Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Management of ventral hernias

David C Brooks, MD
John Cone, MD
Section Editors
Michael Rosen, MD
Lillian S Kao, MD, MS
Deputy Editor
Wenliang Chen, MD, PhD


An estimated one-quarter of all individuals are either born with or will develop a ventral hernia in their lifetimes [1]. In the United States, over $3.4 billion a year is spent on repairing ventral hernias [2].

Ventral hernias occur in the anterior abdominal wall and include epigastric, umbilical, spigelian, parastomal, and most incisional hernias [3]. Epigastric and umbilical are primary ventral hernias. Incisional hernias can develop anywhere an incision has been made but most commonly occur at the midline, given that midline incisions are most commonly used during laparotomies. Spigelian and parastomal hernias occur off the midline and are discussed in detail elsewhere. (See "Parastomal hernia".)

The management of ventral hernias, both primary and incisional, will be reviewed here. The clinical features and diagnosis of ventral hernias and the diagnosis and management of other abdominal wall hernias (eg, groin hernia) are reviewed separately. (See "Overview of abdominal wall hernias in adults" and "Overview of treatment for inguinal and femoral hernia in adults" and "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults".)


Patients with an acutely incarcerated or strangulated ventral hernia require emergency repair (algorithm 1). Among the 2.3 million inpatient abdominal hernia repairs performed from 2001 to 2010 in the United States, an estimated 576,000 were performed emergently [4].

The objective of the emergency surgery is to alleviate any acute problems (eg, bowel infarction, bowel obstruction, abdominal pain) without jeopardizing the opportunity for a satisfactory hernia repair. The optimal technique of hernia repair in this situation varies depending on the anatomy, patient stability, patient comorbidities, and the degree of contamination of the operative field [5].

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Sep 2017. | This topic last updated: Aug 17, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Bedewi MA, El-Sharkawy MS, Al Boukai AA, Al-Nakshabandi N. Prevalence of adult paraumbilical hernia. Assessment by high-resolution sonography: a hospital-based study. Hernia 2012; 16:59.
  2. Poulose BK, Beck WC, Phillips SE, et al. The chosen few: disproportionate resource use in ventral hernia repair. Am Surg 2013; 79:815.
  3. Muysoms FE, Miserez M, Berrevoet F, et al. Classification of primary and incisional abdominal wall hernias. Hernia 2009; 13:407.
  4. Beadles CA, Meagher AD, Charles AG. Trends in emergent hernia repair in the United States. JAMA Surg 2015; 150:194.
  5. Liang MK, Holihan JL, Itani K, et al. Ventral Hernia Management: Expert Consensus Guided by Systematic Review. Ann Surg 2016.
  6. Earle D, Roth JS, Saber A, et al. SAGES guidelines for laparoscopic ventral hernia repair. Surg Endosc 2016; 30:3163.
  7. Holihan JL, Alawadi ZM, Harris JW, et al. Ventral hernia: Patient selection, treatment, and management. Curr Probl Surg 2016; 53:307.
  8. Bondre IL, Holihan JL, Askenasy EP, et al. Suture, synthetic, or biologic in contaminated ventral hernia repair. J Surg Res 2016; 200:488.
  9. Yegiyants S, Tam M, Lee DJ, Abbas MA. Outcome of components separation for contaminated complex abdominal wall defects. Hernia 2012; 16:41.
  10. Holihan JL, Henchcliffe BE, Mo J, et al. Is Nonoperative Management Warranted in Ventral Hernia Patients With Comorbidities?: A Case-matched, Prospective, Patient-centered Study. Ann Surg 2016; 264:585.
  11. Kokotovic D, Sjølander H, Gögenur I, Helgstrand F. Watchful waiting as a treatment strategy for patients with a ventral hernia appears to be safe. Hernia 2016; 20:281.
  12. Lauscher JC, Leonhardt M, Martus P, et al. [Watchful waiting vs surgical repair of oligosymptomatic incisional hernias: Current status of the AWARE study]. Chirurg 2016; 87:47.
