Preoperative Preparation of the Patient Undergoing Incisional Hernia Repair: Optimizing Chances for Success

  • Robert G. MartindaleEmail author
  • Clifford W. Deveney


Recurrence rates following successful incisional hernia repair are reported to be between 10 and 60 %. Although most recurrences occur within 2 years of repair, they can recur for up to 30 years, with repairs of recurrent hernias having an even higher recurrence rate. Although some causes of hernia recurrences are related to surgical technique, several patient factors contribute profoundly to hernia recurrence by delaying wound healing, or actually causing necrosis or absorption of connective tissue. Modifiable factors, such as smoking, obesity, and hyperglycemia should be addressed and corrected before elective repair, if possible. By eliminating or reducing these factors, one optimizes a patient’s chance of undergoing successful hernia repair without recurrence, post-op infectious complications, or delayed wound healing.

Because the success of hernia repair is often measured by the absence of recurrence, the focus of preoperative optimization aims at eliminating factors that inhibit wound healing. The focus of preoperative optimization on these entities and their correction, if they are abnormal, will give the patient the best chance for successful repair.

In addition, interventions performed in the immediate perioperative period, like the appropriate choosing and timing of prophylactic antibiotics, metabolic preparation with specific nutrients and/or carbohydrate-loading, choice of alcohol-containing skin preps, and preoperative decolonization of MRSA and MSSA from the nostrils and skin, are important interventions, which, when implemented, will minimize perioperative morbidity.


Incisional hernia repair Hernia recurrence Preoperative optimization Nutritional intervention Preoperative metabolic preparation Antibiotic prophylaxis Preoperative skin preparation Treatments to reduce risk Preoperative and perioperative interventions Perioperative morbidity 


  1. 1.
    Flum DR, Horvath K, Koepsell T. Have outcomes of incisional hernia repair improved with time? A population-based analysis. Ann Surg. 2003;237(1):129–35.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Slater NJ, Montgomery A, Berrevoet F, Carbonell AM, Chang A, Franklin M, et al. Criteria for definition of a complex abdominal wall hernia. Hernia. 2014;18(1):7–17.CrossRefPubMedGoogle Scholar
  3. 3.
    Martindale RG, Deveney CW. Preoperative risk reduction: strategies to optimize outcomes. Surg Clin North Am. 2013;93(5):1041–55.CrossRefPubMedGoogle Scholar
  4. 4.
    Khullar D, Maa J. The impact of smoking on surgical outcomes. J Am Coll Surg. 2012;215(3):418–26.CrossRefPubMedGoogle Scholar
  5. 5.
    Mastracci TM, Carli F, Finley RJ, Muccio S, Warner DO. Members of the evidence-based reviews in surgery G. Effect of preoperative smoking cessation interventions on postoperative complications. J Am Coll Surg. 2011;212(6):1094–6.CrossRefPubMedGoogle Scholar
  6. 6.
    Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med. 2011;124(2):144–54.CrossRefPubMedGoogle Scholar
  7. 7.
    Sorensen LT. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Ann Surg. 2012;255(6):1069–79.CrossRefPubMedGoogle Scholar
  8. 8.
    Kuri M, Nakagawa M, Tanaka H, Hasuo S, Kishi Y. Determination of the duration of preoperative smoking cessation to improve wound healing after head and neck surgery. Anesthesiology. 2005;102(5):892–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Sorensen LT. Wound healing and infection in surgery. The clinical impact of smoking and smoking cessation: a systematic review and meta-analysis. Archiv Surg. 2012;147(4):373–83.CrossRefGoogle Scholar
  10. 10.
    Sorensen LT, Toft BG, Rygaard J, Ladelund S, Paddon M, James T, et al. Effect of smoking, smoking cessation, and nicotine patch on wound dimension, vitamin C, and systemic markers of collagen metabolism. Surgery. 2010;148(5):982–90.CrossRefPubMedGoogle Scholar
  11. 11.
