International Surgery Journal

Nigam A et al. Int Surg J. 2020 May;7(5):1587-1592

http://www.ijsurgery.com pISSN 2349-3305 | eISSN 2349-2902

DOI: http://dx.doi.org/10.18203/2349-2902.isj20201874
Original Research Article

Study prevalence of risk factors and clinical presentation of ventral

incisional hernia an observational study
Anjana Nigam, S. L. Nirala*, Niraj Bhusakhare

Department of General Surgery, Pt. J.N.M. Medical College, Raipur, Chhattisgarh, India

Received: 11 March 2020

Accepted: 15 April 2020

*Correspondence:
Dr. S. L. Nirala,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Incisional hernia is the second most common type of hernia after inguinal hernia. It is a complication of
abdominal surgery, reported in up to 11% of patients generally and in up to 20% of those who developed post
operative wound infection. The list of predictive factors associated with development of incisional hernia is obesity,
diabetes mellitus, steroid, smoking, old age, malnutrition, COPD and type of incision.
Methods: This was a hospital based cross sectional observational study carried out from February 2018 - October
2019 in surgery department of Dr. B.R.A.M. Hospital Raipur C.G, with diagnosis of incisional hernia. Total 100
patients were included in the study.
Results: In present study the mean age of study subjects was 47.27±13.16 years. Around two-third 64% were
females. 40% of perforation and 35% of LSCS cases later develop to Incisional hernia. Risk factors profile showed
that 31% were alcoholic, 27% smokers, 48% pre-obese and 5% were obese. 36% were hypertensive, 48% diabetic,
and 12% had constipation. 25% had prolonged cough, 35% had surgical site infection, 45% had anemia. Clinical
presentation of study subjects showed that 63% had swelling, 33% had swelling and pain and 4% had obstruction.
Conclusions: Incisional hernia is more common in female than males and in cases above the age of 45 years. It is
more common in patients who underwent the previous surgery on an emergency basis especially in perforation and
obstruction and LSCS cases. Risk factors associated with incisional hernia are smoker, alcoholic, obesity,
hypertension, diabetes, constipation, prolong cough and anemia.

Keywords: Incisional hernia, Prevalence, Risk factors, Clinical presentation

INTRODUCTION surgery, reported in upto 11% of patients generally and in

up to 20% of those who developed post-operative wound
Incisional hernia is the hernia occurring through the infection.2,3 It is an important source of morbidity.
operative scar. It is the result of failure of the line of Treatment involves further major surgery and the result
closure of the abdominal wall following laparotomy. may be poor, with recurrence rates of up to 49%.
Incisional hernia (IH) is defined by the European hernia Incisional hernias after laparotomy are mostly related to
society as “any abdominal wall gap with or without a failure of the fascia to heal and involve technical and
bulge in the area of postoperative scar perceptible or biological factors. Approximately 50% of all incisional
palpable by clinical examination or imaging”.1 hernias develop or present within the first 2 years
following surgery, and 74% occur within 3 years.4 In
It is the second most common type of hernia after spite of the frequency of the condition and its potential
inguinal hernia. It is a complication of abdominal morbidity, no consensus on the best method of repair has

International Surgery Journal | May 2020 | Vol 7 | Issue 5 Page 1587

 Nigam A et al. Int Surg J. 2020 May;7(5):1587-1592

been established. A wide spectrum of surgical techniques develop incisional hernia in different earlier surgeries.
has been developed ranging from sutured techniques to P value <0.05 is considered as statistically significant.
the use of various types of prosthetic mesh. This has
created uncertainty and confusion among surgeons RESULTS
regarding the optimum method of repair.
In present study total 100 patients were enrolled with the
The list of predictive factors associated with development mean age of study subjects was 47.27±13.16 years. Table
of incisional hernia is obesity, diabetes mellitus, steroid, 1 showed the socio-demographic details of study subjects
smoking, old age, malnutrition, COPD, type of incision, with incisional hernia. Around two-third 64% were
type of suture material and SSI post laparotomy. The females. 41% of the study subjects were living in rural
present study was done to evaluate the risk factors and areas and 59% were in urban areas. Socioeconomic status
clinical presentation of incisional hernia to reduce its showed that 27% belongs to lower class of socioeconomic
occurrence by developing a preventive strategy to profile (as per modified GB Prasad), 37% belongs to
patients undergoing laparotomy. lower middle class and 36% belongs to middle class.
Occupational status showed that, 61% were house wives
METHODS and 17% were farmers.

