A detailed general health history should be obtained including past medical history, current medications, allergies, social habits (alcohol, illicit drug use, smoking history) as well as previous adjuvant treatments, which may impact any attempt at operative repair (e.g., previous pelvic or abdominal radiation). Consideration of other common abdominal pathology, such as symptomatic cholelithiasis or colon cancer, may need evaluation prior to hernia repair and results should be documented.

A detailed history regarding obstructive symptomology (nausea, vomiting, passage of flatus, bowel frequency, abdominal pain) the patient may have experienced in the recent or distant past should be recorded. For all patients undergoing evaluation of incisional hernia, medical records should be obtained and reviewed, emphasizing surgical history and operative reports from previous pertinent surgeries and hernia repairs. Attention should be directed toward specifics of previous abdominal operations, especially hernia repairs: anatomic location of initial hernia defect, previous attempts at hernia repair, presence and type of previously placed mesh, location of any previously placed mesh (intraperitoneal, preperitoneal, retrorectus, fascial onlay, etc.), method of mesh fixation, and previous operative complications. Also, the extent of previous skin and subcutaneous dissection and the presence and extent of a components separation can be very helpful.

The presence of comorbidities known to be associated with increased risk of postoperative wound complications or recurrence (current or smoking history, obesity, diabetes, immunocompromised status, cirrhosis, chronic obstructive pulmonary disease [COPD], current or chronic infections such as urinary or pulmonary infection, history of previous mesh or other methicillin-resistant Staphylococcus aureus [MRSA] infections), as well as any history of previous or current wound infections and any current abdominal wall wound issues should be noted.

A complete physical exam should be performed paying particular attention to the existence and location of abdominal scarring, nonhealing wounds, erythema that may indicate deeper pathology, identification of any abdominal wall defects (either incisional or primary), presence and nature of hernia contents within defects, reducibility of hernia contents, and tenderness to palpation of noted defects. Fascial defect size should be estimated to aid in preoperative planning.

Other physical findings or review of symptoms points may alert a surgeon to medical issues that require workup prior to surgery, such as heart failure, COPD, vascular disease, liver or kidney disease.

A thorough examination should be performed looking for the existence of other potential hernia sites (umbilical, inguinal, femoral, parastomal, etc.), which may be addressed at the time of surgery. By neglecting other potential hernias, the opportunity to repair them at the same time as the primary hernia may be lost.

The presence of a gastrointestinal stoma, active wound infection, or chronic draining sinus tracts should also be taken into account, as these situations influence operative planning, risk counseling, and may influence an open versus a laparoscopic repair. A laparoscopic repair with synthetic mesh placement is not appropriate for an actively infected field.

The presence of peritoneal signs (abdominal rigidity, guarding, rebound tenderness) should alert the surgeon to the likelihood of intraabdominal issues and may mandate an emergent laparotomy.

Although physical exam is the gold standard of diagnosis, obese body habitus, abdominal scarring, and the presence of previously placed mesh may preclude physical diagnosis of an incisional hernia. For these reasons, computed tomography (CT) is a valuable tool for diagnosis and operative planning in cases of a suspected incisional hernia (FIG 1).

Advantages of CT imaging for the evaluation of incisional hernias are multifactorial: accurate diagnosis in cases of obscure or small defects; proper identification of hernia contents (small bowel, colon, solid organs, omentum, etc.); definition of defect size; location of previously placed mesh; distinction from other or concomitant potential diagnoses (seroma, abscess, hematoma, etc.); identification of bowel incarceration; obstruction or possible ischemia, necrosis, or perforation; and planning of where to enter the abdomen safely.

When feasible, it is helpful for the operating surgeon to review the actual CT images, as the information discussed earlier may not be included in a radiologist’s reading of the films. It is also helpful to have CT images available to be viewed intraoperatively as they can serve as a reference during the operative procedure.

Colon cancer screening with colonoscopy or other appropriate means is often considered for those patients who have reached appropriate age for screening, have a significant family history, or other colonic symptoms prior to hernia repair.