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Wound dehiscence and incisional hernia after laparotomy: A narrative review of risk factors and management approaches
*Corresponding author: Prince Xavier, Department of Therapeutic and Specialized Disciplines, Satkynbai Tentishev Asian International University, Kant, Kyrgyzstan. princexavier654@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Xavier P, Kulambaev B. Wound dehiscence and incisional hernia after laparotomy: A narrative review of risk factors and management approaches. Med India. 2025;4:62-6. doi: 10.25259/MEDINDIA_25_2025
Abstract
Wound dehiscence (WD) and incisional hernia (IH) are common and serious complications following laparotomy, resulting in increased morbidity, mortality, and healthcare costs. This review highlights key patient-related risk factors such as high body mass index, obesity, malnutrition, anemia, diabetes mellitus, advanced age, and male sex, alongside surgical and post-operative contributors, including surgical site infection, emergency surgery, ostomy creation, pulmonary complications, and poor surgical technique. Previous laparotomy, high American Society of Anesthesiologists scores, and certain suture materials also influence risk. Prevention strategies emphasize pre-operative optimization of patient health, meticulous surgical techniques, and the use of modified closure methods such as reinforced tension line and retention sutures, which significantly reduce incidence rates without increasing post-operative complications. Infection control and nutritional management remain critical. Prophylactic mesh use in high-risk patients shows promise for reducing IH. Management approaches vary from conservative care for WD to open or laparoscopic repair for IH, with laparoscopic methods offering lower infection and recurrence rates. Emerging predictive tools, including artificial intelligence models, enhance risk stratification and clinical decision-making. Overall, comprehensive prevention and individualized management strategies are essential to improve outcomes and reduce the burden of these complications after laparotomy.
Keywords
Incisional hernia
Laparotomy
Risk factors
Surgical complications
Wound dehiscence
INTRODUCTION
Wound dehiscence (WD) and incisional hernia (IH) are significant post-operative complications following laparotomy, contributing to increased morbidity, mortality, and healthcare costs.[1-3] Laparotomy, a widely performed surgical procedure involving a large abdominal incision for diagnostic or therapeutic purposes, carries a considerable risk of wound complications.[4] WD refers to the partial or complete separation of a surgical incision, while IH involves the protrusion of abdominal contents through a weakened or disrupted incision site.[5] These complications can lead to prolonged hospitalization, repeated surgical interventions, and decreased quality of life.[6,7]
Their etiology is multifactorial, encompassing patient-related factors such as obesity, advanced age, and comorbidities such as diabetes mellitus (DM) and malnutrition; surgical factors including operative technique, incision type, and urgency of the procedure; and post-operative factors such as surgical site infection (SSI), pulmonary complications, and wound stress.[8-11] Recent advancements – such as modified closure techniques (MCTs) (small-bite and tension-line reinforcement) and the prophylactic use of mesh – have shown promise in reducing the incidence of these complications.[12]
Moreover, predictive tools, particularly those utilizing artificial intelligence (AI) and machine learning algorithms, have improved early identification of high-risk patients, allowing for targeted preventive strategies and personalized management.[11,12] This literature review aims to consolidate current evidence on the risk factors, prevention methods, and management options for WD and IH following laparotomy, providing critical insights for clinicians to improve surgical outcomes and alleviate the healthcare burden.
METHODOLOGY
This literature review was conducted to synthesize and critically analyze the available evidence on the risk factors, prevention strategies, and management approaches for WD and IH following laparotomy.
Search strategy
A comprehensive literature search was performed across electronic databases, including PubMed, Scopus, Web of Science, and Google Scholar. The search included studies published between January 2000 and May 2025, with a preference for recent evidence (2010 onward). Keywords combined with Boolean operators (“AND,” “OR”) included: WD, IH, laparotomy, risk factors, SSI, closure techniques, prophylactic mesh, and post-operative complications.
Inclusion criteria
Studies were included if they:
Were published in English between 2000 and 2025
Focused on risk factors, prevention, or management of WD and/or IH following laparotomy
Included human adult patients undergoing midline or open abdominal laparotomy
Reported original research, systematic or narrative reviews, meta-analyses, or retrospective/prospective cohort studies published in peer-reviewed journals
Reported data relevant to patient-related, surgical, or post-operative contributors to these complications.
Exclusion criteria
Studies were excluded if they:
Were non-human or animal studies
Were not published in English or lacked full-text availability
Were editorials, letters, conference abstracts, or case reports without original data
Focused solely on unrelated post-operative complications (e.g., oncologic or thoracic outcomes).