  13. Verhelst J, Timmermans L, van de Velde M, et al. Watchful waiting in incisional hernia: is it safe? Surgery 2015; 157:297.
  14. Holihan JL, Flores-Gonzalez JR, Mo J, et al. A Prospective Assessment of Clinical and Patient-Reported Outcomes of Initial Non-Operative Management of Ventral Hernias. World J Surg 2017; 41:1267.
  15. Kaoutzanis C, Leichtle SW, Mouawad NJ, et al. Risk factors for postoperative wound infections and prolonged hospitalization after ventral/incisional hernia repair. Hernia 2015; 19:113.
  16. Danzig MR, Stey AM, Yin SS, et al. Patient profiles and outcomes following repair of irreducible and reducible Ventral Wall Hernias. Hernia 2016; 20:239.
  17. 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; 220:405.
  18. Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 2000; 343:392.
  19. DiBello JN Jr, Moore JH Jr. Sliding myofascial flap of the rectus abdominus muscles for the closure of recurrent ventral hernias. Plast Reconstr Surg 1996; 98:464.
  20. Shell DH 4th, de la Torre J, Andrades P, Vasconez LO. Open repair of ventral incisional hernias. Surg Clin North Am 2008; 88:61.
  21. Sailes FC, Walls J, Guelig D, et al. Synthetic and biological mesh in component separation: a 10-year single institution review. Ann Plast Surg 2010; 64:696.
  22. Nguyen MT, Berger RL, Hicks SC, et al. Comparison of outcomes of synthetic mesh vs suture repair of elective primary ventral herniorrhaphy: a systematic review and meta-analysis. JAMA Surg 2014; 149:415.
  23. Christoffersen MW, Helgstrand F, Rosenberg J, et al. Lower reoperation rate for recurrence after mesh versus sutured elective repair in small umbilical and epigastric hernias. A nationwide register study. World J Surg 2013; 37:2548.
  24. Shankar DA, Itani KMF, O'Brien WJ, Sanchez VM. Factors Associated With Long-term Outcomes of Umbilical Hernia Repair. JAMA Surg 2017; 152:461.
  25. Winsnes A, Haapamäki MM, Gunnarsson U, Strigård K. Surgical outcome of mesh and suture repair in primary umbilical hernia: postoperative complications and recurrence. Hernia 2016; 20:509.
  26. Holihan JL, Alawadi Z, Martindale RG, et al. Adverse Events after Ventral Hernia Repair: The Vicious Cycle of Complications. J Am Coll Surg 2015; 221:478.
  27. den Hartog D, Dur AH, Tuinebreijer WE, Kreis RW. Open surgical procedures for incisional hernias. Cochrane Database Syst Rev 2008; :CD006438.
  28. de Vries Reilingh TS, van Goor H, Charbon JA, et al. Repair of giant midline abdominal wall hernias: "components separation technique" versus prosthetic repair : interim analysis of a randomized controlled trial. World J Surg 2007; 31:756.
  29. Wéber G, Horváth OP. [Results of ventral hernia repair: comparison of suture repair with mesh implantation (onlay vs sublay) using open and laparoscopic approach--prospective, randomized, multicenter study]. Magy Seb 2002; 55:285.
  30. Conze J, Kingsnorth AN, Flament JB, et al. Randomized clinical trial comparing lightweight composite mesh with polyester or polypropylene mesh for incisional hernia repair. Br J Surg 2005; 92:1488.
  31. Korenkov M, Sauerland S, Arndt M, et al. Randomized clinical trial of suture repair, polypropylene mesh or autodermal hernioplasty for incisional hernia. Br J Surg 2002; 89:50.
  32. Afifi RY. A prospective study between two different techniques for the repair of a large recurrent ventral hernia: a double mesh intraperitoneal repair versus onlay mesh repair. Hernia 2005; 9:310.
