Br. J. Surg. 1985, Vol.

72, January, 70-71

lncisional hernia: a 10 year
prospective study of incidence and
attitudes

Five hundred and sixty-four patients reviewed 1 year after major

Marjorie Mudge and
L. E. Hughes
Department of Surgery, Welsh
National School of Medicine,
Heath Park, Cardiff CF4 4XN, UK
Correspondence to: Marjorie
Mudge
abdominal surgery have been studied prospectively by a single observer
for 10 years to determine the incidence and significance of incisional
hernia. Of 337 (60 per cent) patients completing the 10 year follow-up
37 (I1 per cent) developed an incisional hernia and 13 (35 per cent) of
these first appeared at 5 years or later. One in three hernias caused
symptoms. T h e late appearing hernias were smaller than the early ones,
and caused little trouble. Of the 18 patients who consulted their general
practitioner, I 1 had symptoms and of these six (55 per cent) were
referred for surgical opinion. Many hernias were diagnosed at routine
outpatient follow-up and were likely to receive treatment from the
surgeon. Most symptomatic patients were offered surgery with the
remainder usually being offered a corset. In about half our patients
(mainly those without symptoms) surgery was refused or advised against
although the patients would have accepted it. Recurrence is common after
surgical repair (40 per cent) but seems to be related to surgical technique.
T h e possibility of complications occurring from an incisional hernia does
not appear to be discussed with patients although obstruction occurred in
14 per cent of our patients with troublesome hernia.
Keywords: Incisional hernia, late development, incidence

Since incisional hernia is one of the major elements of morbidity
after abdominal surgery, its incidence is of concern to abdominal
surgeons. Incidence figures vary considerably but most studies
have assessed incidence at 1 year, assuming that incisional
hernias will be obvious by that time. A prospective study of
morbidity in a large surgical population begun in 1972-1973
showed that late development of incisional hernias was not
uncommon up to 5 years after operation’. Follow-up of this
cohort of patients to the tenth year is complete and the results
are now reported. The clinical significance of these hernias has
been assessed in relation to: symptoms and incapacity caused;
the necessity for treatment; and the attitudes of general prac-
titioners and surgeons consulted.
Patients and methods
Eight hundred and thirty-one patients aged 40 years or over undergoing
elective major abdominal surgery of the gastrointestinal tract, biliary
tree or colon, and studied in the South Wales Dextran Trial in 1972-
1973’. were entered into a long-term follow-up survey. A variety of
techniques were used to repair the abdominal wall. The four chief
methods, in decreasing order of frequency were: continuous catgut to
peritoneum/posterior sheath and continuous nylon to anterior sheath/
linea alba; continuous nylon/both layers; continuous nylon/interrupted
nylon; and continuous catgut both layers. Patients were examined by
the same observer at 1 year postoperatively, and subsequently in the
fourth, sixth, eighth and tenth years. Development of incisional hernia
was noted. Of 564 patients surviving and willing to enter the study at the
end of the first year, 337 were followed up for at least 9 years. Of the
remainder, 128 patients had died and 99 patients had an incomplete
follow-up for various reasons. Patients were questioned regarding
symptoms and incapacity in relation to their hernias. Details of
consultation with general practitioners, referral to surgeons and
consequent treatment were recorded.
Results
Of all 564 patients, 62 (11 per cent) have developed incisional
hernias as defined by Pollock and his colleagues3 as ‘a bulge,
visible and palpable when the patient is standing, and often
requiring support or repair’. The incidence is the same for the
337 patients completing follow-up to 10 years as in those who
died or were lost before 10 years. In addition, three patients have
developed incisional hernias but have not been included in the
figures since they do not conform to the definition. In one case
the herniation was found at operation for another condition, in
another a small hernia was palpable but not visible and in the
third case the herniation is only visible when the patient lies
down and lifts his shoulders from the bed. Two patients with
herniation at a drain site have also been omitted from the figures.
More than half the hernias presented later than 12 months after
operation (Table 1).
Table I shows the incidence of incisional hernias and their
appearance in relation to time after operation, the number of
patients troubled by their hernia and who subsequently seek
advice. Presence or absence of symptoms in relation to
treatment is illustrated in Tuble2. Symptoms varied but included
difficulty in bending, discomfort from the size of the hernia,
persistent abdominal pain and episodes of subacute obstruction
requiring hospital admission. Of three patients with subacute
obstruction, two have had herniorrhaphy at a later date and a
third patient is awaiting a surgical opinion. One patient was
retired from work by his general practitioner on the grounds of
the size of the hernia although it was not troublesome and no
treatment was advised. Ninety per cent of troublesome hernias
occurred within 3 years of operation. Those developing later
were smaller in size and not particularly troublesome, although
in two cases the hernia has become larger between years 5 and 10
and in one an additional hernia has developed. Of the patients
with a hernia before 5 years, two have developed additional
hernias through a separate portion of the scar by year 10.
Fifty-eight per cent of the patients sought medical advice.
From Table 1 it can be seen that the majority (86 per cent) of
patients who sought advice did so within 3 years after operation.
Those who were symptom-free sought advice on grounds of size
of the hernia or enquiry as to the nature of the lump. Three
patients who did not actively seek advice and were symptom-
free were supplied with an abdominal support: one who

