to elective repair, it is generally recommended that the underlying liver condition be managed appropriately.

Pregnancy

Elective incisional hernia surgery is typically postponed during pregnancy until complications such as incarceration or strangulation develop. When feasible, hernia repair surgery is usually considered after childbirth to not affect the health condition of the mother and growing fetus during pregnancy.

Limited life expectancy or poor functional status

Elective surgery may not be appropriate for patients with advanced terminal illness or severely limited functional status where the potential risks outweigh the expected benefits. Treatment decisions are individualised based on the patient's overall condition and goals of care.

The primary goal of incisional hernia surgery is to repair the abdominal wall defect, relieve symptoms, and lower the risk of hernia-associated complications. When performed on suitably selected individuals, surgical repair can improve abdominal wall function, improve quality of life, and produce long-term results. The common benefits of incisional hernia surgery include:

• Restores abdominal wall integrity and abdominal wall function
• Relieves hernia-related symptoms
• Reduces the risk of hernia progression
• Prevents hernia-related complications
• Enhances quality of life
• Provides long-term hernia repair
  
  

Restores abdominal wall integrity and abdominal wall function

Incisional hernia surgery closes the abdominal wall defect and reinforces the weakened tissues, helping to restore the normal structure and stability of the abdominal wall.

Relieves hernia-related symptoms

Surgical hernia repair can reduce pain, discomfort, abdominal heaviness, and the visible bulge or enlarged area caused by the existing hernia, allowing patients to perform daily routine activities more comfortably.

Reduces the risk of hernia progression

Repairing the hernia may help prevent further enlargement of the abdominal wall defect, reducing the likelihood of developing a more complex hernia in the future.

Prevents hernia-related complications

Timely surgical intervention through incisional hernia repair lowers the risk of serious complications caused by a hernia, such as incarceration, strangulation, bowel obstruction, or compromised blood supply to the herniated tissues.

Enhances quality of life

Relief from persistent symptoms and restoration of abdominal wall function may improve mobility, physical activity, work performance, and overall quality of life.

Provides long-term hernia repair

Advanced hernia repair surgical treatments, particularly those that involve adequate mesh reinforcement when necessary, are meant to provide long-term abdominal wall support while lowering the chance of hernia recurrence, resulting in superior outcomes.

Incisional hernia surgery is performed to repair a defect in the abdominal wall that develops at the site of a previous surgical incision. The choice of surgical approach depends on the size and location of the hernia, the condition of the abdominal wall, previous abdominal surgeries, the presence of recurrent or complex hernias, and the surgeon's clinical assessment. The incisional hernia surgery procedure generally includes the following:

Before the Procedure

• A comprehensive preoperative evaluation is performed to assess the patient's overall health, hernia characteristics (enlarged or bulged), and suitability for hernia surgery.
• A detailed medical history, previous abdominal operations, current medications, any allergies, and associated medical conditions are reviewed before the surgical procedure is to be performed.
• The abdomen is examined to assess the size and location of the hernia, reducibility, abdominal wall integrity, skin condition, and the presence of multiple or recurrent defects.
• Blood investigations (blood work)/blood tests including a complete blood count (CBC), Coagulation Profile Test, electrocardiography (ECG) or EKG, chest X-ray imaging, or other preoperative tests are performed when indicated to evaluate fitness for anaesthesia and surgery.
• Ultrasound or computed tomography (CT) of the abdomen may be recommended to define the size of the defect, identify the hernia contents, and assist in operative planning, particularly in complex incisional hernias.
• Current medications, including anticoagulants, antiplatelet agents, or other medicines that may influence surgery, are reviewed and adjusted when appropriate.
• Patients are generally advised to stop smoking before surgery because smoking may impair wound healing and increase the risk of postoperative complications.
• Weight optimisation, blood sugar control, and nutritional assessment may be recommended in selected patients to improve surgical outcomes.
• Fasting instructions are provided before surgery according to anaesthetic recommendations.
• The surgeon explains the planned procedure, possible benefits, potential risks, and available alternatives before obtaining written informed consent.
  
  

During the Procedure

Depending on the patient's condition, the repair may be performed using an open, laparoscopic, or robotic-assisted technique, with primary suture repair, mesh reinforcement, or abdominal wall reconstruction when indicated. The abdomen is cleaned with an antiseptic solution and sterile drapes are applied after the administration of general anaesthesia.