  33. Burger JW, Luijendijk RW, Hop WC, et al. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 2004; 240:578.
  34. Mathes SJ, Steinwald PM, Foster RD, et al. Complex abdominal wall reconstruction: a comparison of flap and mesh closure. Ann Surg 2000; 232:586.
  35. Schmidbauer S, Ladurner R, Hallfeldt KK, Mussack T. Heavy-weight versus low-weight polypropylene meshes for open sublay mesh repair of incisional hernia. Eur J Med Res 2005; 10:247.
  36. Matthews BD, Pratt BL, Pollinger HS, et al. Assessment of adhesion formation to intra-abdominal polypropylene mesh and polytetrafluoroethylene mesh. J Surg Res 2003; 114:126.
  37. Kokotovic D, Bisgaard T, Helgstrand F. Long-term Recurrence and Complications Associated With Elective Incisional Hernia Repair. JAMA 2016; 316:1575.
  38. Itani KM. New Findings in Ventral Incisional Hernia Repair. JAMA 2016; 316:1551.
  39. Moreno-Egea A, Carrillo-Alcaraz A, Soria-Aledo V. Randomized clinical trial of laparoscopic hernia repair comparing titanium-coated lightweight mesh and medium-weight composite mesh. Surg Endosc 2013; 27:231.
  40. Bellows CF, Alder A, Helton WS. Abdominal wall reconstruction using biological tissue grafts: present status and future opportunities. Expert Rev Med Devices 2006; 3:657.
  41. Bringman S, Conze J, Cuccurullo D, et al. Hernia repair: the search for ideal meshes. Hernia 2010; 14:81.
  42. DeMaria EJ, Moss JM, Sugerman HJ. Laparoscopic intraperitoneal polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral hernia. Prospective comparison to open prefascial polypropylene mesh repair. Surg Endosc 2000; 14:326.
  43. Gray SH, Hawn MT, Itani KM. Surgical progress in inguinal and ventral incisional hernia repair. Surg Clin North Am 2008; 88:17.
  44. Candage R, Jones K, Luchette FA, et al. Use of human acellular dermal matrix for hernia repair: friend or foe? Surgery 2008; 144:703.
  45. Chavarriaga LF, Lin E, Losken A, et al. Management of complex abdominal wall defects using acellular porcine dermal collagen. Am Surg 2010; 76:96.
  46. Wéber G, Baracs J, Horváth OP. ["Onlay" mesh provides significantly better results than "sublay" reconstruction. Prospective randomized multicenter study of abdominal wall reconstruction with sutures only, or with surgical mesh--results of a five-years follow-up]. Magy Seb 2010; 63:302.
  47. Holihan JL, Hannon C, Goodenough C, et al. Ventral Hernia Repair: A Meta-Analysis of Randomized Controlled Trials. Surg Infect (Larchmt) 2017; 18:647.
  48. Albino FP, Patel KM, Nahabedian MY, et al. Does mesh location matter in abdominal wall reconstruction? A systematic review of the literature and a summary of recommendations. Plast Reconstr Surg 2013; 132:1295.
  49. Chevrel JP, Rath AM. The use of fibrin glues in the surgical treatment of incisional hernias. Hernia 1997; 1:9.
  50. Hodgman EI, Watson MJ. Revisiting the Anterior Rectus Sheath Repair for Incisional Hernia: A 10-Year Experience. World J Surg 2017; 41:713.
  51. Mommers EH, Leenders BJ, Leclercq WK, et al. A modified Chevrel technique for ventral hernia repair: long-term results of a single centre cohort. Hernia 2017.
  52. Haskins IN, Voeller GR, Stoikes NF, et al. Onlay with Adhesive Use Compared with Sublay Mesh Placement in Ventral Hernia Repair: Was Chevrel Right? An Americas Hernia Society Quality Collaborative Analysis. J Am Coll Surg 2017; 224:962.