This was a hospital based cross sectional observational Table 1: Socio-demographic information of study
study carried out from February 2018 to October 2019 subjects.
with aim to identify the prevalence of physical,
behavioral, medical and modifiable risk factors for the Frequency Percentage (%)
development of incisional hernia and their clinical Age (in years)
presentation. During the study period all patients 20-40 37 37
attending at outpatient department of surgery and those 41-60 46 46
admitted in surgery ward of Dr. B.R.A.M. Hospital 61-80 17 17
Raipur C.G, with diagnosis of incisional hernia and who Sex
fulfill the inclusion criteria. Total 100 patients were taken Male 36 36
in the study. Female 64 64
Place of residence
Inclusion criteria Rural 41 41
All patients with incisional hernia above 18 years of age, Urban 59 59
patients who were willing to give consent to be part of Education
the study were included. Illiterate 2 2
Middle school 12 12
Exclusion criteria Higher secondary 62 62
Graduate 24 24
Patients who did not give consent for study, seriously ill Marital status
patient, pregnancy with incisional hernia were excluded. Married 96 96
Unmarried 4 4
All the patients were investigated about the duration of Socioeconomic class
hernia, progression and the main associated symptoms
Lower class 27 27
like pain, vomiting, cough, dysuria, reducibility of the
Lower middle class 37 37
swelling, association with pregnancy. Past-history
pertaining to previous surgery its nature, duration, type of Middle class 36 36
surgery and closure was recorded. Patients were also Occupation
asked about wound infection of previous surgery. Farmer 17 17
Recording about the scar of the previous surgery, the Housewife 62 62
hernia defect its position, size, shape, cough impulse, Informal work 9 9
reducibility and the overlying skin over the defect were Formal work 12 12
made. Other co-morbidities like anaemia, jaundice, Total 100 100
hypertension, obesity, physical stress were recorded.
Behavioral aspects like smoking, alcohol and tobacco Table 2 showed that 40% cases were perforation and
uses were also asked from the patients. obstruction, 35% were LSCS, 10% were hysterectomy
and 5% were cholecystectomy. Nature of surgery showed
All relevant data entered into predesigned proforma was that 22% of the surgery were elective and 78% of the
analysed using Microsoft SPSS software for windows surgery was emergency. Nature of surgery 22% of the
TM version 20.0, IBM TM Corp NY and Microsoft excel surgery were elective and 78% of the surgery was
TM, Microsoft Inc USA. Logistic regression analysis was emergency.
done to predict the odds of being the risk factor to