    Praveen Raj P, Senthilnathan P, Kumaravel R, Rajpandian S, Rajan PS, Anand Vijay N, et al. Concomitant laparoscopic ventral hernia mesh repair and bariatric surgery: a retrospective study from a tertiary care center. Obesity Surg. 2012;22(5):685–9.CrossRefGoogle Scholar
  12. 12.
    Eid GM, Wikiel KJ, Entabi F, Saleem M. Ventral hernias in morbidly obese patients: a suggested algorithm for operative repair. Obesity Surg. 2013;23(5):703–9.CrossRefGoogle Scholar
  13. 13.
    Dronge AS, Perkal MF, Kancir S, Concato J, Aslan M, Rosenthal RA. Long-term glycemic control and postoperative infectious complications. Archiv Surg. 2006;141(4):375–80.CrossRefGoogle Scholar
  14. 14.
    Berbari EF, Osmon DR, Lahr B, Eckel-Passow JE, Tsaras G, Hanssen AD, et al. The Mayo prosthetic joint infection risk score: implication for surgical site infection reporting and risk stratification. Infect Control Hosp Epidemiol. 2012;33(8):774–81.CrossRefPubMedGoogle Scholar
  15. 15.
    Ramos M, Khalpey Z, Lipsitz S, Steinberg J, Panizales MT, Zinner M, et al. Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery. Ann Surg. 2008;248(4):585–91.PubMedGoogle Scholar
  16. 16.
    Martindale RG, McClave SA, Taylor B, Lawson CM. Perioperative nutrition: what is the current landscape? J Parenter Enteral Nutr. 2013;37(5 Suppl):5S–20S.CrossRefGoogle Scholar
  17. 17.
    Daley J, Khuri SF, Henderson W, Hur K, Gibbs JO, Barbour G, et al. Risk adjustment of the postoperative morbidity rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. J Am Coll Surg. 1997;185(4):328–40.PubMedGoogle Scholar
  18. 18.
    Munroe C, Frantz D, Martindale RG, McClave SA. The optimal lipid formulation in enteral feeding in critical illness: clinical update and review of the literature. Curr Gastroenterol Rep. 2011;13(4):368–75.CrossRefPubMedGoogle Scholar
  19. 19.
    Jie B, Jiang ZM, Nolan MT, Zhu SN, Yu K, Kondrup J. Impact of preoperative nutritional support on clinical outcome in abdominal surgical patients at nutritional risk. Nutrition. 2012;28(10):1022–7.CrossRefPubMedGoogle Scholar
  20. 20.
    Kondrup J, Rasmussen HH, Hamberg O, Stanga Z, Ad Hoc EWG. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr. 2003;22(3):321–36.CrossRefPubMedGoogle Scholar
  21. 21.
    Heyland DK, Dhaliwal R, Jiang X, Day AG. Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Crit Care. 2011;15(6):R268.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Gianotti L, Braga M, Nespoli L, Radaelli G, Beneduce A, Di Carlo V. A randomized controlled trial of preoperative oral supplementation with a specialized diet in patients with gastrointestinal cancer. Gastroenterology. 2002;122(7):1763–70.CrossRefPubMedGoogle Scholar
  23. 23.
    Braga M, Gianotti L, Vignali A, Schmid A, Nespoli L, Di Carlo V. Hospital resources consumed for surgical morbidity: effects of preoperative arginine and omega-3 fatty acid supplementation on costs. Nutrition. 2005;21(11–12):1078–86.CrossRefPubMedGoogle Scholar
  24. 24.
    Braga M, Gianotti L, Nespoli L, Radaelli G, Di Carlo V. Nutritional approach in malnourished surgical patients: a prospective randomized study. Archiv Surg. 2002;137(2):174–80.CrossRefGoogle Scholar
  25. 25.
    Manchio JV, Litchfield CR, Sati S, Bryan DJ, Weinzweig J, Vernadakis AJ. Duration of smoking cessation and its impact on skin flap survival. Plast Reconstr Surg. 2009;124(4):1105–17.CrossRefPubMedGoogle Scholar
  26. 26.
