[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Conditions](https://durgical.com/en/conditions/) › Incisional (ventral) hernia

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# Incisional (ventral) hernia

An incisional hernia is a bulge through a weak area in an old surgical scar on the belly, most often after a midline abdominal operation.

Updated 2026-10-29

## Structures involved

Tap one to see what it is and open it in 3D.

- [Linea alba](https://durgical.com/en/anatomy/linea-alba/)
- [Rectus sheath](https://durgical.com/en/anatomy/rectus-sheath/)
- [Rectus abdominis](https://durgical.com/en/anatomy/rectus-abdominis-muscle/)
- [Transversalis fascia](https://durgical.com/en/anatomy/transversalis-fascia/)
- [External oblique](https://durgical.com/en/anatomy/external-abdominal-oblique-muscle/)
- [Internal oblique](https://durgical.com/en/anatomy/internal-abdominal-oblique-muscle/)
- [Transversus abdominis](https://durgical.com/en/anatomy/transversus-abdominis-muscle/)
- [Peritoneum](https://durgical.com/en/anatomy/peritoneum/)
- [Greater omentum](https://durgical.com/en/anatomy/greater-omentum/)
- [Epigastric vessels](https://durgical.com/en/anatomy/inferior-epigastric-artery/)

## In the clinical exam

- [Abdominal inspection](https://durgical.com/en/clinical-exam/abdominal-inspection/)
- [Examination of the groin and abdominal wall for hernias](https://durgical.com/en/clinical-exam/examination-of-the-groin-and-abdominal-wall-for-hernias/)

## Why it happens

- [What delays healing: infection, diabetes, nutrition, glucocorticoids, poor blood flow](https://durgical.com/en/general-pathology/what-delays-healing-infection-diabetes-nutrition-glucocorticoids-poor-blood-flow/)
- [Healing of skin wounds: first and second intention](https://durgical.com/en/general-pathology/healing-of-skin-wounds-first-and-second-intention/)
- [Abnormal repair: chronic wounds, hypertrophic scar, keloid, contracture](https://durgical.com/en/general-pathology/abnormal-repair-chronic-wounds-hypertrophic-scar-keloid-contracture/)
- [Collagen synthesis](https://durgical.com/en/biochemistry/topics/collagen-synthesis/)
- [Wound healing: phases and scar](https://durgical.com/en/histology/wound-healing-phases-and-scar/)

## What it is

A hernia through a weak area in a previous surgical scar of the abdominal wall, most often after a midline laparotomy. It is a type of ventral hernia.

## Who gets it

One of the most common long-term complications of open abdominal surgery. Rates vary widely between studies and rise with wound infection, obesity and emergency operations.

## Causes

- Failure of the fascial closure after laparotomy
- Surgical site infection or wound dehiscence
- Trocar-site hernia after laparoscopy (especially at the umbilicus)
- Stoma site (parastomal hernia)

## Risk factors

- Surgical site infection
- Obesity, smoking and diabetes
- Emergency surgery and midline incisions
- Chronic cough (COPD), constipation, ascites, pregnancy after surgery
- Malnutrition, corticosteroids and immunosuppression
- Abdominal aortic aneurysm and connective tissue disorders
- Closure technique (large bites, rapidly absorbable suture)

## Pathophysiology

The fascial edges separate in the weeks after surgery, often before the scar has gained strength. [Peritoneum](https://durgical.com/en/anatomy/peritoneum/), omentum or bowel then pushes through the gap. Over time the hernia can enlarge until much of the bowel lives outside the abdominal cavity (loss of domain).

