Incision Hernia – Recognizing Hernias and Treating Them Safely Under Medical Supervision

An incisional hernia usually develops along the surgical scar following a previous abdominal surgery. The abdominal wall is weakened at this site, allowing a hernial opening to form. Through this weak spot, portions of the intestine or abdominal tissue can protrude outward.

The most common risk factors for an incisional hernia include:

• severe obesity
• Smoking
• Connective tissue disorders
• multiple previous abdominal surgeries
• Problems closing the abdominal wall during surgery
• Bleeding or infections in the surgical area

Conditions such as diabetes or anemia also impair wound healing and increase the risk of developing an incisional hernia. 

Whether an incisional hernia develops depends on various factors—including the number of previous abdominal surgeries and the individual characteristics of the connective tissue.

In an abdominal wall hernia, contents from the abdominal cavity protrude outward through a weak spot. In incisional hernias, the weak spot is a previous surgical scar © blueringmedia | AdobeStock

A incisional hernia can present in a variety of ways: Some patients initially have no symptoms at all, while others notice typical signs early on.

The most common symptoms include:

• a pulling pain in the area of the scar
• a palpable or visible swelling or bulge in the abdominal area, which can often be pushed back into the abdominal cavity
• an increase in the bulge when standing up, coughing, or during physical exertion
• Pain when coughing, having a bowel movement, or engaging in physical activity

The bulge may remain visible even when lying down.

The condition becomes dangerous if the intestine becomes trapped in the hernia ring. This causes sudden, severe pain, and the bulge can no longer be pushed back into place. There is a risk of life-threatening intestinal obstruction. In this case, the affected section of the intestine no longer receives adequate blood flow and may die. Typical accompanying symptoms include fever, nausea, vomiting, and colicky abdominal pain.

If an incarceration is suspected, it is considered a medical emergency. Those affected should go to a hospital immediately, as surgery is usually necessary right away. Even in the absence of acute symptoms, it is advisable not to unnecessarily delay scheduled incisional hernia surgery, as the risk of complications increases over time. Other typical symptoms include increasing pressure in the abdomen and symptoms that become increasingly difficult to control over time. Strangulated bowel segments can cause severe pain and must be treated immediately.

If symptoms persist or worsen, medical treatment is usually necessary, and abdominal surgery is often required.

A scar hernia is primarily diagnosed through a physical examination. The doctor palpates the scar and checks for a bulge in the area of the surgical scar. During this examination, the doctor checks whether the hernial sac can be pushed back into the abdominal cavity. If this is not possible, there is a risk of incarceration, which requires immediate surgery for the incisional hernia.

Depending on the size and location of the hernia, as well as the patient’s weight, additional tests may be necessary to more accurately assess the stability of the abdominal wall. These include, among others:

• Ultrasound
• Computed tomography (CT)
• Colonoscopy

These methods reliably visualize the layers of the abdominal wall and any potential hernial defects. Further imaging procedures are generally not required.

Surgery is also recommended if:

• Symptoms persist
• quality of life is significantly impaired
• there is a risk of, or an existing inability to work
• social withdrawal occurs

A minimum interval of three months—preferably six—should be observed between a previous abdominal surgery and a planned incisional hernia repair. After the examination is complete, the doctor will discuss the possible surgical procedures and the next steps with the patient.

The most effective treatment for an incisional hernia is surgery. Doctors make distinctions based on the size of the hernia and the patient’s overall health:

• Small incisional hernias can sometimes be repaired under local anesthesia.
• Larger incisional hernias, which require opening the abdominal cavity, are usually performed under general anesthesia.

Before any incisional hernia surgery, an anesthesiologist explains the anesthesia process and potential risks.

The hospital stay following surgery under general anesthesia usually lasts between five and ten days. Depending on the findings, some minor procedures can also be performed on an outpatient basis. For larger incisional hernias, treatment is generally performed as an inpatient procedure in the hospital, while outpatient surgery is only an option for minor procedures.

To prepare for surgery, patients are often given a mild laxative and a blood-thinning medication the day before. On the day of surgery, the doctor administers a sedative to make the procedure as comfortable as possible.

The surgical method used for an incisional hernia repair depends on the size of the hernia and any previous abdominal surgery. There are essentially two procedures available:

• Open surgery
• Minimally invasive surgery (keyhole surgery, laparoscopy)

In many cases, the standard procedure is open repair of the incisional hernia with reinforcement using a synthetic mesh.

Open Incisional Hernia Surgery

In open surgery, the hernial sac is exposed through an incision in the skin. The surgeon carefully pushes the contents—usually parts of the intestine—back into the abdominal cavity.

The hernial orifice can be closed in various ways:

• direct suturing of the fascia (the supporting fibrous layer of the abdominal wall)
• fascial reinforcement (Mayo method for incisional hernia repair)
• Stabilization using synthetic materials

For larger incisional hernias, doctors typically reinforce the suture with a non-absorbable synthetic mesh or a combination of mesh and the body’s own tissue.

These surgical methods serve to reinforce the abdominal wall and ensure that the suture remains closed.

The closed procedure is performed using a minimally invasive technique called laparoscopy. To do this, the surgeon makes several small incisions in the abdominal wall and inserts a camera and special instruments. The surgeon can monitor the procedure inside the abdomen in real time on a monitor.

The hernia opening is closed, and a synthetic mesh is also inserted into the abdominal wall.