  53. Tandon A, Pathak S, Lyons NJ, et al. Meta-analysis of closure of the fascial defect during laparoscopic incisional and ventral hernia repair. Br J Surg 2016; 103:1598.
  54. Zhang Y, Zhou H, Chai Y, et al. Laparoscopic versus open incisional and ventral hernia repair: a systematic review and meta-analysis. World J Surg 2014; 38:2233.
  55. Cobb WS, Kercher KW, Heniford BT. Laparoscopic repair of incisional hernias. Surg Clin North Am 2005; 85:91.
  56. Cassar K, Munro A. Surgical treatment of incisional hernia. Br J Surg 2002; 89:534.
  57. Bingener J, Buck L, Richards M, et al. Long-term outcomes in laparoscopic vs open ventral hernia repair. Arch Surg 2007; 142:562.
  58. Tsuruta A, Hirai T, Nakamura M. Retrospective comparison of open versus laparoscopic ventral and incisional hernia repair. Asian J Endosc Surg 2014; 7:246.
  59. Rogmark P, Petersson U, Bringman S, et al. Short-term outcomes for open and laparoscopic midline incisional hernia repair: a randomized multicenter controlled trial: the ProLOVE (prospective randomized trial on open versus laparoscopic operation of ventral eventrations) trial. Ann Surg 2013; 258:37.
  60. Carbajo MA, Martín del Olmo JC, Blanco JI, et al. Laparoscopic treatment vs open surgery in the solution of major incisional and abdominal wall hernias with mesh. Surg Endosc 1999; 13:250.
  61. Pring CM, Tran V, O'Rourke N, Martin IJ. Laparoscopic versus open ventral hernia repair: a randomized controlled trial. ANZ J Surg 2008; 78:903.
  62. Olmi S, Scaini A, Cesana GC, et al. Laparoscopic versus open incisional hernia repair: an open randomized controlled study. Surg Endosc 2007; 21:555.
  63. Eker HH, Hansson BM, Buunen M, et al. Laparoscopic vs. open incisional hernia repair: a randomized clinical trial. JAMA Surg 2013; 148:259.
  64. Asencio F, Aguiló J, Peiró S, et al. Open randomized clinical trial of laparoscopic versus open incisional hernia repair. Surg Endosc 2009; 23:1441.
  65. Itani KM, Hur K, Kim LT, et al. Comparison of laparoscopic and open repair with mesh for the treatment of ventral incisional hernia: a randomized trial. Arch Surg 2010; 145:322.
  66. Moreno-Egea A, Carrasco L, Girela E, et al. Open vs laparoscopic repair of spigelian hernia: a prospective randomized trial. Arch Surg 2002; 137:1266.
  67. Navarra G, Musolino C, De Marco ML, et al. Retromuscular sutured incisional hernia repair: a randomized controlled trial to compare open and laparoscopic approach. Surg Laparosc Endosc Percutan Tech 2007; 17:86.
  68. Misra MC, Bansal VK, Kulkarni MP, Pawar DK. Comparison of laparoscopic and open repair of incisional and primary ventral hernia: results of a prospective randomized study. Surg Endosc 2006; 20:1839.
  69. Othman IH, Metwally YH, Bakr IS, et al. Comparative study between laparoscopic and open repair of paraumbilical hernia. J Egypt Soc Parasitol 2012; 42:175.
  70. Novitsky YW, Cobb WS, Kercher KW, et al. Laparoscopic ventral hernia repair in obese patients: a new standard of care. Arch Surg 2006; 141:57.
  71. Itani KM, Neumayer L, Reda D, et al. Repair of ventral incisional hernia: the design of a randomized trial to compare open and laparoscopic surgical techniques. Am J Surg 2004; 188:22S.
  72. Sauerland S, Walgenbach M, Habermalz B, et al. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Cochrane Database Syst Rev 2011; :CD007781.
  73. Fekkes JF, Velanovich V. Amelioration of the effects of obesity on short-term postoperative complications of laparoscopic and open ventral hernia repair. Surg Laparosc Endosc Percutan Tech 2015; 25:151.