    Braga M. Perioperative immunonutrition and gut function. Curr Opin Clin Nutr Metab Care. 2012;15(5):485–8.CrossRefPubMedGoogle Scholar
  27. 27.
    Drover JW, Dhaliwal R, Weitzel L, Wischmeyer PE, Ochoa JB, Heyland DK. Perioperative use of arginine-supplemented diets: a systematic review of the evidence. J Am Coll Surg. 2011;212(3):385–99.CrossRefPubMedGoogle Scholar
  28. 28.
    Serhan CN. Pro-resolving lipid mediators are leads for resolution physiology. Nature. 2014;510(7503):92–101.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Pluess TT, Hayoz D, Berger MM, Tappy L, Revelly JP, Michaeli B, et al. Intravenous fish oil blunts the physiological response to endotoxin in healthy subjects. Intensive Care Med. 2007;33(5):789–97.CrossRefPubMedGoogle Scholar
  30. 30.
    Calder PC. Fatty acids and inflammation: the cutting edge between food and pharma. Eur J Pharmacol. 2011;668 Suppl 1:S50–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Marik PE, Flemmer M. The immune response to surgery and trauma: implications for treatment. J Trauma Acute Care Surg. 2012;73(4):801–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Rudolph FB, Van Buren CT. The metabolic effects of enterally administered ribonucleic acids. Curr Opin Clin Nutr Metab Care. 1998;1(6):527–30.CrossRefPubMedGoogle Scholar
  33. 33.
    Burden S, Todd C, Hill J, Lal S. Pre-operative nutrition support in patients undergoing gastrointestinal surgery. Cochrane Database Syst Rev. 2012;11:CD008879.Google Scholar
  34. 34.
    Svanfeldt M, Thorell A, Hausel J, Soop M, Nygren J, Ljungqvist O. Effect of “preoperative” oral carbohydrate treatment on insulin action—a randomised cross-over unblinded study in healthy subjects. Clin Nutr. 2005;24(5):815–21.CrossRefPubMedGoogle Scholar
  35. 35.
    Soop M, Nygren J, Myrenfors P, Thorell A, Ljungqvist O. Preoperative oral carbohydrate treatment attenuates immediate postoperative insulin resistance. Am J Physiol Endocrinol Metab. 2001;280(4):E576–83.PubMedGoogle Scholar
  36. 36.
    Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 2005;24(3):466–77.CrossRefPubMedGoogle Scholar
  37. 37.
    Awad S, Constantin-Teodosiu D, Constantin D, Rowlands BJ, Fearon KC, Macdonald IA, et al. Cellular mechanisms underlying the protective effects of preoperative feeding: a randomized study investigating muscle and liver glycogen content, mitochondrial function, gene and protein expression. Ann Surg. 2010;252(2):247–53.CrossRefPubMedGoogle Scholar
  38. 38.
    Awad S, Fearon KC, Macdonald IA, Lobo DN. A randomized cross-over study of the metabolic and hormonal responses following two preoperative conditioning drinks. Nutrition. 2011;27(9):938–42.CrossRefPubMedGoogle Scholar
  39. 39.
    Maung AA, Davis KA. Perioperative nutritional support: immunonutrition, probiotics, and anabolic steroids. Surg Clin North Am. 2012;92(2):273–83.CrossRefPubMedGoogle Scholar
  40. 40.
    Baucom RB, Beck WC, Holzman MD, Sharp KW, Nealon WH, Poulose BK. Prospective evaluation of surgeon physical examination for detection of incisional hernias. J Am Coll Surg. 2014;218(3):363–6.CrossRefPubMedGoogle Scholar
  41. 41.
    Franklin BR, Patel KM, Nahabedian MY, Baldassari LE, Cohen EI, Bhanot P. Predicting abdominal closure after component separation for complex ventral hernias: maximizing the use of preoperative computed tomography. Ann Plast Surg. 2013;71(3):261–5.CrossRefPubMedGoogle Scholar
  42. 42.
    Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect. 2013;14(1):73–156.CrossRefGoogle Scholar
  43. 43.
