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ACS

Ventral Hernia Repair

A ventral hernia is a bulge through an opening in the muscles on the abdomen. The hernia can occur at a past incision site (incisional), above the navel (epigastric), or other weak muscle sites (primary abdominal).

Ventral Hernia Repair

Common Symptoms

  • Visible bulge on the abdomen, especially with coughing or straining
  • Pain or pressure at the hernia site

Sharp abdominal pain and vomiting may mean that the intestine has slipped through the hernia sac and is strangulated. This is a surgical emergency and immediate treatment is needed.

Treatment Options

Surgical Procedure

Open hernia repair (OVHR)

An incision is made near the site, and the hernia is repaired with mesh or by suturing (sewing) the muscle closed.

Laparoscopic Hernia Repair (LVHR)

The hernia is repaired by mesh or sutures inserted through instruments placed into small incisions in the abdomen.

Nonsurgical Procedure

Watchful waiting is an option for adults with hernias that are reducible and not uncomfortable.1

ventral-hernia-graphic-2.png

Benefits and Risks of Your Operation

Benefits

An operation is the only way to repair a hernia. You can return to your normal activities and, in most cases, will not have further discomfort.

Risks of Not Having an Operation

The size of your hernia and the pain it causes can increase. If your intestine becomes trapped in the hernia pouch, you will have sudden pain and vomiting and require an immediate operation.

If You Decide to Have the Operation, Possible Risks Include:

  • Return of the hernia
  • Infection
  • Injury to the bladder, blood vessels, or intestines
  • Continued pain at the hernia site

Expectations

Before your operation—Evaluation may include blood work, urinalysis, ultrasound, or a CT scan. Your surgeon and anesthesia provider will review your health history, home medications, and pain control options.

The day of your operation—You will not eat or drink for 4 hours before the operation. Most often, you will take your home medication with a sip of water. You will need someone to drive you home.

Your recovery—You may go home within 24 hours for small hernia procedures but may need to stay in the hospital longer for more complex repairs. The average length of stay for patients with a complex hernia repair is 1.5 days.2

Call your surgeon if you have:

  • Severe pain
  • Stomach cramping
  • Chills with a high fever (higher than 101°F)
  • Odor or increased drainage from your incision
  • No bowel movement for 3 days

Work and Return to School

  • After recovery, you can usually return to work or school within 2 to 3 days.
  • You will not be able to lift anything over 10 pounds, climb, or do strenuous activity for 4 to 6 weeks following ventral hernia repair.
  • Lifting limitation may last for 6 months for complex or recurrent repairs.

Keeping You Informed

Abdominal Wall Hernias

They are also called ventral hernias. They can occur:

  • At birth (congenital)
  • Over time due to muscle weakness
  • At a past incision site

Incisional Hernias

Incisional hernias occur in about 12% after major open abdominal surgeries and in about 3% of major laparoscopic surgeries.3 Most appear in the first 5 years after an operation. Risk factors that can contribute to incisional hernia formation include:

  • Obesity, which creates tension and pressure on abdominal muscles
  • Large abdominal incisions
  • Postoperative infection (note that smoking is related to higher infection rates)
  • Weakness of the connective tissue (the material between the cells of the body that gives it strength,
    sometimes called the cellular glue)
  • Diabetes mellitus
  • Pulmonary disease
  • Liver disease
The Condition

A ventral hernia occurs when there is a weakness or hole in the muscles of the abdomen and a loop of intestine or abdominal tissue pushes through the muscle layer.4 If the hernia reduces in size when a person is lying flat or in response to manual pressure, it is reducible. If it cannot be reduced, it is irreducible or incarcerated, and a portion of the intestine may be bulging through the hernia sac. A hernia is strangulated if the intestine is trapped in the hernia pouch and the blood supply to the intestine is decreased. This is a surgical emergency.

The 3 types of Ventral Hernias are:

Epigastric (stomach area) hernia: Just below the breastbone to the navel/umbilicus (belly button).

Umbilical hernia: Occurs in the area of the belly button.

Incisional hernia: Develops at the site of a previous surgical incision or
laparoscopic repair as a result of scar tissue or weakened muscles at the site.

