Recommended Treatment for Incisional Hernia
For an adult patient with incisional hernia and history of heavy lifting, elective surgical repair with mesh is the definitive treatment, as mesh repair reduces recurrence rates from 43% to 24% compared to suture repair alone. 1
Elective Repair Strategy
Primary Recommendation: Mesh Repair
- Mesh repair is superior to suture repair for all incisional hernias, with three-year recurrence rates of 24% versus 43% for suture repair (p=0.02). 1
- This superiority holds regardless of hernia size—even small defects benefit from mesh reinforcement. 1
- The patient's history of heavy lifting/straining is a risk factor for recurrence with suture repair, making mesh even more critical. 1
Surgical Approach Selection
- Laparoscopic repair is preferred when feasible, offering shorter hospital stays, lower perioperative complication rates, and decreased recurrence rates compared to open repair. 2
- For defects <3 cm, primary suture repair may be considered, though mesh still provides better long-term outcomes. 3
- For defects >10 cm, onlay polypropylene mesh is specifically recommended. 4
Mesh Type and Fixation
- Synthetic mesh (polypropylene) is the standard in clean, elective cases with significantly lower recurrence rates than biological mesh (3.2% vs 27.2%). 5
- Mesh fixation technique (absorbable vs nonabsorbable tacks, sutures, or combinations) shows negligible differences in outcomes—choose based on surgeon preference and availability. 6
- Combined fascial and prosthetic mesh repair demonstrates low recurrence (3%) and modest complication rates with mean follow-up of 20 months. 7
Risk Modification Before Surgery
Address Modifiable Risk Factors
- Counsel on activity modification: Heavy lifting and straining increase recurrence risk. 1
- Evaluate for prostatism (in men), as this is an independent risk factor for recurrence requiring preoperative management. 1
- Optimize wound healing: Previous infection and abdominal aortic aneurysm surgery are additional risk factors. 1
Emergency Scenarios (When Applicable)
Immediate Surgery Required If:
- Suspected intestinal strangulation with signs of bowel compromise (SIRS, elevated lactate, CPK, D-dimer, or CT findings of strangulation). 8, 3
- Peritonitis from bowel perforation or obvious clinical peritonitis on examination. 8
- These are absolute indications for immediate surgery to prevent bowel necrosis and death. 8
Emergency Repair Considerations:
- For contaminated fields (CDC class III) with small defects (<3 cm), primary repair is recommended. 5
- For larger defects in contaminated fields, biological mesh may be used, though this carries higher recurrence rates (27.2%) than synthetic mesh in clean fields. 5
- Laparoscopic approach can be used for incarcerated (non-strangulated) hernias, with significantly lower wound infection rates (p<0.018) than open repair. 5, 3
Common Pitfalls to Avoid
- Do not use suture repair alone for defects >10 cm—recurrence approaches 100% in some series. 4
- Do not delay repair in symptomatic patients, as progression to incarceration/strangulation significantly increases morbidity and mortality. 5
- Avoid biological mesh in clean elective cases—the evidence shows higher recurrence rates (27.2% vs 3.2%) compared to synthetic mesh without clear infection benefit in uncontaminated fields. 5
- Do not underestimate seroma risk with mesh repair (12.7% with mesh vs 3.4% with suture repair), though this rarely affects long-term outcomes. 4