    Luijendijk RW, Hop WC, van den Tol MP, de Lange DC, Braaksma MM, IJzermans JN, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med. 2000;343(6):392–8.CrossRefPubMedGoogle Scholar
  44. 44.
    Cassar K, Munro A. Surgical treatment of incisional hernia. Br J Surg. 2002;89(5):534–45.CrossRefPubMedGoogle Scholar
  45. 45.
    Swenson BR, Hedrick TL, Metzger R, Bonatti H, Pruett TL, Sawyer RG. Effects of preoperative skin preparation on postoperative wound infection rates: a prospective study of 3 skin preparation protocols. Infect Control Hosp Epidemiol. 2009;30(10):964–71.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Darouiche RO, Wall Jr MJ, Itani KM, Otterson MF, Webb AL, Carrick MM, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med. 2010;362(1):18–26.CrossRefPubMedGoogle Scholar
  47. 47.
    Swenson BR, Sawyer RG. Importance of alcohol in skin preparation protocols. Infect Control Hosp Epidemiol. 2010;31(9):977.CrossRefPubMedGoogle Scholar
  48. 48.
    Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2011(11):CD004122.Google Scholar
  49. 49.
    Jakobsson J, Perlkvist A, Wann-Hansson C. Searching for evidence regarding using preoperative disinfection showers to prevent surgical site infections: a systematic review. Worldviews Evid Based Nurs. 2011;8(3):143–52.CrossRefPubMedGoogle Scholar
  50. 50.
    Dumville JC, McFarlane E, Edwards P, Lipp A, Holmes A. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev. 2013;3:CD003949.Google Scholar
  51. 51.
    Manunga Jr J, Olak J, Rivera C, Martin M. Prevalence of methicillin-resistant Staphylococcus aureus in elective surgical patients at a public teaching hospital: an analysis of 1039 patients. Am Surg. 2012;78(10):1096–9.PubMedGoogle Scholar
  52. 52.
    Savage JW, Anderson PA. An update on modifiable factors to reduce the risk of surgical site infections. Spine J. 2013;13(9):1017–29.CrossRefPubMedGoogle Scholar
  53. 53.
    Edmiston Jr CE, Okoli O, Graham MB, Sinski S, Seabrook GR. Evidence for using chlorhexidine gluconate preoperative cleansing to reduce the risk of surgical site infection. AORN J. 2010;92(5):509–18.CrossRefPubMedGoogle Scholar
  54. 54.
    Chlebicki MP, Safdar N, O’Horo JC, Maki DG. Preoperative chlorhexidine shower or bath for prevention of surgical site infection: a meta-analysis. Am J Infect Control. 2013;41(2):167–73.CrossRefPubMedGoogle Scholar
  55. 55.
    Bode LG, Kluytmans JA, Wertheim HF, Bogaers D, Vandenbroucke-Grauls CM, Roosendaal R, et al. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med. 2010;362(1):9–17.CrossRefPubMedGoogle Scholar
  56. 56.
    Kim DH, Spencer M, Davidson SM, Li L, Shaw JD, Gulczynski D, et al. Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery. J Bone Joint Surg Am. 2010;92(9):1820–6.CrossRefPubMedGoogle Scholar
  57. 57.
    Huang SS, Septimus E, Kleinman K, Moody J, Hickok J, Avery TR, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255–65.CrossRefPubMedGoogle Scholar
  58. 58.
    Justinger C, Moussavian MR, Schlueter C, Kopp B, Kollmar O, Schilling MK. Antibacterial [corrected] coating of abdominal closure sutures and wound infection. Surgery. 2009;145(3):330–4.CrossRefPubMedGoogle Scholar
  59. 59.
    Justinger C, Slotta JE, Ningel S, Graber S, Kollmar O, Schilling MK. Surgical-site infection after abdominal wall closure with triclosan-impregnated polydioxanone sutures: results of a randomized clinical pathway facilitated trial (NCT00998907). Surgery. 2013;154(3):589–95.CrossRefPubMedGoogle Scholar
  60. 60.
