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Incisional hernia

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of incisional hernia are prepared by our editorial team based on guidelines from the European Hernia Society (EHS/AHS 2022), the International Endohernia Society (IEHS 2019), and the World Society of Emergency Surgery (WSES 2017).
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Classification and risk stratification

Risk factors
As per AHS/EHS 2022 guidelines:
Recognize that incisional hernia formation results from a combination of factors, such as:
patient comorbidities
genetics
anatomy
health-related behaviors
immunosuppressive medications
surgical technique
soft tissue healing
surgical site infection
E
Insufficient evidence to recommend a universal or standard definition of what constitutes a high-risk patient, as risk varies significantly across procedures and specialties. Take into consideration risk relative to a specific procedure and specialty.
I
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  • Classification

Diagnostic investigations

Evaluation for bowel strangulation: as per WSES 2017 guidelines, assess for systemic inflammatory response syndrome, obtain contrast-enhanced CT, serum lactate, creatinine phosphokinase, and D-dimer to assess for bowel strangulation.
B
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Perioperative care

Antibiotic prophylaxis: as per WSES 2017 guidelines, administer short-term antimicrobial prophylaxis in patients with intestinal incarceration with no evidence of ischemia and no bowel resection (CDC wound class I).
B
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Surgical interventions

Indications for emergency repair
As per IEHS 2019 guidelines:
Consider repairing enterotomy followed by a mesh repair of the hernia in patients with recognized bowel injury, without significant enteric fluid leakage.
C
Consider repairing the hernia laparoscopically after 5-7 days in the absence of signs of infection if there is a conversion to open surgery to repair the enterotomy.
C
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  • Technical considerations for surgery

Specific circumstances

Patients with obesity
As per IEHS 2019 guidelines:
Prefer the laparoscopic approach due to its lower wound infection and wound complication rates in patients with obesity presenting with a ventral or incisional hernia.
A
Consider undertaking additional technical steps (greater mesh fixation, more overlap, suture closure of the defect) when using the laparoscopic approach in patients with obesity, as they are at increased risk of recurrence.
C
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Preventative measures

Incision techniques, surgical approach
As per AHS/EHS 2022 guidelines:
Recognize that there is a decreased risk of both incisional hernia and surgical site occurrences in patients undergoing laparoscopic operations compared with open operations.
E
Consider performing laparoscopic surgery when safe and feasible to reduce the risk of incisional hernia and surgical site occurrence.
C
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  • Incision techniques (incision type)

  • Abdominal closure techniques (trocar site closure)

  • Abdominal closure techniques (laparotomy closure)

  • Prophylactic mesh augmentation

  • Postoperative abdominal binders

  • Postoperative activity restrictions