Study selection and data extraction
After removing duplicates, titles and abstracts were screened to assess relevance. Eligible full-text articles were reviewed according to the inclusion criteria. Data were extracted manually and organized into thematic categories: (1) patient-related risk factors, (2) surgical and post-operative contributors, (3) prevention and closure techniques, and (4) management approaches.
A total of 12 core studies were included in the final analysis. Findings were compared, summarized, and synthesized to identify consistent trends, emerging strategies, and evidence-based recommendations for clinical practice.
RESULTS
This section presents the key findings from the reviewed literature regarding the risk factors, prevention strategies, and management approaches for wound WD and IH following laparotomy. The analysis highlights significant patient-related and surgical factors influencing these complications, as well as the effectiveness of various surgical techniques and interventions in reducing their incidence. A comparison of the major risk factors associated with WD and IH is summarized in Table 1.
| Risk factor | Wound dehiscence | Incisional hernia |
|---|---|---|
| High BMI/obesity | Yes | Yes |
| Wound infection | Yes | Yes |
| Emergency surgery | Yes | Yes |
| Poor nutrition/anemia | Yes | Possible |
| Pulmonary complications | Yes | Yes |
| Ostomy creation | Yes | Yes |
| Surgical technique | Yes | Yes |
WD: Wound dehiscence, IH: Incisional hernia, BMI: Body mass index
Risk factors
Patient-related factors: High body mass index (BMI), obesity, malnutrition, anemia, diabetes, old age, and male sex increase the risk of both WD and IH.[1,2,5-7,9] Advanced age, obesity (particularly BMI >30), malnutrition, DM, chronic obstructive pulmonary disease, anemia, hypoalbuminemia, and smoking have been identified as significant risk factors.[12]
Other factors: Previous laparotomy, high American Society of Anesthesiologists score, peritonitis, and the use of certain suture materials or techniques also play a role.[4-6,7,9] SSIs are a leading cause of WD. Other contributing factors include post-operative pulmonary complications, mechanical ventilation, coughing, vomiting, and abdominal distension.[12]
Surgical and post-operative factors: Wound infection, emergency surgery, creation of an ostomy, post-operative pulmonary problems (e.g., coughing and ventilator support), bowel obstruction, contaminated wounds, and poor surgical technique are significant contributors.[1,2,5-7,9] Emergency surgeries, prolonged operative times, improper suture techniques, and the creation of ostomies increase the risk of wound complications.[12]
Prevention strategies
A comprehensive analysis of various closure techniques was conducted to prevent IH and abdominal WD post-laparotomy.
Key findings:
Incidence rates: IH is a common complication post-laparotomy, with incidences ranging from 10% to 23%, potentially reaching 40% in specific populations
MCTs: Techniques such as small bites, reinforced tension line (RTL), and retention sutures were analyzed
Effectiveness:
RTL and retention sutures: Both significantly reduced the incidence of IH and abdominal wound dehiscence (AWD).
Small bites: Also effective in reducing IH, though to a slightly lesser extent.
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Statistical outcomes:
RTL showed the best outcomes with a number needed to treat of 3, indicating high efficacy.
Pre-operative optimization: Addressing nutritional deficiencies, controlling diabetes, and improving lung function can reduce risk.[6,7]
Surgical technique: MCTs, such as small bites, RTL, and retention sutures, significantly reduce the incidence of IH and WD.[4,7,8] In cases where IHs develop, surgical repair – either open or laparoscopic – is the definitive treatment. The choice of technique depends on the hernia’s size, location, and the patient’s overall health status.[12]
Infection control: Preventing SSIs is critical, as infection is a major risk factor for both complications.[1,2,5,9]
Prophylactic mesh: The use of mesh in high-risk patients is being explored as a preventive measure.[8]
Meticulous surgical techniques, including appropriate suture methods and tension-free closures, are essential. The use of prophylactic mesh reinforcement in high-risk patients has shown promise in reducing the incidence of IHs.[12]
Post-operative complications: The study found no significant increase in complications such as hematoma, seroma, or SSIs with the use of MCTs.