The Procedure

Surgical Treatment

The type of operation depends on the hernia  size, location, and if it is a repeat hernia. Your health, age, anesthesia risk, and the surgeon’s expertise are also important. An operation is the only treatment for a hernia repair.

Open Hernia Repair

The surgeon makes an incision near the hernia site. The bulging tissue is gently pushed back into the abdomen. Sutures, or a tissue flap is used to close the muscle. With complex or large hernias, small drains may be placed going from inside to the outside of the abdomen. The site is closed using sutures, staples, or surgical glue.

Open Mesh Repair

The hernia sac is removed. Mesh is placed over the hernia site. The mesh is attached using sutures sewn into the stronger tissue surrounding the hernia site. Mesh is often used for large hernia repairs and may reduce the risk that the hernia will come back. The site is closed using sutures,
staples, or surgical glue. The most basic approach is a primary open repair without mesh, used for defects of less than 2 cm.5

Laparoscopic Hernia Repair

The surgeon will make several small punctures or incisions in the abdomen. Ports or trocars (hollow tubes) are inserted into the openings. Surgical tools are placed into the ports. The abdomen is inflated with carbon dioxide gas to make it easier for the surgeon to see the hernia. Mesh is sutured, stapled, or clipped to the muscle around the hernia site. The hernia site can also be sewn directly together.

Nonsurgical Treatment

Watchful waiting is an option for a hernia without symptoms. In a large study, 19 % (1 in 5) of incisional hernias and 16% (1 in 7) of umbilical/epigastric hernias patients did watchful waiting. Four percent of those needed emergency surgery within 5 years. There were no differences in 30-day readmission, reoperation or death rates between patients who had surgery and patients who waited for hernia repair.1 All patients should get treatment if they have sudden sharp abdominal pain and vomiting. These symptoms can indicate an incarcerated hernia and bowel obstruction.

Trusses may help the comfort in about 1/3 of those who use them. Surgery is the only option to fix the hernia.

Common Tests

History and Physical

The site is checked for a bulge.

Additional Tests (see Glossary)

  • Other tests may include:
  • Ultrasound
  • Computerized tomography (CT) scan
  • Blood tests
  • Urinalysis
  • Electrocardiogram (ECG)—for patients over 45 or if high risk of heart problems

Keeping You Informed

Open versus Laparoscopic Incisional Repair

There is no one type of repair that is good for all ventral hernias. Laparoscopic repairs are associated with lower infection rates and shorter hospital stays. There is no difference in recurrence rates, long-term pain,
or quality of life.6 For patients with strangulated intestines and infections, the laparoscopic approach may not be an option.

Will My Hernia Come Back?

Mesh reduces the risk that the hernia will return again.7 Absorbable mesh has been shown to decrease the risk the hernia will return and improves the quality of life.7 Mesh can be tacked, stapled, or sutured.

Obesity and wound complications increase the risk of recurrence.8,9 You may be placed on a weight loss, smoking cessation, or a diabetes control program before an elective repair to support the best outcome.

Risks of this Procedure

Risks Based on the ACS Risk Calculator in July, 2022*

Percentage

Keeping You Informed

Wound infection: Infection at the area of the incision or near the organ where surgery was performed

Open: 5.8%
Laparoscopic: Less than 1%

Antibiotics and drainage of the wound may be needed. Smoking can increase the risk of infection.

Return to surgery: The need to go back to the operating room due to a problem after the prior surgery

Open: 3.7%
Laparoscopic: Less than 1%

Significant pain and bleeding may cause a return to surgery. Your surgical and anesthesia team is prepared to reduce all risks of return to surgery.

Pneumonia: Infection in the lungs

Open: 0.8%
Laparoscopic: Less than 1%

Stopping smoking, movement and deep breathing after your operation can help prevent respiratory infections.

Urinary tract infection: Infection of the bladder or kidneys

Open: 0.7%
Laparoscopic: Less than 1%

Drinking fluids and catheter care decrease the risk of
bladder infection.

