Incisional hernia is a frequently encountered long-term complication following abdominal surgery, with a reported incidence ranging between 10% and 20% depending on patient factors and the duration of postoperative follow-up [1,2]. It occurs due to the failure of fascial healing at the site of a prior surgical incision, resulting in the protrusion of intra-abdominal contents through the weakened abdominal wall [1].

Among the various abdominal surgical approaches, midline laparotomy continues to be extensively utilized because of its ease of execution and superior access to abdominal organs. However, this technique is associated with a higher risk of incisional hernia, particularly in the presence of patient-related risk factors such as advanced age, obesity, diabetes mellitus, and smoking, as well as surgery-related factors including emergency procedures, wound infections, and prolonged operative time [1,3,5].

The development of incisional hernia is not merely a cosmetic or physical inconvenience. It can lead to significant morbidity, such as bowel obstruction, incarceration, or strangulation, and often necessitates secondary surgical intervention, thereby increasing healthcare burden and adversely affecting patients’ quality of life [2,4].

Despite advancements in surgical techniques and the use of improved suture materials, the incidence of incisional hernia remains high. Emerging evidence also supports the role of prophylactic mesh placement in reducing its occurrence, particularly in high-risk patients [6]. Therefore, understanding the prevalence and identifying modifiable risk factors is crucial for implementing preventive strategies and enhancing surgical outcomes [3].

The present study aims to determine the prevalence of incisional hernia following midline laparotomy and to identify associated risk factors in a tertiary care setting.

Study Design and Setting

This was a hospital-based observational cross-sectional study conducted at the Department of General Surgery, Government Medical College and General Hospital, Suryapet.

Study Period

The study was carried out over a period of eight months, from September 2023 to April 2024.

Study Population

The study included patients who had previously undergone midline laparotomy and presented for follow-up at the surgical outpatient department during the study period.

Inclusion Criteria

Patients aged ≥18 years.

Patients who underwent midline laparotomy for any indication at least 6 months prior to enrollment.

Willing to provide informed consent.

Exclusion Criteria

Patients with laparoscopic incisions or non-midline abdominal incisions.

Patients with known recurrent or previous incisional hernias.

Patients with terminal illness or unable to attend follow-up.

Sample Size

A total of 100 patients who met the inclusion criteria were enrolled consecutively during the study period.

Data Collection

A structured data collection form was used to obtain information on:

Demographic variables: Age, gender, BMI.

Clinical factors: Comorbidities such as diabetes, history of smoking.

Surgical factors: Nature of surgery (elective/emergency), duration of surgery, postoperative wound infection.

Physical examination was performed to detect incisional hernia.

Radiological confirmation (if needed) was done using ultrasonography or CT scan.

Ethical Considerations

Necessary permissions were obtained before starting the study. Informed written consent was obtained from all participants prior to inclusion in the study.

Statistical Analysis

Data were analyzed using SPSS version 25. Descriptive statistics (mean, standard deviation, frequencies, percentages) were used to summarize the data. Associations between incisional hernia and risk factors were analyzed using Chi-square test or Fisher’s exact test for categorical variables and Student’s t-test for continuous variables. A p-value of <0.05 was considered statistically significant.

Out of the 100 patients who underwent midline laparotomy, 18 patients developed incisional hernia, yielding a prevalence of 18% (Table 1).

Table 1: Prevalence of Incisional Hernia

Demographic characteristics revealed that the mean age of patients with hernia was significantly higher (58.3 ± 10.2 years) compared to those without hernia (48.7 ± 11.6 years; p = 0.003). A higher proportion of patients with hernia had a BMI >25 kg/m² (77.8%) as compared to those without hernia (43.9%), which was statistically significant (p = 0.009). Gender distribution showed no significant association with hernia development (Table 2).

Table 2: Demographic Characteristics

Figure 1. Demographic Characteristics:With vs Without incisional Hernia

Surgical and clinical factors were also analyzed. Emergency surgery, diabetes mellitus, wound infection, and prolonged operative duration (>2 hours) were significantly associated with a higher incidence of incisional hernia (p < 0.05 for each). Although smoking history appeared more common among hernia patients, the difference was not statistically significant (p = 0.07) (Table 3).

Table 3: Surgical and Clinical Risk Factors

Figure 2. Risk Factors for Incisional Hernia

Among the 18 patients with incisional hernia, the most common time of presentation was between 6 to 12 months postoperatively (44.4%), followed by within the first 6 months (33.3%). All hernias occurred at the infraumbilical site, with 72.2% of cases having a defect size less than 5 cm, while 27.8% had larger defects (Table 4).

Table 4: Characteristics of Incisional Hernias (n = 18)

The present study identified an 18% prevalence of incisional hernia among patients who had undergone midline laparotomy, which is consistent with rates reported in previous literature, typically ranging between 10% and 20% [9,12]. This notable prevalence highlights the clinical burden of incisional hernias as a common and impactful postoperative complication.

Age emerged as a significant risk factor, with older patients demonstrating a higher likelihood of hernia development. Age-related impairments in collagen remodeling and tissue regeneration may compromise fascial integrity, increasing hernia susceptibility a trend similarly reported in large multicenter reviews [9].

Obesity (BMI >25 kg/m²) was also strongly associated with incisional hernia in our study. Elevated intra-abdominal pressure, poor vascularity, and delayed wound healing are key mechanisms underlying this risk. Our findings are in agreement with recent evidence showing significantly higher hernia rates among obese individuals’ post-laparotomy [11].

Likewise, diabetes mellitus was identified as a significant predictor, supporting prior studies indicating its detrimental effect on wound healing due to impaired collagen synthesis and microvascular circulation [10]. Among modifiable factors, postoperative wound infection demonstrated a particularly strong association with hernia formation. Wound sepsis contributes to fascial breakdown, as emphasized in risk analyses involving both elective and emergency surgeries [7,10].