70 0007-1323/85/010070-02$3.00 @ 1985 Butterworth & Co (Publishers) Ltd

 lncisional hernia: M. Mudge and L. E. Hughes

Table 1 Summary of patient statistics

Number of Number Number Number Number Number

patients presenting presenting presenting presenting presenting
with IH year 1 year 3 year 5 year 7 year 9

Total 564 62 27 22 2 6
Complete follow-up to 9 years 337 37 9 15 2 6
Incomplete follow-up to 9 years 99 10 6 4 0 0
Dead by 9 years 128 15 12 3 0 0
Percentage of 62 I00 44 35 3 10

Number of patients with symptoms

Seeking advice 21 11 8 1
Not seeking advice 2 1 0 0
Number of patients without symptoms
Seeking advice 15 4 8 0
Not seeking advice 24 11 6 1

Table 2 Details of treatment of incisional hernia
Patients Patients
with without
symptoms symptoms Total
Number of patients with IH 23 39 62
Number who sought advice but
were not offered treatment 6 9 15
Corset 6* 5 11*
Corset and repair 4 0 4 operatively must underestimate the incidence of incisional
Surgical repair 5 1 6 hernias. When the concept of late development of incisional
* Includes patient still awaiting appointment with surgeon
developed the hernia immediately postoperatively and was
given the support on discharge from hospital; one because the
hernia was noticed at routine follow-up, and one who developed
a large hernia within a few weeks of the operation. Only two
patients suffered discomfort but did not seek advice. Of 18
patients who saw their general practitioner six (five with
symptoms) were referred for a surgical opinion. Of the 12
patients who saw only their family doctor, one was prescribed a
corset with the option of referral for surgery, one already referred
to was retired from work, two were reassured and the remaining
eight were discouraged from having treatment. Twenty-three
patients have been seen by a surgeon. Only five of these were as
the result of specific referral by the general practitioner, the sixth
patient is still waiting for an outpatient appointment after
2 years, and meanwhile wears an abdominal support.
Of the 23 patients seen by a surgeon, ten underwent repair
(one of nine without symptoms and nine of eleven with
symptoms). One patient was offered but refused surgical repair.
Of the remaining 12 patients of the 23 seen by a surgeon, 5 were
not offered surgical repair and 7 were refused or advised against
it, although 9 of these were prescribed a corset. The seven
patients were variously told ‘nothing can be done’, ‘you will have
to live with it’, ‘not enough skin’ and ‘too old for the operation’.
Altogether 14 patients were prescribed a corset by the
surgeon concerned. In five of these this was additional to surgical
repair either before or where repair has failed.
Three patients (with symptoms) consulted two surgeons and
one patient (with symptoms) three surgeons. In general, patients
seemed to accept the advice given, although one of the patients,
who consulted his general practitioner and two surgeons, is not
happy in that he has been unable to obtain a surgical repair. Of
the 14patients prescribed a corset only 3 patients did not wear it,
2 on grounds of discomfort and 1 elderly patient who could not
fasten the buckles.
The hernia recurred in four patients (40 per cent) and in two
of these a repeat herniorrhaphy was performed, so far without
recurrence in one, the other patient having since died. The ten
hernia repairs were carried out by five surgeons, using a wide
variety of techniques. Two surgeons have 100 per cent
recurrence rate (two each) and the other three surgeons have no
recurrence as yet.
Discussion
A single observer has followed a large cohort of patients
prospectively over nine postoperative years. Since more than
half the hernias developed later than 1 year after operation,
previous studies reporting the incidence at 1 year post-
hernias was first put forward with our 5 year results in 1981 to a
meeting of the Section of Surgery of the Royal Society of
Medicine, London, it met with considerable scepticism during
discussion, but another group has subsequently confirmed our
findings4. Our 10 year results extend the concept since new
hernias continue to develop, and small hernias to enlarge up to
9 years. It is noted that the incidence is similar in patients
followed to 9 years, to patients with shorter follow-up. This
probably reflects a higher incidence of hernia in patients with
serious conditions-much of our mortality has been associated
with advanced cancer. It appears that hernias which develop
within 3 years of operation are more likely to be troublesome
and larger in size than late developing hernias, and advice is
more likely to be sought.
Most patients with symptoms see a surgeon and are offered
operative treatment or a support. Most patients without
symptoms were discouraged from having surgery.
A wide variety of techniques of repair are still in use. Four
hernias were repaired by a technique of interrupted horizontal
near-and-far mattress sutures of Prolene, without recurrence.
Techniques based on ‘double breasting’ or interrupted silk
closure had a high recurrence rate.
Acknowledgements
We are indebted to Mrs Sandra Hooper for expert secretarial assistance
throughout the study.
References
1. Harding KG, Mudge M, Leinster SJ, Hughes LE. Late develop-
ment of incisional hernia: an unrecognised problem. Br Med J
1983; 286: 519-20.
2. Kline A, Hughes LE. Campbell H, Williams A, Zlosnick J. Leach
KG. Dextran 70 in the prophylaxis of thromboembolic disease
after surgery: a clinically orientated randomised dou ble-blind trial.
Br Med J 1975; 2 : 109-12.
3. Greenall MJ, Evans M. Pollock AV. Midline or transverse
laparotomy? A random controlled clinical trial. Part 1 : Influence
on healing. Br J Surg 1980; 67: 188-90.
4. Ellis H, Gajraj H, George CD. Incisional hernias: when do they
occur? Br J Surg 1983; 70: 290-1.
Paper accepted 26 June 1984

Br. J. Surg., Vol. 72, No. 1, January 1985 71