International Surgery Journal | May 2020 | Vol 7 | Issue 5 Page 1588

 Nigam A et al. Int Surg J. 2020 May;7(5):1587-1592

Table 2: Type of surgical procedure later develop to Table 3: Risk factors profile in study subjects.
Incisional hernia and nature of surgery.
Risk factors Frequency %
Frequency % Behavioral risk factors profile in study subjects
Type of surgical procedure Alcoholic 31 31
Surgery for perforation Smoking 27 27
40 40
and obstruction Tobacco user 20 20
Cholecystectomy 5 5 Modifiable risk factors in study subjects
Hysterectomy 10 10 BMI
Incisional hernia 1 1 Normal weight (BMI 18.5-
Iliostomy closure 1 1 47 47
24.9)
LSCS 35 35 overweight (BMI 25-29.9) 48 48
Sigmoid volvulus 2 2 Obese class I (BMI 30-34.9) 5 5
Umblical hernia 2 2 Hypertension
Deroofing hydratid cyst 2 2 High normal (130-139/85-89) 3 3
Gastrojejunostomy 1 1 Grade I (140-159/90-99) 19 19
Bilateral ovarian mass Grade II (160-179/100-109) 12 12
1 1
excision Grade III (≥180/>110) 2 2
Total 100 100 Diabetes 48 48
Nature of surgery Constipation 12 12
Nature Medical risk factors in study subjects
Elective 22 22 Pregnancy 60 60
Emergency 78 78 Prolong cough 25 25
Total 100 100 Surgical site infection 35 35
Anemia
Table 3 showed different risk factors in study subjects. Mild (9-11 gm/dl) 37 37
Behavioral risk factors profile showed that 31% were Moderate (7-9 gm/dl) 8 8
alcoholic, 27% were smokers, and 20% were tobacco Physical risk factors in study subjects
users. Modifiable risk factors profile showed that, 48%
Exposure to radiation 2 2
were in pre-obese category of BMI, 5% were obese class I
of obesity scale. Hypertension status in study subjects Physical stress
showed that 3% had high normal, 19% had grade I Heavy 11 11
hypertension, 12% had grade II hypertension and 2% had Moderate 36 36
Grade III hypertension. Diabetic profile showed that 48% Sedentary 53 53
of study subjects were diabetic and 12% were having
constipation. Table 4: Defect size in study subjects (USG finding).

Medical risk factors in study subjects showed that 64% Size (cm) Percentage (%) Mean size (cm)
female were having pregnancy.25% had history of 1-2 24 1.61
prolong cough, 35% had surgical site infection, 37% had 2-3 40 2.8
mild anemia and 8% had moderate anemia. 3-4 17 3.63
4-5 12 4.67
Physical risk factors profile showed that only 2% of the 5-6 5 6.08
study subjects were exposed to radiation, 11% of the >6 2 9.35
study subjects were exposed to heavy physical stress, 36% Total 100 4.69
were exposed to moderate physical stress and 53% were
exposed to sedentary work.
Table 5 showed the risk factor for developing incisional
hernia in perforation cases. Risk factors which have high
Clinical presentation of study subjects showed that 63%
odds ratio were smoking (OR 20.213, p value 0.04),
had swelling, 33% had swelling/pain and 4% had
anemia (OR 3.321, p value 0.08) and moderate physical
obstruction.
stress (OR 2.906, p value 0.122). In all the risk factor
smoking was statistically significant also (p value 0.05).
Table 4 showed the defect size in study subjects (USG
Table 6 showed the risk factor for developing incisional
finding). The mean defect size was 4.60 cm. 40% of the
hernia in LSCS cases. Risk factors which have high odds
study subjects had defect size 2-3 cm, 24% had 1-2 cm,
ratio were obese (OR 10.82, p value 0.133), overweight
17% had 3-4 cm, 12% had 4-5 cm, 5% had 5-6 cm and
(OR 2.274, p value 0.244) and constipation (OR 1.160, p
2% had more than 6 cm.
value 0.754). In all the risk factor hypertension, prolong
cough were statistically significant (p value <0.05).

International Surgery Journal | May 2020 | Vol 7 | Issue 5 Page 1589

 Nigam A et al. Int Surg J. 2020 May;7(5):1587-1592

Table 5: Risk factor for developing incisional hernia in perforation and obstruction cases.

Risk factors for perforation Odds ratio (OR) Std. Err. P value 95% Conf. interval
Alcohol use 1.570 1.725 0.681 0.182 13.523
Smoking 20.213 30.554 0.047 1.045 391.125
Tobacco use 0.507 0.719 0.632 0.031 8.195
Overweight 0.242 0.160 0.032 0.066 0.882
Obese 0.658 0.869 0.751 0.050 8.750
Diabetes 1.206 0.831 0.786 0.312 4.655
Hypertension 2.319 1.769 0.27 0.520 10.344
Constipation 1.640 1.844 0.66 0.181 14.847
Prolong cough 1.778 1.106 0.355 0.525 6.019
Anemia 3.321 2.314 0.085 0.847 13.016
Surgical site infection 0.658 0.403 0.495 0.198 2.188
Moderate physical stress 2.906 2.005 0.122 0.752 11.235
Heavy physical stress 1.067 1.322 0.958 0.094 12.097
Cons 0.117 0.096 0.009 0.023 0.588

Table 6: Risk factor for developing incisional hernia in LSCS cases.