Emergency procedures were significantly correlated with incisional hernia in our cohort, likely due to inadequate preoperative preparation and increased intraoperative contamination patterns mirrored in large-scale observational data [12]. The predominance of hernias in the infraumbilical region within the first-year post-surgery is consistent with anatomical and biomechanical observations documented in hernia prevention guidelines [9].

Although smoking history did not show statistical significance in this study, the trend toward increased risk suggests a possible association, as smoking has been linked to impaired oxygenation and collagen turnover [8]. Larger sample sizes or prospective follow-up may clarify this relationship.

This study is not without limitations. The cross-sectional design restricts causal inference, and being single-centered, findings may not be universally generalizable. However, the results reinforce established risk factors and stress the importance of preventive strategies in high-risk patients such as early identification, patient optimization, and consideration of prophylactic mesh placement where appropriate.

Incisional hernia remains a common and significant complication following midline laparotomy, with a prevalence of 18% observed in the present study. Several factors were found to be significantly associated with its occurrence, including advanced age, obesity, diabetes mellitus, emergency surgery, prolonged operative duration, and postoperative wound infection. Early identification and targeted management of these modifiable risk factors such as optimizing glycemic control, preventing surgical site infections, and minimizing operative time can play a vital role in reducing the incidence of incisional hernias. Routine postoperative follow-up and patient education are also essential for timely detection and intervention.

1. Itatsu K, Yokoyama Y, Sugawara G, Kubota H, Tojima Y, Kurumiya Y, et al. Incidence of and risk factors for incisional hernia after abdominal surgery. Br J Surg. 2014 Oct;101(11):1439-47. doi: 10.1002/bjs.9600. PMID: 25123379.
2. Ortega-Deballon P, Renard Y, de Launay J, Lafon T, Roset Q, Passot G. Incidence, risk factors, and burden of incisional hernia repair after abdominal surgery in France: a nationwide study. 2023 Aug;27(4):861-871. doi: 10.1007/s10029-023-02825-9. PMID: 37368183; PMCID: PMC10374769.
3. Bosanquet DC, Ansell J, Abdelrahman T, Cornish J, Harries R, Stimpson A, et al. Systematic review and meta-regression of factors affecting midline incisional hernia rates: analysis of 14,618 patients. PLoS One. 2015 Sep 21;10(9):e0138745. doi: 10.1371/journal.pone.0138745. PMID: 26389785; PMCID: PMC4577082.
4. Wu XW, Yang DQ, Wang MW, Jiao Y. Occurrence and prevention of incisional hernia following laparoscopic colorectal surgery. World J Gastrointest Surg. 2024 Jul 27;16(7):1973-1980. doi: 10.4240/wjgs.v16.i7.1973. PMID: 39087097; PMCID: PMC11287670.
5. Mingoli A, Puggioni A, Sgarzini G, Luciani G, Corzani F, Ciccarone F, et al. Incidence of incisional hernia following emergency abdominal surgery. Ital J Gastroenterol Hepatol. 1999 Aug-Sep;31(6):449-53. PMID: 10575560.
6. Jairam AP, López-Cano M, Garcia-Alamino JM, Pereira JA, Timmermans L, Jeekel J, et al. Prevention of incisional hernia after midline laparotomy with prophylactic mesh reinforcement: a meta-analysis and trial sequential analysis. BJS Open. 2020 Jun;4(3):357-368. doi: 10.1002/bjs5.50261. PMID: 32057193; PMCID: PMC7260413.
7. Kim Y, Kim KH, Seo KW, Lee SH, Son GM. Risk factors of incisional hernia after laparoscopic colorectal surgery with periumbilical minilaparotomy incision: a propensity score matching analysis. J Minim Invasive Surg. 2022 Mar 15;25(1):24-31. doi: 10.7602/jmis.2022.25.1.24. PMID: 35603344; PMCID: PMC8977500.
8. Pereira-Rodríguez JA, Bravo-Salva A, Argudo-Aguirre N, Amador-Gil S, Pera-Román M. Defining high-risk patients suitable for incisional hernia prevention. J Abdom Wall Surg. 2023 Feb 3;2:10899. doi: 10.3389/jaws.2023.10899. PMID: 38312422; PMCID: PMC10831640.
9. Sanders DL, Pawlak MM, Simons MP, Aufenacker T, Balla A, Berger C, et al. Midline incisional hernia guidelines: the European Hernia Society. Br J Surg. 2023 Nov 9;110(12):1732-1768. doi: 10.1093/bjs/znad284. Erratum in: Br J Surg. 2024 Jan 3;111(1):znad349. doi: 10.1093/bjs/znad349. PMID: 37727928; PMCID: PMC10638550.
10. Rios-Diaz AJ, Cunning J, Hsu JY, Elfanagely O, Marks JA, Grenda TR, et al. Incidence, burden on the health care system, and factors associated with incisional hernia after trauma laparotomy. JAMA Surg. 2021 Sep 1;156(9):e213104. doi: 10.1001/jamasurg.2021.3104. PMID: 34259810; PMCID: PMC8281005.
11. Wehrle CJ, Shukla P, Miller BT, Blake KE, Prabhu AS, Petro CC, et al. Incisional hernia rates following midline laparotomy in the obese patient: a retrospective review. 2023 Jun;27(3):557-563. doi: 10.1007/s10029-022-02688-6. PMID: 36318389.
12. Ray M, Kumar A, Maranna H. Incidence of incisional hernia in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: an observational clinical study from a tertiary oncology referral care center in India. World J Surg Oncol. 2024 May 17;22(1):132. doi: 10.1186/s12957-024-03408-3. PMID: 38760663; PMCID: PMC11100235.