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What is Incisional Hernia (Laparocele)?
An incisional hernia is a protrusion of the abdominal viscera (internal organs) through a weakness that develops at the site of a previous surgical scar. This distinguishes it from a standard abdominal hernia, which arises from pre-existing anatomical weak points or natural channels in the abdominal wall rather than from a surgical incision.
Incisional hernia is a recognized complication of any open abdominal surgery performed via laparotomy. This classical surgical technique involves making a cut through the abdominal wall to access the internal organs. Despite continuous advances in surgical technique, it is estimated that between 15% and 20% of patients who undergo laparotomy will eventually develop an incisional hernia.
Importantly, this condition cannot resolve on its own. Unlike minor soft tissue injuries, an incisional hernia will not heal spontaneously and typically requires a second surgical procedure for definitive repair.
Causes
Laparotomy is the traditional open surgical approach for accessing the organs of the abdominal cavity, involving an incision of variable length through the skin, subcutaneous tissue, and abdominal wall muscles.
An incisional hernia develops as a consequence of weakening of the abdominal muscles at the site of the surgical incision. This weakening can occur after virtually any procedure requiring an incision of the abdominal wall. As the wound heals, if the layers of the abdominal wall do not fuse properly or are put under excessive strain during recovery, a gap can form. Through this gap, abdominal contents, most commonly loops of intestine or fatty tissue called omentum, can protrude.
Less commonly, incisional hernias may arise following traumatic injuries to the abdominal wall, even without prior surgery.
Risk Factors
Incisional hernias can develop in individuals of any age, sex, or ethnic background. However, several factors are known to significantly increase the risk:
- Longitudinal (midline) surgical incisions, which are cuts running parallel to the body’s vertical axis (top-to-bottom), are associated with a higher risk than transverse cuts.
- Emergency surgery: operations performed urgently, without optimal patient preparation.
- Creation of a stoma (an artificial opening connecting the bowel to the abdominal surface).
- Post-operative wound infection: bacterial contamination of the surgical site significantly impairs healing
- Chronic diseases, including diabetes mellitus and chronic kidney failure (which impair tissue healing)
- Long-term use of corticosteroids and/or other immunosuppressants: these medications interfere with normal wound healing and collagen synthesis.
- Smoking: reduces oxygen delivery to tissues and impairs the healing process.
- Obesity: excess body weight increases intra-abdominal pressure and places greater mechanical stress on the wound.
- Surgical technique errors: inadequate closure of the abdominal wall layers.
Incisional hernias are most likely to appear within three to six months of surgery, when the healing wound is at its most vulnerable. During this critical recovery period, any sudden or sustained increase in intra-abdominal pressure poses a significant risk. This includes:
- Excessive physical strain (including involuntary events such as violent coughing or vomiting)
- Pregnancy
- Weight gain
That said, incisional hernias can also develop months or even years after surgery, particularly if the underlying risk factors (such as obesity or chronic disease) persist.
Symptoms and Complaints
The most characteristic and recognizable sign of an incisional hernia is the appearance of a visible or palpable lump (mass) at or near the site of the surgical scar. In some patients, the bulge may be located slightly away from the incision line. A classic confirmatory finding is the increase in the size or pressure of the hernia when the patient coughs. This is often used during clinical examination to confirm the diagnosis.
As with other types of abdominal hernia, it is often possible to manually reduce the hernia by applying gentle pressure, temporarily pushing it back into the abdominal cavity. However, it will typically protrude again as soon as the patient coughs, strains, or stands up.
While the bulge itself may be the only complaint in many cases, some patients also experience:
- Abdominal pain, particularly around the scar area; this can range from a dull ache to sharp discomfort, especially with physical activity
- Bowel disturbances such as constipation or passage of narrow, ribbon-like stools (suggestive of partial intestinal compression)
For the majority of patients, the hernia represents a significant limitation to physical activity, either because of associated pain and discomfort, or as a precautionary measure to avoid worsening the hernia or triggering complications.
Complications
The most serious and potentially life-threatening complication of an incisional hernia is hernia incarceration: the trapping of a portion of the bowel or other abdominal organ through the fascial defect (the gap in the abdominal wall) in a position where it can no longer be manually reduced.