Risk factors for LSCS Odds ratio (OR) Std. err. P value 95% Conf. interval
Overweight 2.274 1.604 0.244 0.571 9.062
Obese 10.820 17.133 0.133 0.486 241.018
Diabetes 0.732 0.568 0.687 0.160 3.353
Hypertension 0.048 0.047 0.002 0.007 0.326
Constipation 1.435 1.652 0.754 0.150 13.701
Prolong cough 0.231 0.177 0.056 0.052 1.036
Anemia 0.298 0.219 0.099 0.071 1.255
Surgical site infection 1.160 0.762 0.821 0.320 4.202
Moderate physical stress 0.694 0.512 0.62 0.164 2.944
Cons 6.466 5.772 0.037 1.124 37.189

Table 7: Risk factor for developing incisional hernia in cholecystectomy cases.

Risk factors for cholecystectomy Odds ratio (OR) Std. Err. P value 95% Conf. interval
Alcohol use 0.845 1.776 0.936 0.014 51.929
Smoking 0.589 1.594 0.845 0.003 118.645
Tobacco 2.521 5.687 0.682 0.030 209.813
Overweight 1.111 1.282 0.928 0.116 10.673
Diabetes 0.703 0.796 0.756 0.076 6.474
Hypertension 0.695 1.059 0.811 0.035 13.792
Prolong cough 0.747 0.816 0.789 0.088 6.358
Anemia 0.980 1.255 0.988 0.080 12.060
Surgical site infection 1.271 1.383 0.826 0.151 10.724
Exposure of radiation 22.277 39.497 0.08 0.690 719.516
Moderate physical stress 1.543 2.015 0.74 0.119 19.952
Cons 0.056 0.079 0.041 0.004 0.886

Table 7 showed the risk factor for developing incisional the risk factor for developing incisional hernia in
hernia in cholecystectomy cases. Risk factors which have Hysterectomy cases. Risk factors which have high odds
high odds ratio were exposure to radiation (OR 22.277, p ratio were hypertension (OR 20.638, p value 1.760),
value 0.08), tobacco uses (OR 2.521, p value 0.682) prolong cough (OR 1.536, p value 0.241) and anemia (OR
surgical site infection (OR 1.271, p value 0.151) and 1.199, p value 0.179). In all the risk factor hypertension
overweight (OR 1.111, p value 0.928). Table 8 showed was statistically significant (p value <0.05).

International Surgery Journal | May 2020 | Vol 7 | Issue 5 Page 1590

 Nigam A et al. Int Surg J. 2020 May;7(5):1587-1592

Table 8: Risk factor for developing incisional hernia in hysterectomy cases.

Hysterectomy Odds ratio (OR) Std. Err. P value 95% Conf. Interval
Overweight 0.438 0.434 0.405 0.063 3.056
Diabetes 0.425 0.461 0.43 0.051 3.555
Hypertension 20.638 25.925 0.016 1.760 242.061
Constipation 0.633 1.049 0.783 0.025 16.303
Prolong cough 1.536 1.452 0.65 0.241 9.797
Anemia 1.199 1.164 0.852 0.179 8.040
Surgical site infection 0.711 0.579 0.676 0.144 3.503
Moderate physical stress 0.319 0.390 0.35 0.029 3.507
Cons 0.152 0.178 0.109 0.015 1.520