Advantages of laparoscopic incisional hernia surgery:

• less pain after the procedure
• lower rate of wound infection
• faster return to physical activity

For very small incisional hernias with a hernial orifice smaller than 2 cm, doctors often perform what is known as the Spitzy procedure. In this procedure, the hernial defect is closed by directly suturing the edges of the hernia with a strong suture.

This procedure is usually performed on an outpatient basis under general anesthesia.

Advantages of the Spitzy procedure:

• Short procedure
• minimal tissue trauma
• low complication rate

One disadvantage is that no synthetic mesh is used for stabilization. This increases the risk of a recurrent incisional hernia. In addition, patients should take it easy physically for several weeks after the procedure so as not to jeopardize the healing of the abdominal wall.

This procedure is not sufficient for large incisional hernias or if the hernia has grown larger over time. In rare cases, even small hernias can lead to complications that require a different surgical method.

In many incisional hernia surgeries, doctors additionally stabilize the abdominal wall with a synthetic mesh. This is inserted either during open surgery or via minimally invasive keyhole surgery (laparoscopy). Most meshes are made of polypropylene, which is generally very well tolerated.

Important: The mesh must not come into direct contact with the intestinal loops, as this can lead to adhesions. To reduce this risk, modern meshes are available with a special coating that prevents such adhesions.

The main difference between the procedures lies in the position of the synthetic mesh within the abdominal wall. The most common methods include:

• Sublay technique – mesh placed beneath the abdominal muscles
• Intraperitoneal Onlay Mesh (IPOM) – mesh between the bowel and the peritoneum
• Inlay technique – the mesh is inserted directly into the hernia defect

Below you will find detailed information about these procedures.

In this method, the abdominal cavity is first filled with gas (pneumoperitoneum). The surgeon then separates any adhesions (adhesiolysis).

A synthetic mesh, which is secured to the abdominal wall between the intestine and the peritoneum, covers the hernia defect from the inside.

The IPOM technique is performed using minimally invasive keyhole surgery. This results in a lower rate of wound infection and less postoperative pain. However, this procedure is not always suitable for very large incisional hernias.

The Sublay-Mesh technique is an open surgical procedure that is particularly suitable for large incisional hernias. The surgery is performed exclusively under general anesthesia.

First, the surgeon makes an incision over the hernial sac, exposes the hernia, and removes it if necessary.

The surgeon then separates any adhesions in the abdominal cavity and pushes the contents of the hernia sac back into the abdominal cavity. The synthetic mesh is secured beneath the abdominal muscles using sutures or fibrin glue.

As with any surgical procedure, there are potential complications following incisional hernia surgery. These do not occur in all patients, but you should be aware of them:

• Wound infections
• Seroma formation (accumulation of fluid in the wound area)
• Hematomas (bruising)

When a synthetic mesh is used, the infection rate can be as high as ten percent. Seromas and hematomas also occur more frequently in these cases than when the hernia is closed directly without a mesh.

In most cases, fluid accumulations resolve on their own within two to six weeks. If there is a large amount of fluid, the doctor can remove it via a puncture.

Other possible complications include:

• Hardening in the surgical area
• Temporary or, rarely, permanent numbness due to nerve damage
• Limited mobility and abdominal pain

Despite modern surgical techniques, there remains a risk of a recurrent hernia even when a synthetic mesh is used.

After surgery, most patients can resume eating normally; if necessary, dietary intake is gradually increased.

The results of the surgery are regularly monitored via ultrasound. Immediately after the procedure, doctors apply an elastic abdominal binder to support healing of the abdominal wall. It should be worn day and night for several weeks.

The sutures are removed about ten to twelve days after incisional hernia surgery. Afterward, physical activity can be gradually increased. However, patients should avoid lifting heavy loads over 20 kilograms for about three months to reduce the risk of complications or a recurrent hernia. As early as the day after surgery, doctors usually begin with gentle mobility exercises to support healing.

Special follow-up care is generally not necessary—however, rest, medical checkups, and consistent use of the abdominal support garment are important.

Incisional hernias are a specific type of hernia and almost always develop in the area of surgical scars. Depending on their size and location, immediate surgery may be necessary to prevent complications such as incarceration or intestinal obstruction. 

An incisional hernia grows larger over time, and there is a risk that portions of the intestine could become incarcerated. Therefore, an incisional hernia should always be treated surgically as part of hernia surgery.

Surgery for an incisional hernia should be performed no sooner than 3 to 6 months after the initial abdominal surgery. During the procedure, the hernial sac is first repositioned back into the abdominal cavity. The surgeon then permanently closes the hernial defect using sutures or a synthetic mesh.

The surgery can be performed either as an open surgical procedure or using minimally invasive laparoscopic or endoscopic techniques.

When performing incisional hernia surgery, specialists first assess the risk of complications and determine whether the hernia requires prompt treatment. Surgery is always necessary when parts of the abdominal cavity protrude into the hernial sac or when symptoms occur. Especially in the case of larger incisional hernias, a synthetic mesh is often used to permanently stabilize the surgical site and prevent a recurrence.

The choice of surgical technique—whether to treat the incisional hernia using open surgery or laparoscopic surgery—depends, among other factors, on whether an incisional hernia is suspected in the area of a scar or whether the hernias are small and can be easily repaired. The goal of any treatment is to resolve the hernia by completely closing the hernia and securing the structures that protect the abdominal cavity. As soon as organs have prolapsed from the abdominal cavity, a mesh should be inserted promptly to prevent further problems.