The incisional hernia surgery time generally ranges from 1 to 3 hours, depending on the size and complexity of the hernia, the surgical approach, and the repair technique used.

Open Incisional Hernia Repair

• An incision is made over the previous surgical scar or hernia site to expose the abdominal wall defect.
• The hernia sac is carefully separated, and the protruding abdominal contents are returned to the abdominal cavity after confirming their viability.
• Scar tissue and adhesions are released when necessary to facilitate safe repair.
• The abdominal wall defect is repaired using the planned technique, with or without mesh reinforcement, depending on the clinical findings.

Laparoscopic Incisional Hernia Repair

• Several small incisions are created to introduce a laparoscope and specialised surgical instruments into the abdominal cavity.
• The hernia contents are reduced, and the abdominal wall defect is identified under magnified visualisation.
• Mesh is commonly positioned and secured to reinforce the weakened abdominal wall using appropriate fixation methods.

Robotic-Assisted Incisional Hernia Repair

• Robotic surgical instruments are introduced through small abdominal incisions after establishing minimally invasive access.
• The robotic system provides enhanced visualisation and instrument control to facilitate precise dissection, defect closure, and mesh placement in appropriately selected patients.

Mesh Placement and Abdominal Wall Reconstruction (Hernioplasty Surgery When Required)

• Mesh reinforcement is frequently performed to strengthen the abdominal wall and reduce the likelihood of hernia recurrence.
• Large or complex abdominal wall defects may require component separation or abdominal wall reconstruction to achieve a tension-reduced repair and restore abdominal wall function.
• After satisfactory repair, meticulous haemostasis is confirmed, surgical drains may be placed when required, and the incisions are closed using sutures or surgical staples before sterile dressings are applied.

After the Procedure

• Patients are monitored in the recovery area until the effects of anaesthesia gradually resolve and vital signs remain stable.
• Pain management, early mobilisation, breathing exercises, and venous thromboembolism prevention measures are initiated according to the postoperative care plan.
• Oral fluids and diet are gradually resumed as tolerated based on the patient's recovery and bowel function.
• Temporary swelling, bruising, or mild discomfort around the surgical site are common during the early postoperative period.
• Surgical drains, when used, are removed once drainage decreases to an appropriate level.
• Heavy lifting, strenuous exercise, and activities that increase abdominal pressure are generally restricted during the initial healing period.
• Follow-up visits are scheduled to evaluate wound healing, monitor recovery, remove sutures or staples when necessary, and assess the integrity of the hernia repair.
• Recovery recommendations, including activity progression and return to work, are individualised according to the type of repair performed and the patient's overall recovery.
  

Although incisional hernia surgery is a commonly performed and generally safe surgical procedure used to treat an incisional hernia, chances of complications may occur during or after surgery. The likelihood of these complications depends on factors such as the patient's overall health, the size and complexity of the hernia, the surgical technique used, and adherence to postoperative care. The potential risks and complications of incisional hernia surgery include:

• General Surgical Risks
• Bleeding
• Infection
• Anaesthesia-related complications
• Blood clots
• Seroma or hematoma
• Procedure-Specific Risks
• Hernia recurrence
• Chronic postoperative pain
• Mesh-related complications
• Injury to surrounding structures
• Wound healing problems
• Adhesion formation
• Abdominal wall weakness

General Surgical Risks

Bleeding

Bleeding may occur during or after surgery and, in uncommon cases, may require additional treatment or blood transfusion.

Infection

Surgical site infection can involve the skin, underlying tissues, or, less commonly, the implanted mesh (by chance, although this is rare). Early diagnosis and appropriate hernia specialist guided treatment help reduce the risk of further complications.

Anaesthesia-related complications

General or regional anaesthesia may occasionally be associated with breathing issues, allergic reactions, cardiovascular related events, or other anaesthesia-related complications, particularly in patients with significant underlying medical conditions.

Blood clots

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are rare complications of incisional hernia surgery, especially in patients with extended immobilization or other risk factors.

Seroma or hematoma

Fluid (seroma) or blood (hematoma) may accumulate beneath the surgical wound during the early healing period. Most resolve with conservative management, although some such conditions may require drainage.

Procedure-Specific Risks

Hernia recurrence

Despite successful hernia repair, an incisional hernia may recur over time because of patient-related factors (obesity), wound healing problems, or persistent stress on the abdominal wall.

