Clinical Review

The modern management of incisional hernias

BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e2843 (Published 09 May 2012) Cite this as: BMJ 2012;344:e2843
  1. David L Sanders, speciality trainee in upper gastrointestinal surgery1,
  2. Andrew N Kingsnorth, consultant surgeon2
  1. 1Upper Gastrointestinal Surgery, Royal Cornwall Hospital, Truro TR1 3LJ, UK
  2. 2Peninsula College of Medicine and Dentistry, Plymouth, UK
  1. Correspondence to: D L Sanders dsanders{at}doctors.org.uk
  • Accepted 12 April 2012

Summary points

  • Incisional hernias are a common complication of abdominal surgery

  • Incisional hernias can occur many years after the index operation

  • Surgical site infection doubles the risk of incisional hernia

  • In case of uncertainty, ultrasonography can help confirm the diagnosis before specialist referral

  • Laparoscopic repair is generally reserved for small hernias (fascial defect <10 cm), although some surgeons report good results with larger defects

Before the introduction of general anaesthesia by Morton in 1846, incisional hernias were rare. As survival after abdominal surgery became more common so did the incidence of incisional hernias.1 Since then, more than 4000 peer reviewed articles have been published on the topic, many of which have introduced a new or modified surgical technique for prevention and repair. Despite considerable improvements in prosthetics used for hernia surgery, the incidence of incisional hernias and the recurrence rates after repair remain high. Arguably, no other benign disease has seen so little improvement in terms of surgical outcome.

Sources and selection criteria

We searched PubMed from 1970-2012 and Embase and the Cochrane Library from inception using the terms “hernia” and “incisional” (using the Boolean operator AND) and “ventral” (using the Boolean operator OR). The reference lists were also used to identify studies of interest. Both authors independently identified publications for inclusion and differences were resolved by discussion. We gave priority to research published in the past five years and highly regarded older publications.

Unlike other abdominal wall hernias, which occur through anatomical points of weakness, incisional hernias occur through a weakness at the site of abdominal wall closure. Why, unlike primary abdominal wall hernias, are the results after repair so poor? Perhaps it is because in the repair of incisional hernias several problems need to be overcome: a multilayered wall structure of different tissue properties in constant motion has to be sutured; positive abdominal …

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