Incisional hernia is defined as a protrusion of abdominal contents through a defect in the abdominal wall at the site of a previous surgical incision. It represents a failure of fascial healing following abdominal surgery and remains a common complication of laparotomy.1

The reported incidence ranges from 10% to 20%, with higher rates observed in high-risk populations. Incisional hernias significantly impair quality of life and may lead to complications such as bowel obstruction, incarceration, and strangulation, often necessitating complex surgical repair.

The pathogenesis is multifactorial, involving patient-related, disease-related, and technical factors. Impaired collagen synthesis, increased intra-abdominal pressure, surgical site infection, and inadequate fascial closure contribute to fascial failure.1,2 Patient-related factors such as obesity, diabetes mellitus, smoking, anaemia, and advanced age adversely affect wound healing and reduce the tensile strength of the abdominal wall.3

Current international guidelines recommend continuous small-bite suturing using slowly absorbable sutures over rapidly absorbable materials, as this technique has been shown to reduce the risk of incisional hernia formation.4

Most incisional hernias develop within the first two years following surgery, highlighting the importance of adequate postoperative follow-up and early detection.1

Despite advances in surgical techniques and perioperative care, incisional hernia continues to pose a significant clinical burden, particularly in tertiary care settings. There is limited region-specific data regarding the pattern and associated risk factors of incisional hernia in our population.

This study was undertaken to evaluate the burden and identify risk factors associated with incisional hernia following abdominal surgery in a tertiary care centre.

MATERIALS AND METHODS

This prospective observational study was conducted in the Department of General Surgery at J.L.N. Medical College and Associated Group of Hospitals, Ajmer, Rajasthan, India, over a period of 18 months from June 2024 to December 2025.

Ethical Approval

Approval was obtained from the Institutional Ethics Committee. Written informed consent was taken from all participants.

Study Population

The study population consisted of patients presenting with incisional hernia following previous abdominal surgery during the study period.

Inclusion Criteria

• Patients aged more than 18 years with a history of previous abdominal surgery.
• Patient giving written and informed consent.

Exclusion Criteria

• Patients below 18 years
• Patients unwilling to participate in the study.

Data Collection

Data were collected using a structured proforma. The following variables were recorded:

Patient-related factors

• Age, gender
• Body Mass Index (BMI)
• Diabetes mellitus
• Hypertension
• Chronic kidney disease
• Smoking

Disease-related factors

• Indication for surgery
• Elective vs emergency surgery
• Wound contamination
• Type of incision

Postoperative factors

• Surgical site infection (SSI)
• Wound dehiscence

Clinical Assessment

All patients were subjected to a comprehensive clinical assessment, including general physical examination and a detailed abdominal examination. Particular attention was given to the characteristics of the hernia, including its location, size, reducibility, and any associated complications such as obstruction or strangulation.

Laboratory Investigations

Baseline laboratory investigations were carried out in all patients, including complete blood count, blood glucose levels, liver and renal function tests, serum electrolytes, and screening for viral markers. Additional tests such as electrocardiography and coagulation profile were performed in patients planned for operative management.

Radiological Evaluation

Ultrasonography of the abdomen and pelvis was utilised to assess the contents of the hernial sac and detect any associated complications. Computed tomography of the abdomen was reserved for selected patients with complex or large hernias. Chest radiography was performed in patients undergoing surgical intervention.

Outcome Measures

The burden of incisional hernia and associated risk factors were evaluated. The proportion of incisional hernia cases was calculated among patients presenting with abdominal wall hernias during the study period.

Statistical Analysis

Data were analyzed using SPSS version [31.0].

• Continuous variables expressed as mean ± SD
• Categorical variables as percentages

RESULTS

Overall Distribution

During the study period, a total of 832 cases of abdominal wall hernia were evaluated, of which 65 were incisional hernias, yielding a proportion of 7.81% (Table 1, Figure 1).

Demographic Profile

The mean age of patients was 53.8 ± 12.95 years (range 24–81 years). The highest frequency was observed in the 51–60 years age group (29.23%), followed by 61–70 years (27.69%).(Table 2, Figure 2).

The study population exhibited a female predominance, comprising 38 females (58.46%) and 27 males (41.54%). [table 3] [figure 3]

Time Interval from Previous Surgery

Most incisional hernias developed within six months of the index surgery (72.31%), followed by 6–12 months (20%), while a smaller proportion presented after more than one year (Table 4, Figure 4).

Type of Previous Surgery

A majority of cases occurred following emergency abdominal surgeries (81.54%), whereas 18.46% developed after elective procedures, including stoma closure and laparoscopic surgeries (Table 5, Figure 5).

Exploratory laparotomy was the most common preceding procedure (58.46%). Midline incision was the most frequent incision type (64.62%), followed by Pfannenstiel and other incision types. A small proportion of patients (6.2%) had a history of laparoscopic surgery (Table 6, Figure 6).

Risk Factors

Several patient-related risk factors were identified. The most common were anaemia (20%), diabetes mellitus (15.38%), hypertension (13.85%), and smoking (13.85%) (Table 7, Figure 7).

Body Mass Index

A majority of patients (64.6%) were obese (BMI ≥25), while 13.8% had normal BMI. Overweight and underweight categories accounted for 13.8% and 7.7% of cases, respectively (Table 8, Figure 8).

Postoperative Complications

Postoperative wound-related complications were observed in a significant proportion of patients. Surgical site infection (SSI) was the most common complication (46.1%), followed by wound dehiscence (7.7%) and wound sinus (7.7%). Overall, 61.5% of patients had wound-related complications (Table 9, Figure 9).