DISCUSSION hernia in cholecystectomy cases which have high odds

ratio were exposure to radiation (OR 22.277), tobacco
This cross sectional observational study a total of 100 uses (OR 2.521) surgical site infection (OR 1.271) and
patients with ventral incisional hernia were evaluated for overweight (OR 1.111).
the prevalence of risk factors and clinical presentational
of ventral incisional hernia was conducted in surgery Weissler et al evaluated the development of incisional
department of Dr. B.R.A.M. Hospital, Raipur hernia risk model after colectomy significant risk factors
Chhattisgarh. were obesity (odds ratio=1.49; p<0.0001), and alcohol
abuse (odds ratio=1.39; p=0.010). Shah et al found that
In present study the mean age of study subjects was obesity, smoking, cough and diabetes were implicated as
47.27±13.16 years. Maximum 46% of study subjects the common etiological factors for the development of
were b/w 41-60 years age group and 64% of the study ventral hernias. Sorensen et al reported that smokers had
subjects were female. Kumar et al did a similar study and a 4-fold higher risk of incisional hernia (odds ratio (OR),
patient age group of 30-60 years found to have highest 3.93 (95% confidence interval (CI), 1.82-8.49))
incidence, females outnumbered the males with the ratio independent of other risk factors and confounders.6,8,13
of 4:1. Llaguna et al found that mean age was 62 years
and 52% were male.5,9 Nagaraju et al revealed that obesity is a common
predisposing factor. Obese female has an increased
In present study type of major surgical procedure later predilection toward incisional hernia. Obesity is
develops to Incisional hernia showed that 40% cases were associated with more risk of post-operative wound
perforation, 35% were LSCS, 10% were hysterectomy infection and both resulted in an increased incidence of
and 5% were cholecystectomy. Agbakwuru et al reported incisional hernia.12 Walming et al also reported that BMI
that index surgeries leading to the hernias were 30–35 was a risk factor for incisional hernia.14
emergency caesarian section (59.1%), emergency Degloorkar et al reported that wound infection was the
exploratory laparotomy (13.6%), and elective surgeries risk factor in 26% patients. Repeat surgery history was
(27.3%).7 In present study out of 100 ventral incisional given by one patient.15
hernia cases, 22% of the surgeries were elective and 78%
of the surgeries were emergency. Sidhu et al reported that In present study modifiable risk factors profile of study
there were equal numbers of elective (n=22) and subjects showed that 46% of the study subjects had their
emergency (n=23) operations that developed an incisional high blood pressure, 48% were diabetic and 12% had
hernia.3 constipation and 45% of had anemia. Hypertension (OR
2.319), anemia (or 3.321), constipation (or 1.640) and
In present study the behavioral risk factors profile of diabetes were the risk factors for development of
study subjects showed that out of 100 study subjects 31% incisional hernia in perforation cases. Constipation (OR
were alcoholic, 27% were smokers and 20% were 1.435) was also the risk factor for development of
tobacco users. Smoking (OR 20.213, p value.0.04) was incisional hernia in LSCS cases. Hypertension (OR
the major risk factor for developing incisional hernia in 20.638) and anemia (OR 1.199) were also the risk factor
(40/100) perforation cases. Obesity (BMI 30-34.9) was for development of incisional hernia in Hysterectomy
the major risk factor for (OR 18.820) for incisional hernia cases. Sidhu et al revealed that on univariable analysis
in LSCS cases. Surgical site infection was also there in diabetes (OR=2.73, p value=0.004) and hypertension
35% of study subjects. In present study 25% of the study (OR=2.17, p value=0.016) were identified as independent
subjects had history of prolong cough and 75% had no risk factors for ventral hernia development.3 A study by
history of prolong cough. Prolong cough (OR 1.535) was Beltrán et al to identify risk factors for development of
the risk factor for development of incisional hernia in incisional hernia were female gender (p=0.011), diabetes
Hysterectomy cases. Risk factor for developing incisional (p<0.0001) and wound infection (p=0.034).10 Hornby et