Blood clot: A clot in the legs that can travel to the lung

Open: 0.5%
Laparoscopic: Less than 1%

Longer surgery and bed rest increase the risk. Getting up, walking 5 to 6 times per day, and wearing support stockings reduce the risk.

Heart complication: Includes heart attack or sudden stopping of the heart

Less than 1%

Problems with your heart or lungs can be aggravated by general anesthesia. Your anesthesia provider will take your history and suggest the best option for you.

Renal (kidney) failure: Kidneys no longer function in making urine and/or cleaning the blood of toxins

Less than 1%

Preexisting renal conditions; fluid imbalance, Type 1 diabetes; over age 65; antibiotics; and other medications may increase the risk.

Death

Less than 1%

Any complication, including: Surgical infections, breathing difficulties, blood clots, renal (kidney) complications, cardiac complications, and return to the operating room

Open: 10.1%
Laparoscopic: 2.6%

Complications related to general anesthesia and surgery may be higher in smokers, elderly and obese patients, and those with high blood pressure and breathing problems. Wound healing may also be decreased in smokers and those with diabetes and immune system disorders.

Risks from Outcomes Reported in the Last 10 Years of Literature

Percentage

Keeping You Informed

Urinary retention: Inability to urinate after the urinary catheter is removed

21%

General anesthesia, older age, prostate problems, and diabetes may be associated with urinary retention. A temporary catheter or medication may be used to treat retention.

Seroma: A collection of serous (clear/yellow) fluid

12%

A seroma usually goes away on its own within 4 to 6 weeks. Rarely, the fluid is removed with a sterile needle.10

Recurrence: A hernia can recur up to several years after repair

Open: 12%
Laparoscopic: 10%
Non-Mesh: 17% 11

Recurrence rates are higher for complex or infected hernia repair or for repairs done without mesh. Long term follow up shows the use of a mesh as compared with primary suture appears to reduce hernia recurrence, but may increase complications like seroma, infection, or bowel obstruction.11

Intestines/bowel injury

Open: Less than 1.9%
Laparoscopic: 1.9% 12

Injury will be repaired at the time of operation. If there is bowel leakage into the abdominal cavity, the hernia repair will be done after the bowel heals. A nasogastric (NG) tube will be placed to keep the stomach empty until fluid is moving through the bowel.

*The ACS Surgical Risk Calculator estimates the risk of an unfavorable outcome. Data is from a large number of patients who had a surgical procedure similar to this one. If you are healthy with no health problems, your risks may be below average. If you smoke, are obese, or have other health conditions, then your risk may be higher. This information is not intended to replace the advice of a doctor or health care provider. To check your risks, go to the ACS Risk Calculator at http://riskcalculator.facs.org. 

The Day of Your Procedure

Get the details you need about common procedures and know what to expect before you or a loved one has surgery.

Recovery and Discharge

Access resources and information you need to optimize your recovery from surgery.

Safe Pain Management

Your surgical team wants to help you to safely and effectively manage any pain that you may have after surgery.

Surgery FAQ

Answers to common questions surgical patients have before, during, and after a procedure.

Glossary

Advance directives: Documents signed by a competent person giving direction to health care providers about treatment choices.

Blood tests: Tests usually include a Chem-6 profile (sodium, potassium,
chloride, carbon dioxide, blood urea nitrogen, and creatinine) and complete blood count (red blood cell and white blood cell count).

Computerized tomography (CT) scan: A diagnostic test using X ray and a computer to create a detailed, three-dimensional picture of your abdomen.

Electrocardiogram (ECG): Measures the rate and regularity of heartbeats, the size of the heart chambers, and any damage to the heart.

General anesthesia: A treatment with certain medicines that puts you into a deep sleep so you do not feel pain during surgery.

Hematoma: A localized collection of blood in the tissue or organ.

Local anesthesia: The loss of sensation only in the area of the body where an anesthetic drug is applied or injected.

Nasogastric tube: A soft plastic tube inserted in the nose and down to the stomach; used to empty the stomach of contents and gases to rest the bowel.

Seroma: A collection of serous (clear/yellow) fluid.

Ultrasound: Sound waves are used to determine the location of deep structures in the body. A hand roller is placed on top of clear gel and rolled across the abdomen.