Defect Size

According to the European Hernia Society (EHS) classification, most patients (83.1%) had small defects (<4 cm), while 13.8% had medium-sized defects (4–10 cm) and 3.1% had large defects (>10 cm) (Table 10, Figure 10).

DISCUSSION

• Incisional hernia remains a significant complication following abdominal surgery, resulting from failure of fascial healing at the incision site. Despite advances in surgical techniques and perioperative care, it continues to pose a considerable clinical burden due to the complex interplay of patient-related factors, surgical technique, and postoperative events.
• In the present study, the proportion of incisional hernia was 7.81%, which is comparable with previously reported rates ranging from 5% to 20%. Studies by Itatsu et al. and Muysoms et al. have reported similar findings, indicating that incisional hernia remains a persistent challenge in surgical practice.5–9
• Age was found to be an important determinant, with a mean age of 53.8 ± 12.95 years, and the majority of patients belonging to the fifth and sixth decades of life. Similar observations have been reported by Helgstrand et al., who demonstrated that increasing age is associated with impaired wound healing due to reduced collagen strength and tissue elasticity.10,11
• A female predominance (58.46%) was observed in this study, which may be attributed to the higher frequency of abdominal procedures such as caesarean section and hysterectomy. Comparable findings have been reported by Köckerling et al.12
• Most hernias (72.31%) developed within six months of the index surgery, highlighting the importance of early postoperative wound healing. This period corresponds to active collagen remodelling, during which disruption may predispose to hernia formation. Similar temporal patterns have been described in previous studies.13,14
• A majority of cases (81.54%) occurred following emergency surgeries, reflecting the impact of inadequate preoperative optimisation, contamination, and compromised operative conditions on wound healing.
• Exploratory laparotomy was the most common preceding procedure, and midline incisions accounted for the majority of cases (64.62%). Midline laparotomy, although widely used, has been associated with higher rates of incisional hernia due to relatively poor vascularity and increased tension across the wound, as supported by studies including Deerenberg et al. and the European Hernia Society guidelines.6,15
• Patient-related factors such as anaemia, diabetes mellitus, hypertension, and smoking were commonly observed and are known to impair wound healing through mechanisms including reduced oxygen delivery and altered collagen synthesis.10,16,17
• Obesity was a prominent risk factor in the present study (64.6%), contributing through increased intra-abdominal pressure and impaired tissue quality. This is consistent with findings reported in previous studies.18,19
• Postoperative wound complications were identified as the most significant contributing factors, with 61.5% of patients affected, particularly surgical site infection (46.1%). Surgical site infection leads to collagen degradation and disruption of fascial integrity and has been consistently reported as a major risk factor for incisional hernia.6,16
• Although minimally invasive surgery is associated with reduced wound complications, it is not entirely risk-free. Studies such as those by Hiraki et al. have demonstrated that hernias may still occur at trocar or specimen extraction sites. In the present study, 6.2% of patients had a history of laparoscopic procedures, supporting this observation.20,21
• An important observation was that the majority of hernias were small defects (<4 cm) (83.1%), suggesting relatively early presentation and potential for timely intervention.
• Proper abdominal wall closure techniques play a crucial role in prevention. Recent evidence-based reviews emphasise the importance of optimal suture technique, tension-free closure, and strict infection control in reducing the risk of incisional hernia (Agrawal and Jaiswal, 2026).22
• Overall, the present study supports the multifactorial nature of incisional hernia, resulting from a combination of biological impairment in wound healing and mechanical stress on the abdominal wall.11,23 Among these, postoperative wound infection and obesity emerged as the most important modifiable risk factors.
• From a clinical perspective, these findings highlight the need for patient optimisation, meticulous surgical technique, appropriate incision selection, and strict infection control measures to reduce the burden of incisional hernia.

Strengths

The present study has several strengths. It was conducted using a prospective design with systematic data collection. Standardised clinical evaluation was performed in all patients. Additionally, multivariate analysis was utilised to identify independent risk factors associated with incisional hernia.

Limitations

This study has certain limitations. It was a single-centre study, which may limit the generalisability of the findings. Furthermore, larger multicentric studies with longer follow-up are required to validate these results.

CONCLUSION

• The present study demonstrated that incisional hernia constituted 7.81% of abdominal wall hernias in patients presenting to a tertiary care centre. The condition was more commonly observed in middle-aged individuals, with a female predominance. Most incisional hernias developed within the first six months following abdominal surgery, underscoring the importance of early postoperative wound healing.
• Emergency abdominal surgeries, exploratory laparotomy, and midline incisions were the most common surgical factors associated with incisional hernia. Patient-related factors such as anaemia, diabetes mellitus, hypertension, and smoking were frequently observed. In addition, postoperative wound infection emerged as a major contributing factor, highlighting the importance of meticulous surgical technique and effective infection control.
• Early identification and optimisation of modifiable risk factors, along with careful abdominal wall closure and appropriate postoperative care, may help reduce the burden of incisional hernia following abdominal surgery. Evidence-based techniques such as small-bite fascial closure have been shown to reduce the risk of incisional hernia formation.24
• For large or complex defects, advanced reconstructive techniques such as component separation with mesh reinforcement may provide improved outcomes.25

Declarations

Funding: None

Conflict of Interest: The authors declare no conflict of interest.

Ethical Approval: Obtained from the Institutional Ethics Committee.

Informed Consent: Written informed consent was obtained from all participants.

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