Prevention of incisional hernia following abdominal surgery: Evidence-based strategies and technical considerations—A narrative review

Abstract Incisional hernia represents one of the most common complications following abdominal surgery, occurring in 10%–20% of patients after midline laparotomy and imposing a substantial healthcare burden through reoperation costs, morbidity, and reduced quality of life. Despite being a frequent complication, incisional hernias are potentially preventable through evidence-based surgical techniques, patient optimization, and selective prophylactic mesh reinforcement. This narrative review synthesizes current evidence on strategies for preventing incisional hernia development, emphasizing preoperative risk stratification, technical aspects of fascial closure, the role of prophylactic mesh augmentation, and postoperative care optimization. A comprehensive literature search was conducted across PubMed, Embase, and Cochrane databases covering publications from 2000 to 2024, focusing on randomized controlled trials, systematic reviews, and high-quality observational studies. Patient-specific risk factors, including obesity, diabetes, smoking, chronic cough, immunosuppression, and malnutrition, substantially increase hernia risk and guide preventive strategy selection. Surgical technique factors, including suture material selection, suture-to-wound length ratio, stitch interval, and closure method, profoundly influence hernia incidence. The small bites technique using continuous, slowly absorbable monofilament suture with a suture-to-wound length ratio of at least 4:1 reduces incisional hernia rates by approximately 50% compared to traditional large-bite closures based on high-quality randomized controlled trials. Prophylactic mesh reinforcement in high-risk patients, particularly those undergoing abdominal aortic aneurysm repair or with multiple risk factors, demonstrates efficacy in reducing hernia incidence, though optimal patient selection, mesh type, and placement location remain areas requiring further investigation. This review acknowledges inherent limitations of narrative synthesis, including potential selection bias, heterogeneity in study populations and follow-up duration, and challenges in establishing definitive evidence hierarchies across diverse clinical contexts.