Incisional hernia

Causes and risk factors

• Surgical-site infection or wound breakdown
• Obesity
• Smoking
• Diabetes, especially if poorly controlled
• Malnutrition, steroid treatment, immunosuppression
• Chronic cough/COPD, constipation, or other causes of raised intra-abdominal pressure
• Poor tissue quality, closure under tension, or inadequate closure technique
• Previous laparotomy and a midline incision

Clinical features

• A swelling or bulge at or near an operative scar
• Becomes more noticeable while coughing, standing, straining, or lifting
• May reduce when lying down or with gentle pressure
• Discomfort, dragging pain, poor cosmesis, difficulty with activity or clothing
• It may enlarge over months or years
• Multiple defects can exist along one scar

Diagnosis

Management

• Sudden severe or persistent pain
• An irreducible, tender, firm swelling
• Redness or skin discoloration over the hernia
• Vomiting, abdominal distension, inability to pass stool or flatus
• Fever or systemic illness

Elective/non-emergency management

• A small, painless, stable hernia can sometimes be managed with observation after discussion of risks and preferences.
• An abdominal binder may reduce symptoms but does not repair the defect.
• Optimize before elective repair: weight management, smoking cessation, diabetes control, nutrition, fitness, and treatment of chronic cough or constipation.
• Surgery is generally considered for pain, functional limitation, progressive enlargement, recurrent obstruction, skin problems, or patient preference.

Paraumbilical hernia treatment

Seek emergency care now if

• The lump becomes painful, hard, tender, or cannot be pushed back
• Vomiting, abdominal swelling, inability to pass stool or gas
• Red, purple, or dark skin over the lump
• Fever or severe persistent abdominal pain

Non-operative management

• Observation with medical review if it enlarges or becomes symptomatic
• Reduce strain: treat constipation or chronic cough, avoid heavy lifting where possible
• Weight reduction and smoking cessation can reduce operative and recurrence risks
• An abdominal belt/binder can provide comfort temporarily but will not close or cure the hernia

Elective surgery

1. Suture repair
   • The defect is closed with stitches alone.
   • May be considered for very small defects.
   • Has a higher risk of recurrence as the defect size increases.
2. Mesh repair
   • A mesh reinforces the abdominal wall, commonly placed in the preperitoneal plane during open repair.
   • Generally preferred for many adult symptomatic paraumbilical hernias because it lowers recurrence risk compared with stitches alone.
   • The European and American Hernia Society guideline recommends mesh repair for symptomatic umbilical/epigastric hernias, usually by an open approach with a preperitoneal flat mesh. A laparoscopic approach may be chosen for a large defect or increased risk of wound problems, such as obesity. See the EHS/AHS guideline.
3. Laparoscopic or robotic repair
   • Often considered for larger hernias, recurrent hernias, or patients at higher risk of wound complications.
   • The appropriate approach is individualized based on defect size, contents, previous operations, body habitus, and surgeon experience.

Before planned repair

• Stop smoking
• Aim for weight reduction if overweight
• Control diabetes
• Improve nutrition and fitness
• Manage chronic cough and constipation

Onlay versus inlay mesh repair

1. Onlay repair

1. Dissect the hernia sac and reduce its contents.
2. Close the fascial defect with sutures.
3. Create space superficial to the fascia.
4. Place a mesh with wide overlap around the repaired defect.
5. Fix mesh to fascia. A drain is often used.

• Technically relatively straightforward.
• Useful if deeper planes are scarred or difficult to access.
• Mesh does not contact bowel.

• Requires raising skin and subcutaneous flaps.
• Higher risk of seroma, wound infection, skin-flap ischemia/necrosis, and mesh exposure if the wound breaks down.
• Generally less mechanically favorable than a retromuscular/preperitoneal mesh plane.

2. Inlay repair, also called bridging repair

• May be necessary when the fascia cannot be approximated without excessive tension.
• Can serve as a temporary or damage-control option in selected emergency or very complex situations.

• Higher recurrence because tension is concentrated at the mesh-fascia junction.
• It does not restore normal abdominal-wall continuity or function as well as fascial closure with reinforcement.
• For elective hernia repair, it is generally avoided whenever possible.

Practical comparison