If the blood supply to the trapped tissue becomes compromised, the hernia is said to be strangulated. A strangulated hernia is a surgical emergency: without prompt intervention, the affected tissue will rapidly undergo ischemia and necrosis (tissue death due to lack of oxygen), which can be fatal.
Warning signs of hernia strangulation include:
- Sudden, severe abdominal pain at the hernia site
- A hernia that can no longer be pushed back in (non-reducible)
- Redness, warmth, or discoloration of the skin over the hernia
- Nausea and vomiting
- Fever
In most incisional hernias, the herniated tissue originates from the intestines. Because of this, there is also a risk of developing an intestinal obstruction (bowel blockage), which requires urgent medical or surgical treatment.
Diagnosis
The diagnosis of an incisional hernia is primarily clinical, based on:
- Physical examination: The physician directly inspects and palpates the abdominal wall to identify the hernial bulge and assess its characteristics, such as size, reducibility, and tenderness.
- Confirmed history of previous abdominal surgery: this detail is essential to classify the hernia as incisional rather than primary.
In cases of diagnostic uncertainty, or when more detailed anatomical information is needed, the clinician may request imaging studies:
- Abdominal ultrasound is a first-line imaging tool. It is non-invasive, widely available, and useful for confirming the diagnosis and characterizing the hernia contents.
- MRI (Magnetic Resonance Imaging) or CT scan (Computed Tomography) are second-level investigations. They are used for complex or large hernias, or when surgical planning requires detailed anatomical mapping.
Important: A strangulated hernia is a medical emergency that requires immediate surgical intervention. In this context, there is no time for an extensive diagnostic workup. The clinical picture alone is sufficient to guide urgent surgical management.
Occasionally, small incisional hernias are discovered incidentally during other abdominal surgeries performed for unrelated reasons.
Treatment
The appropriate therapeutic approach depends on several factors, including the patient’s overall health status, the location and size of the hernia, the degree of symptoms, and the level of physical activity. However, the only definitive treatment for an incisional hernia is surgical repair.
Watchful Waiting
In selected cases, particularly for patients with small, asymptomatic hernias and no risk of strangulation or for those who are poor surgical candidates due to significant comorbidities, a strategy of watchful waiting (active surveillance without immediate surgery) may be appropriate. This approach allows for careful monitoring rather than proceeding with surgery right away. This approach involves regular clinical follow-up to monitor for any changes or complications.
However, it is important to understand that incisional hernias tend to enlarge progressively over time. For this reason, large or symptomatic hernias should generally be repaired surgically to prevent complications and improve quality of life, unless there are clear contraindications.
Surgical Repair
There are two main surgical techniques for incisional hernia repair:
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Open (conventional) surgery: A classical incision is made to expose and repair the hernia. The surgeon returns the herniated tissue to its proper position within the abdominal cavity and reinforces the abdominal wall, typically using a synthetic mesh to reduce the risk of recurrence.
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Laparoscopic surgery is a minimally invasive technique: the surgeon inserts a camera and specialized instruments through a few small incisions. This approach is associated with shorter hospital stays, faster recovery, less postoperative pain, and lower wound complication rates compared to open surgery, though it may not be suitable for all patients or hernia configurations.
For a detailed comparison of surgical techniques and their indications, refer to our dedicated article on abdominal hernia treatments.
Risk of Recurrence
Unfortunately, incisional hernia repair carries a notable risk of recurrence, estimated at approximately 5–20% of cases, depending on hernia size, surgical technique, use of mesh, and patient-related factors such as obesity, smoking, and nutritional status. Patients are therefore advised to address modifiable risk factors (weight loss, smoking cessation) both before and after surgery to minimize this risk.
Sources and Bibliography
- Incisional Hernia – StatPearls, NCBI Bookshelf
- Hopkins Medicine – Incisional Hernia
- Mount Sinai – Incisional Hernia
- Muysoms FE, et al. Classification of primary and incisional abdominal wall hernias. Hernia. 2009;13(4):407–414.
- Bosanquet DC, et al. Systematic review and meta-regression of factors affecting midline incisional hernia rates: analysis of 14,618 patients. PLOS ONE. 2015;10(9):e0138745.