International Surgery Journal | May 2020 | Vol 7 | Issue 5 Page 1591

 Nigam A et al. Int Surg J. 2020 May;7(5):1587-1592

al reported that diabetes mellitus (3.54; 1-12.56) clinical profile, risk factors and prevention. Int Surg
significantly increased the risk of incisional hernia.11 J. 2016;3:1292-5.
Jaykar et al did a clinical study of ventral hernia. Obesity 6. Shah PP, Shaikh S, Panchabhai S. Prevalence of
and constipation were found to be the major predisposing anterior abdominal wall hernia and its associated
risk factors.16 risk factors. Int J Anat Radiol Surg. 2016;5(3):7-10.
7. Agbakwuru E, Olabanji J, Alatise O, Okwerekwu R,
CONCLUSION Esimai O. Incisional hernia in women: predisposing
factors and management where mesh is not readily
In this paper, various risk factors, clinical presentation of available. Libyan J Med. 2009;4(2):66-9.
incisional hernia were evaluated in all the cases which 8. Sørensen LT, Hemmingsen UB, Kirkeby LT,
were patients attending at outpatient department of Kallehave F, Jørgensen LN. Smoking is a risk factor
surgery and those admitted in surgery ward of Dr. for incisional hernia. Arch Surg. 2005;140:119-23.
B.R.A.M. Hospital Raipur Chhattisgarh. Incisional hernia 9. Llaguna OH, Avgerinos DV, Lugo JZ, Matatov T,
is more common in female than males and in cases above Abbadessa B, Martz JE, et al. Incidence and risk
the age of 40 years. Incisional hernia is more common in factors for the development of incisional hernia
patients who underwent the previous surgery on an following elective laparoscopic versus open colon
emergency basis especially in perforation, obstruction resections. Am J Surg. 2010;200:265-9.
and LSCS cases. Behavioral risk factors associated with 10. Beltrán MA, Cruces KS. Incisional hernia after
incisional hernia are smoker, alcoholic and tobacco user. McBurney incision: retrospective case-control study
Modifiable risk factors are Obesity, hypertension, of risk factors and surgical treatment. World J Surg.
diabetes, constipation, prolong cough and anemia. 2008;32:596-601.
Medical risk factors are h/o prolong cough, surgical site 11. Hornby ST, McDermott FD, Coleman M, Ahmed Z.
infection. Two third of the study subjects had swelling Female gender and diabetes mellitus increase the
and one third had swelling with pain. Size of the defect risk of recurrence after laparoscopic incisional
can vary in our study ranged from 1 cm to >10 cm hernia repair. Ann R Coll Surg Engl.
diameter. 2015;97(2):115-9.
12. Nagaraju V, Kumar GS, Geethanjali K. Study of
Funding: No funding sources incisional hernia in relation to specific risk factors.
Conflict of interest: None declared Int J Sci Stud. 2018;6(7):155-8.
Ethical approval: The study was approved by the 13. Weissler JM, Lanni MA, Hsu JY, Tecce MG,
Institutional Ethics Committee Carney MJ, Kelz RR, et al. Development of a
clinically actionable incisional hernia risk model
REFERENCES after colectomy using the healthcare cost and
utilization project. J Am Coll Surg.
1. Muysoms FE, Miserez M, Berrevoet F, Campanelli 2017;225(2):274-84.
G, Champault GG, Chelala E, et al. Classification of 14. Walming S, Angenete E, Block M, Bock D, Gessler
primary and incisional abdominal wall hernias. B, Haglind E. Retrospective review of risk factors
Hernia. 2009;13:407-14. for surgical wound dehiscence and incisional hernia.
2. Bailey H, Bulstrode CJ, Love RM, O'Connell PR. BMC Surg. 2017;17(1):19.
Bailey and Love's short practice of surgery. CRC 15. Degloorkar AG, Ganpatrao G. Official Journals By
Press; 2008. Stat Person Publication. Medpulse-Res Publ.
3. Sidhu A, Siedler D, Turner R. Factors affecting the 2020;7(1):12-4.
development of ventral incisional hernia post 16. Jaykar RD, Varudkar AS, Akamanchi AK. A
abdominal surgery: a retrospective cohort study. Int clinical study of ventral hernia. Int Surg J.
Surg J. 2017;4(10):3225-7. 2017;4(7):23-6.
4. Calisto JL. Laparoscopic repair of incisional hernia.
Available at http:// emedicine. medscape. com/ Cite this article as: Nigam A, Nirala SL, Bhusakhare
article/ 1892407- overview. Accessed on 10 May N. Study prevalence of risk factors and clinical
2016. presentation of ventral incisional hernia an
5. Kumar SJG, Kumar UK, Manangi M, Madhu KP, observational study. Int Surg J 2020;7:1587-92.
Arun BJ, Nagaraj N. Incisional hernia: incidence,

International Surgery Journal | May 2020 | Vol 7 | Issue 5 Page 1592