Urinalysis: A visual and chemical examination of the urine, most often used to screen for urinary tract infections and kidney disease.

DISCLAIMER

The American College of Surgeons (ACS) is a scientific and educational association of surgeons that was founded in 1913 to improve the quality of care for the surgical patient by setting high standards for surgical education and practice. The ACS endeavors to provide procedure education for prospective patients and those who educate them. It is not intended to take the place of a discussion with a qualified surgeon who is familiar with your situation.  The ACS makes every effort to provide information that is accurate and timely, but makes no guarantee in this regard.

Reviewed 2012, 2014, 2017 and 2022 by:
David Feliciano, MD, FACS
Mary T. Hawn, MD, FACS
Kathleen Heneghan, PhD, MSN, RN, FAACE
Nancy Strand, MPH, RN

References

The information provided in this report is chosen from recent articles based on relevant clinical research or trends. The research below does not represent all that is available for your surgery. Ask your doctor if he or she recommends that you read any additional research.

  1. Kokotovic D, Sjølander H, Gögenur I, et al. Watchful waiting as a
    treatment strategy for patients with a ventral hernia appears to be
    safe. Hernia 20, 281–287 (2016). https://doi.org/10.1007/
    s10029-016-1464
  2. ACS Risk calculator: https://riskcalculator.facs.org/RiskCalculator/
  3. Goodenough CJ, Ko TC, Kao LS, et al. Development and validation of a risk stratification score for ventral incisional hernia after abdominal surgery: hernia expectation rates in intra-abdominal surgery (the HERNIA Project). J Am Coll Surg. 2015 Apr;220(4):405-13. doi: 10.1016/j. jamcollsurg.2014.12.027.
  4. Ventral Hernia. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/16531-ventral-hernia 2018.
  5. Smith J, Parmely JD. Ventral Hernia. [Updated 2021 Aug 11]. In:
    StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;
    2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/
    NBK499927/
  6. Ecker, B. L. et al. Laparoscopic versus open ventral hernia repair:
    Longitudinal outcomes and cost analysis using statewide claims data. Surg Endosc. 30(3), 906–915. https://doi.org/10.1007/s00464-015-4310-y (2016).
  7. Rosen MJ, Bauer JJ, Harmaty M, et al. Multicenter, Prospective,
    Longitudinal Study of the Recurrence, Surgical Site Infection, and
    Quality of Life After Contaminated Ventral Hernia Repair Using
    Biosynthetic Absorbable Mesh: The COBRA Study. Ann Surg. 2017
    Jan;265(1):205-211. doi: 10.1097/SLA.0000000000001601. PMID:
    28009747; PMCID: PMC5181129.
  8. Nieto EP, Ponz CB, Ananin SF, et al. Obesity as a risk factor for
    complications and recurrences after ventral hernia repair. Int J Abdom Wall Hernia Surg 2020;3:1-3
  9. Veilleux E, Lutfi R. Obesity and Ventral Hernia Repair: Is There Success in Staging? J Laparoendosc Adv Surg Tech A. 2020 Aug;30(8):896-899.
    doi: 10.1089/lap.2020.0265. Epub 2020 May 21. PMID: 32453617.
  10. Blount AL, Craft RO, Harold KL. Safety of laparoscopic ventral
    hernia repair in octogenarians. JSLS. 2009 Jul-Sep;13(3):323-6. PMID: 19793470; PMCID: PMC3015979.
  11. Kokotovic D, Bisgaard T, Helgstrand F. Long-term recurrence and
    complications associated with elective incisional hernia repair. JAMA.
    2016; 316(15):1575–1582. https://doi.org/10.1001/jama.2016. 15217 PMID: 27750295
  12. Colavita PD, Tsirline VB, Belyansky I, Walters AL, Lincourt AE, Sing
    RF, Heniford BT. Prospective, long-term comparison of quality
    of life in laparoscopic versus open ventral hernia repair. Ann
    Surg. 2012 Nov;256(5):714-22; discussion 722-3. doi: 10.1097/
    SLA.0b013e3182734130. PMID: 23095614.X