Chronic postoperative pain

After incisional hernia surgery, some people may face constant chronic pain or discomfort near the hernia surgical site. This could be the due to scar tissue formation, nerve discomfort, or mesh-related complications.

Mesh-related complications

When mesh is used, complications such as mesh infection, migration, contraction, or adhesion formation may occur, although these events are relatively uncommon with modern and latest surgical techniques.

Injury to surrounding structures

The bowel, urinary bladder, blood vessels, or other nearby structures of the body may rarely be injured during hernia repair, particularly in patients with previous abdominal surgery or dense adhesions.

Wound healing problems

Delayed wound healing, wound separation, or skin necrosis may occur, especially in patients with diabetes, obesity, smoking history, or poor nutritional status.

Adhesion formation

Internal scar tissue may develop following abdominal surgery and, in some cases, contribute to chronic abdominal discomfort or bowel obstruction.

Abdominal wall weakness

Although the goal of surgery is to restore abdominal wall strength, some patients may continue to experience reduced abdominal wall function, particularly after repairing large or complex hernias.

The incisional hernia surgery recovery time varies depending on the size and complexity of the incisional hernia, the surgical approach, the incisional hernia repair technique used, and the patient's overall health. Most patients gradually resume routine daily activities within 1 to 2 weeks, while complete recovery generally takes 6 to 12 weeks. Recovery after minimally invasive surgery such as laparoscopic incisional hernia repair surgery, or robotic-assisted incisional hernia repair technique is often faster than after open repair, although healing time may be longer following complex abdominal wall reconstruction.

What questions can patients ask the healthcare team about Incisional Hernia Surgery?

• Does an incisional hernia always require surgery?
• Which type of incisional hernia surgery is recommended?
• How should preparation for incisional hernia surgery be carried out?
• What tests are required before incisional hernia surgery?
• What happens during incisional hernia surgery?
• How long will incisional hernia surgery take?
• What type of anaesthesia is used during the procedure?
• Is mesh always required for incisional hernia surgery?
• When can heavy lifting be resumed after incisional hernia surgery?
• Can an incisional hernia recur after surgery?

How long does incisional hernia surgery take?

The incisional hernia surgery time generally ranges from 1 to 3 hours, depending on the hernia size and complexity of the hernia, previous abdominal operations, and the surgical approach used. More extensive abdominal wall reconstruction procedures may require additional operative time.

Is mesh always required for incisional hernia surgery?

Mesh is commonly used because it strengthens the abdominal wall and reduces the risk of hernia recurrence. However, small hernias with suitable tissue quality may occasionally be repaired using sutures alone, depending on the hernia specialist or gastrointestinal (GI) surgeon's assessment and individual clinical factors.

Is laparoscopic incisional hernia surgery better than open hernia surgery?

Neither technique is considered universally superior, and the appropriate technique is decided by hernia specialists and the gastrointestinal (GI) surgical team after reviewing the patient's condition. Laparoscopic incisional hernia repair is often associated with smaller incisions, less postoperative discomfort, and faster recovery in selected patients, whereas open hernia surgery may be more appropriate for large, recurrent, or complex incisional hernias.

What foods should be eaten after incisional hernia surgery?

A well-balanced diet rich in protein, fruits, vegetables, whole grains, and adequate fluids supports wound healing and recovery after incisional hernia surgery. Foods that help prevent constipation are also beneficial because excessive straining may increase pressure on the healing abdominal wall repair.

Can an incisional hernia become strangulated?

Yes. Although not all incisional hernias become strangulated, the blood supply to the trapped abdominal contents can occasionally become compromised. This is a surgical emergency that requires immediate medical attention to prevent tissue damage.

Is incisional hernia surgery painful?

Some pain or discomfort is expected during the early recovery period and is usually managed with prescribed pain-relieving medications. The intensity and duration of discomfort vary according to the size of the hernia, the surgical approach, and the extent of the repair.

Will there be a scar after incisional hernia surgery?

A surgical scar is expected after incisional hernia repair, although its size and appearance depend on the technique performed. Minimally invasive procedures generally result in smaller scars than open surgery, and most scars gradually become less noticeable as they heal.

Can incisional hernia surgery be performed in obese patients?

Yes. Incisional hernia surgery can be performed in patients with obesity; however, obesity increases the risk of wound complications and hernia recurrence. Weight optimisation before elective surgery may be recommended to improve surgical outcomes whenever feasible.

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