  74. Gonzalez A, Escobar E, Romero R, et al. Robotic-assisted ventral hernia repair: a multicenter evaluation of clinical outcomes. Surg Endosc 2017; 31:1342.
  75. Warren JA, Cobb WS, Ewing JA, Carbonell AM. Standard laparoscopic versus robotic retromuscular ventral hernia repair. Surg Endosc 2017; 31:324.
  76. Prabhu AS, Dickens EO, Copper CM, et al. Laparoscopic vs Robotic Intraperitoneal Mesh Repair for Incisional Hernia: An Americas Hernia Society Quality Collaborative Analysis. J Am Coll Surg 2017; 225:285.
  77. Bikhchandani J, Fitzgibbons RJ Jr. Repair of giant ventral hernias. Adv Surg 2013; 47:1.
  78. Ramirez OM, Ruas E, Dellon AL. "Components separation" method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 1990; 86:519.
  79. de Vries Reilingh TS, van Goor H, Rosman C, et al. "Components separation technique" for the repair of large abdominal wall hernias. J Am Coll Surg 2003; 196:32.
  80. Rosen MJ, Williams C, Jin J, et al. Laparoscopic versus open-component separation: a comparative analysis in a porcine model. Am J Surg 2007; 194:385.
  81. Timmermans L, de Goede B, van Dijk SM, et al. Meta-analysis of sublay versus onlay mesh repair in incisional hernia surgery. Am J Surg 2014; 207:980.
  82. Gurusamy KS, Allen VB. Wound drains after incisional hernia repair. Cochrane Database Syst Rev 2013; :CD005570.
  83. Wai PY, Ruby JA, Davis KA, et al. Laparoscopic ventral hernia repair during pregnancy. Hernia 2009; 13:559.
  84. Jensen KK, Henriksen NA, Jorgensen LN. Abdominal wall hernia and pregnancy: a systematic review. Hernia 2015; 19:689.
  85. Schoenmaeckers E, Stirler V, Raymakers J, Rakic S. Pregnancy following laparoscopic mesh repair of ventral abdominal wall hernia. JSLS 2012; 16:85.
  86. Marsman HA, Heisterkamp J, Halm JA, et al. Management in patients with liver cirrhosis and an umbilical hernia. Surgery 2007; 142:372.
  87. Coelho JC, Claus CM, Campos AC, et al. Umbilical hernia in patients with liver cirrhosis: A surgical challenge. World J Gastrointest Surg 2016; 8:476.
  88. Ammar SA. Management of complicated umbilical hernias in cirrhotic patients using permanent mesh: randomized clinical trial. Hernia 2010; 14:35.
  89. Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic repair of ventral hernias: nine years' experience with 850 consecutive hernias. Ann Surg 2003; 238:391.
  90. Ujiki MB, Weinberger J, Varghese TK, et al. One hundred consecutive laparoscopic ventral hernia repairs. Am J Surg 2004; 188:593.
  91. Sailes FC, Walls J, Guelig D, et al. Ventral hernia repairs: 10-year single-institution review at Thomas Jefferson University Hospital. J Am Coll Surg 2011; 212:119.
  92. Bueno-Lledó J, Torregrosa-Gallud A, Sala-Hernandez A, et al. Predictors of mesh infection and explantation after abdominal wall hernia repair. Am J Surg 2017; 213:50.
  93. Liang MK, Li LT, Nguyen MT, et al. Abdominal reoperation and mesh explantation following open ventral hernia repair with mesh. Am J Surg 2014; 208:670.
  94. Hawn MT, Gray SH, Snyder CW, et al. Predictors of mesh explantation after incisional hernia repair. Am J Surg 2011; 202:28.
  95. Kummerow Broman K, Huang LC, Faqih A, et al. Hidden Morbidity of Ventral Hernia Repair with Mesh: As Concerning as Common Bile Duct Injury? J Am Coll Surg 2017; 224:35.