    Chang WK, Srinivasa S, Morton R, Hill AG. Triclosan-impregnated sutures to decrease surgical site infections: systematic review and meta-analysis of randomized trials. Ann Surg. 2012;255(5):854–9.CrossRefPubMedGoogle Scholar
  61. 61.
    Reid K, Pockney P, Draganic B, Smith SR. Barrier wound protection decreases surgical site infection in open elective colorectal surgery: a randomized clinical trial. Dis Colon Rectum. 2010;53(10):1374–80.CrossRefPubMedGoogle Scholar
  62. 62.
    Horiuchi T, Tanishima H, Tamagawa K, Matsuura I, Nakai H, Shouno Y, et al. Randomized, controlled investigation of the anti-infective properties of the Alexis retractor/protector of incision sites. J Trauma. 2007;62(1):212–5.CrossRefPubMedGoogle Scholar
  63. 63.
    Flores-Maldonado A, Medina-Escobedo CE, Rios-Rodriguez HM, Fernandez-Dominguez R. Mild perioperative hypothermia and the risk of wound infection. Arch Med Res. 2001;32(3):227–31.CrossRefPubMedGoogle Scholar
  64. 64.
    Qadan M, Gardner SA, Vitale DS, Lominadze D, Joshua IG, Polk Jr HC. Hypothermia and surgery: immunologic mechanisms for current practice. Ann Surg. 2009;250(1):134–40.CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Bittner R, Bingener-Casey J, Dietz U, Fabian M, Ferzli G, Fortelny R, et al. Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society [IEHS])-Part III. Surg Endosc. 2014;28(2):380–404.CrossRefPubMedGoogle Scholar
  66. 66.
    Fakhry SM, Montgomery SC. Peri-operative oxygen and the risk of surgical infection. Surg Infect. 2012;13(4):228–33.CrossRefGoogle Scholar
  67. 67.
    Greif R, Akca O, Horn EP, Kurz A, Sessler DI, Outcomes Research G. Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection. N Engl J Med. 2000;342(3):161–7.CrossRefPubMedGoogle Scholar
  68. 68.
    Belda FJ, Aguilera L, Garcia de la Asuncion J, Alberti J, Vicente R, Ferrandiz L, et al. Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. JAMA. 2005;294(16):2035–42.CrossRefPubMedGoogle Scholar
  69. 69.
    Meyhoff CS, Wetterslev J, Jorgensen LN, Henneberg SW, Hogdall C, Lundvall L, et al. Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: the PROXI randomized clinical trial. JAMA. 2009;302(14):1543–50.CrossRefPubMedGoogle Scholar
  70. 70.
    Al-Niaimi A, Safdar N. Supplemental perioperative oxygen for reducing surgical site infection: a meta-analysis. J Eval Clin Pract. 2009;15(2):360–5.CrossRefPubMedGoogle Scholar
  71. 71.
    McFarland LV. Antibiotic-associated diarrhea: epidemiology, trends and treatment. Future Microbiol. 2008;3(5):563–78.CrossRefPubMedGoogle Scholar
  72. 72.
    Hempel S, Newberry SJ, Maher AR, Wang Z, Miles JN, Shanman R, et al. Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-analysis. JAMA. 2012;307(18):1959–69.CrossRefPubMedGoogle Scholar
  73. 73.
    Johnston BC, Ma SS, Goldenberg JZ, Thorlund K, Vandvik PO, Loeb M, et al. Probiotics for the prevention of Clostridium difficile-associated diarrhea: a systematic review and meta-analysis. Ann Intern Med. 2012;157(12):878–88.CrossRefPubMedGoogle Scholar
  74. 74.
    Goldenberg JZ, Ma SS, Saxton JD, Martzen MR, Vandvik PO, Thorlund K et al. Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children. Cochrane Database Syst Rev. 2013;5:CD006095.Google Scholar
  75. 75.
    Valkenet K, van de Port IG, Dronkers JJ, de Vries WR, Lindeman E, Backx FJ. The effects of preoperative exercise therapy on postoperative outcome: a systematic review. Clin Rehabil. 2011;25(2):99–111.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of SurgeryOregon Health and Science UniversityPortlandUSA

Personalised recommendations