## Classification

- Ventral hernias: primary (umbilical, epigastric, Spigelian) vs incisional
- European Hernia Society: midline (M1 to M5) or lateral (L1 to L4) location and defect width (W1 to W3)
- Reducible, incarcerated or strangulated; with or without loss of domain

## Symptoms and signs

- Bulge in or near a surgical scar, larger when standing or straining
- Discomfort, pulling or a dragging pain
- Skin changes or ulceration over large hernias
- Many are asymptomatic

## Red flags

- Sudden pain and a hernia that no longer reduces
- Vomiting, distension and absent stool or gas
- Red, hot or dark skin over the hernia
- Fever or signs of sepsis

## Diagnosis

**Clinical**
Palpation of the scar standing and lying, with Valsalva; defect size, reducibility, [skin](https://durgical.com/en/anatomy/skin/) quality and previous operations are recorded.

**Tests**
Preoperative tests depend on the patient: glucose control, nutrition and smoking status. Blood count, lactate and electrolytes if strangulation is suspected.

**Imaging**
CT defines the defect size, contents, other hidden defects and loss of domain, and guides the choice of repair. Ultrasound can confirm small hernias.

## Differential diagnosis

- Diastasis of the rectus muscles
- Primary umbilical or epigastric hernia
- Seroma, haematoma or abscess in the wound
- Abdominal wall tumour (e.g., desmoid, lipoma)
- Parastomal hernia or prolapse

## Goal of treatment

Close the defect with a durable repair that restores abdominal wall function, while optimising the patient beforehand to reduce complications and recurrence.

## Treatment

**Follow-up**
Watchful waiting is an option for small, asymptomatic hernias or patients with high surgical risk, with clear warning signs explained.

**Lifestyle**
Prehabilitation before elective repair: weight loss, stopping smoking, glucose control and improved nutrition.

**Surgical**
Open repair with mesh, often placed behind the rectus muscles (retromuscular, Rives-Stoppa type); suture repair alone has high recurrence.

**Surgical**
Laparoscopic or robotic repair with intraperitoneal or extraperitoneal mesh for suitable defects.

**Surgical**
Component separation (anterior or [transversus abdominis](https://durgical.com/en/anatomy/transversus-abdominis-muscle/) release) for large defects or loss of domain.

**Acute**
Emergency surgery for incarceration or strangulation, with bowel resection if needed; mesh use in contaminated fields is individualised.

## Complications

- Incarceration, strangulation and bowel obstruction
- Recurrence after repair
- Seroma, wound infection and mesh infection
- Enterocutaneous fistula
- Loss of domain and respiratory problems after reduction of very large hernias

## Prognosis

Incisional hernias tend to grow. Elective repair with mesh in an optimised patient has the best results; recurrence rises with each new repair and with emergency surgery.

## Prevention

- Small-bites closure of midline incisions with slowly absorbable suture, keeping a suture length at least four times the wound length
- Prevention of surgical site infection
- Prophylactic mesh in selected high-risk patients
- Weight control and stopping smoking

## Test yourself

Think of the answer, then tap the question to see it.

## What is the strongest modifiable risk factor for incisional hernia after laparotomy?

Surgical site infection; obesity and smoking are other important modifiable factors.

## Which closure technique for midline laparotomy lowers the rate of incisional hernia?

Small-bites closure with a slowly absorbable continuous suture, with a suture-to-wound length ratio of at least 4:1.

## Why is mesh generally used in incisional hernia repair?

Suture repair alone has a high recurrence rate; mesh reinforcement lowers it.

## What does loss of domain mean in a large incisional hernia?

A large part of the abdominal contents lives in the hernia sac, so returning it can raise abdominal pressure and impair breathing.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/conditions/incisional-hernia/)

## Related conditions

- [Umbilical hernia](https://durgical.com/en/conditions/umbilical-hernia/)
- [Small bowel obstruction](https://durgical.com/en/conditions/small-bowel-obstruction/)
- [Obesity](https://durgical.com/en/conditions/obesity/)
- [Abdominal aortic aneurysm](https://durgical.com/en/conditions/abdominal-aortic-aneurysm/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Ventral Hernia](https://www.ncbi.nlm.nih.gov/books/NBK499927/) (StatPearls (NCBI Bookshelf), 2023).

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Source: https://durgical.com/en/conditions/incisional-hernia/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/incisional-hernia/