Close monitoring for signs of infection, ensuring adequate nutrition, and managing comorbid conditions like diabetes are vital. Early intervention in detecting wound complications can prevent progression to more severe outcomes.[12]
The study recommends the adoption of RTL and retention suture techniques in midline laparotomy closures to effectively reduce the risk of IH and AWD without increasing post-operative complications.[11]
Management approaches
WD: Management ranges from conservative dressings to emergency surgical closure, especially in cases of evisceration or burst abdomen.[3,6]
IH: Repair options include open or laparoscopic techniques, with laparoscopic repair associated with lower infection and recurrence rates, and shorter hospital stays.[3,10]
Auxiliary techniques: Vacuum-assisted closure devices and careful patient assessment are used to support healing and reduce complications.[3]
Predictive tools
AI: Artificial neural networks and logistic regression models can predict the risk of IH using factors such as SSI, emergency surgery, previous laparotomy, and BMI, aiding in clinical decision-making.[5]
DISCUSSION
This literature review highlights that WD and IH remain significant post-operative challenges following laparotomy, with multiple overlapping risk factors contributing to their occurrence. The most consistently reported determinants include high BMI, SSI, emergency surgery, poor nutritional status, and suboptimal surgical techniques. Preventive strategies such as pre-operative optimization, meticulous wound closure methods, infection control, and selective use of prophylactic mesh have demonstrated efficacy in reducing incidence rates without increasing post-operative complications.
The findings underscore the multifactorial nature of post-operative wound complications. Patient-related factors – especially obesity, DM, anemia, and advanced age – exert considerable influence by impairing wound healing and collagen synthesis. Similarly, intraoperative variables such as surgical technique, choice of suture material, and operative duration play critical roles in determining wound integrity. Post-operative factors such as SSI and pulmonary complications further compound these risks, often serving as triggers for WD and IH. These results align with prior studies emphasizing that both patient optimization and surgical precision are equally vital in preventing wound disruption and hernia formation.[1-3]
The review also supports emerging evidence advocating for MCTs such as the small-bite method, RTL, and retention sutures. These approaches distribute mechanical stress more evenly and minimize tissue ischemia, thereby lowering WD and IH rates.[4-6] Moreover, prophylactic mesh reinforcement in high-risk patients – particularly those with obesity, prior laparotomy, or SSI – has shown promise in preventing IH without increasing infection rates.[7,8]
An important advancement noted in recent years is the integration of predictive modeling and AI in surgical risk assessment. AI-based algorithms can stratify patients preoperatively using variables such as BMI, prior surgery, and SSI risk, allowing surgeons to adopt tailored preventive strategies.[9] This precision-medicine approach represents a shift from generalized to individualized surgical care, potentially reducing post-operative complications and hospital burden.
Clinically, these findings emphasize that WD and IH are not inevitable sequelae of laparotomy but largely preventable through evidence-based perioperative management. Surgeons should prioritize pre-operative risk modification, employ standardized closure protocols, and adopt early postoperative surveillance to detect and address complications promptly. From a healthcare policy standpoint, incorporating preventive closure guidelines and AI-driven risk scoring into surgical protocols could improve patient outcomes while reducing healthcare costs.
Future research should focus on long-term comparative trials evaluating the durability of different closure techniques and the cost-effectiveness of prophylactic mesh use. In addition, further validation of AI-based predictive tools is essential before their integration into routine clinical practice.
CONCLUSION
WD and IH following laparotomy remain significant yet largely preventable surgical complications. Early identification of high-risk patients – particularly those with obesity, anemia, DM, or SSI – is essential to reduce morbidity and recurrence. Clinical vigilance and timely diagnosis based on early wound changes can prevent progression to severe complications. Effective prevention relies on comprehensive pre-operative optimization, strict infection control, and precise closure techniques, including small-bite, RTL, or retention sutures. In selected high-risk patients, prophylactic mesh reinforcement can further reduce IH risk without increasing infection. AI-based predictive tools provide valuable support in assessing patient-specific risks and guiding individualized surgical planning, promoting precision surgery. Integrating these evidence-based strategies into clinical practice can improve wound healing, reduce reoperation rates, and shorten hospital stays. Standardized closure techniques, optimization of modifiable risk factors, and use of predictive technology are critical for durable abdominal wall integrity and improved post-operative outcomes.
Author contributions:
PX conceptualized the review, conducted the literature search, performed data extraction and analysis, drafted the manuscript, and approved the final version for submission. KBB reviewed, corrected and finalized the submission.
Ethics approval:
Institutional Review Board approval is not required.
Declaration of patient consent:
Patient’s consent was not required as there are no patients in this study.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that they have used artificial intelligence (AI)-assisted technology solely for language refinement and to improve the clarity of writing. No AI assistance was employed in the generation of scientific content, data analysis or interpretation.
Financial support and sponsorship: Nil.
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