An incisional hernia is a bulge that develops through the scar of a previous abdominal operation. Up to 15–20% of patients who undergo open abdominal surgery (laparotomy, caesarean section, hysterectomy, bowel surgery) eventually develop an incisional hernia at the scar site, often years later. They are also the most challenging hernias to repair, because the abdominal wall has already been weakened and re-operated tissue is scarred and less forgiving. Dr. Vanesha Varik is a female specialist general and laparoscopic surgeon at Medcare Hospital Al Safa, Dubai, with extensive experience in modern incisional hernia repair — including laparoscopic IPOM, eTEP and open component-separation techniques. This guide explains why incisional hernias happen, how they are classified, the modern repair options, and what to realistically expect from surgery and recovery.
What is an incisional hernia?
An incisional hernia is a defect in the abdominal wall that develops through or alongside the scar of a previous operation. It is essentially a failure of the deeper layers (the linea alba and rectus sheath) to heal completely, while the skin scar above looks normal.
It can appear weeks, months or years after the original surgery — and in some patients more than a decade later. The bulge slowly enlarges over time and almost never heals spontaneously.
Why do incisional hernias happen?
Modern surgery uses meticulous closure techniques but several factors increase the risk of fascial breakdown:
- •Obesity (BMI > 30) — the single biggest risk factor
- •Wound infection at the original surgery
- •Smoking and chronic cough
- •Diabetes, especially if poorly controlled
- •Long-term steroid use, immunosuppression
- •Emergency surgery or contaminated operations
- •Previous chemotherapy or radiotherapy to the abdomen
- •Multiple repeat operations through the same incision
- •Heavy lifting or vigorous activity too soon after surgery
- •Large midline incisions are higher risk than transverse incisions
Symptoms
- •A visible bulge along or next to a previous surgical scar
- •Bulge enlarges with standing, coughing, lifting or straining
- •Discomfort, dragging or burning sensation
- •Skin changes if the hernia is large or long-standing
- •Episodes of obstruction — pain, vomiting, no passage of wind/stool — which is a surgical emergency
How incisional hernias are classified
Modern hernia surgeons use the European Hernia Society (EHS) classification:
- •Width — W1 (< 4 cm), W2 (4–10 cm), W3 (> 10 cm)
- •Location — midline (M1–M5) or lateral (L1–L4)
- •Recurrent or primary
Width strongly determines surgical approach: small W1 hernias are usually repaired laparoscopically, while W3 hernias often require open component-separation techniques.
Why mesh is essential
Repairing an incisional hernia by simply sewing the gap closed (suture-only repair) results in recurrence rates over 50% within 5 years. Mesh reinforcement reduces recurrence to under 10%.
Modern meshes used at Medcare include:
- •Polypropylene mesh — strong, well-tolerated, used in most open and laparoscopic repairs
- •Composite mesh (e.g. Symbotex, Physiomesh) — coated to prevent bowel adhesions when placed inside the abdomen
- •Biological mesh — used in contaminated or high-risk fields
Modern repair techniques
1. Laparoscopic IPOM (Intra-Peritoneal Onlay Mesh) — for small to medium hernias. Mesh is placed inside the abdomen against the back of the abdominal wall through 3–4 small incisions. Quick recovery, good cosmetic result.
2. eTEP (extended Totally Extraperitoneal) — newer minimally invasive technique. Mesh is placed in the retromuscular plane (between muscle layers) — the gold-standard mesh position — but through laparoscopic ports rather than a large open incision.
3. Open Sublay/Rives-Stoppa repair — open operation with mesh placed in the retromuscular space. The traditional gold standard for medium-large hernias.
4. Component Separation (TAR — Transversus Abdominis Release) — for very large or recurrent hernias where the muscle edges cannot be brought together. Releases muscle layers to recreate a midline closure with mesh reinforcement.
What to optimise before surgery
Outcomes are dramatically improved by pre-operative optimisation:
- •Weight loss to BMI < 30 wherever possible
- •Stop smoking for at least 4 weeks before surgery
- •Tight diabetic control (HbA1c < 7%)
- •Pre-rehabilitation: walking, core strengthening
- •Treatment of any chronic cough or constipation
- •Botox injections to the abdominal wall in selected very large cases (specialist centres)
Recovery and outcomes
- •Hospital stay: 1–4 nights depending on size and technique
- •Drains: sometimes used for 5–10 days for larger repairs
- •Abdominal binder: worn for 4–6 weeks
- •Desk work: 2–3 weeks
- •Driving: 2–3 weeks
- •Gym (light): 6 weeks
- •Heavy lifting and full sport: 12 weeks
- •Recurrence rate after modern mesh repair in optimised patients: < 10%
Special considerations: hernia after caesarean section
Hernias through Pfannenstiel (caesarean) scars are increasingly common in Dubai given high rates of caesarean delivery. They often co-exist with diastasis recti and stretched skin.
We generally advise: complete your family before elective repair, ideally repair 6–12 months after the last delivery, and consider abdominoplasty/rectus plication at the same operation when there is significant body-contour concern.