Bulging on the stomach
A large soft bulge in the area of the scar or in the middle of the abdomen; increases when you cough or strain, and decreases when lying down.
Postoperative hernia
CONDITION / TORSO AND ABDOMEN
Large abdominal hernia.
A large abdominal hernia is a wide defect in the abdominal wall, often after previous operations or unsuccessful hernia repair. Such a hernia is usually operated on a planned basis, often after preparation, and if necessary, muscles are released to close the defect with own tissues and mesh.
CONCEPTUAL VISUALIZATION- What it is
- Wide defect of the abdominal wall, often postoperative or repeated.
- What threatens
- Pinching. In a Danish cohort of people with a postoperative hernia among those who were observed without surgery, the probability of emergency surgery over 5 years was estimated at 4%.
- How to prepare
- Smoking cessation, weight and sugar control; if necessary, botulinum toxin or pneumoperitoneum in a few weeks.
- Who treats it
- A surgeon who performs reconstruction of the abdominal wall.
01 / WHAT IS ITWhat is
What is
large abdominal hernia.
A hernia is when part of an internal organ, such as the intestine, protrudes through a gap or weak point in the muscles of the abdominal wall. It is visible as a bulge that increases when you cough or strain, and decreases when you lie down.
A large, or complex, hernia differs not only in size. Experts distinguish four groups of signs: the size and location of the defect, the condition of the skin and tissues (in particular, infection), previous operations and concomitant diseases, as well as the circumstances under which the hernia is operated on.
Often this is a postoperative hernia - in the scar after abdominal surgery, or a recurrent one that returned after a previous plastic surgery. When a significant part of the abdominal organs lies in the hernial sac, doctors speak of "loss of domain": it is difficult to return the organs to their place without preparation.
A large hernia may not hurt: the weak point in the muscles is stretched, and the contents of the hernia easily come out and return.
This is general information. The doctor will tell you what will suit you after the examination and CT scan.
02 / SIGNSHow
How
large hernia presents.
Bulging and stretched skin are planned signs. Pain, nausea, or vomiting may indicate entrapment.
Tight skin
The skin over the hernia seems taut and stretched.
Makes it difficult to move
A hernia may not hurt, but it can interfere with bending over, working or playing sports.
The hernia returned
The protrusion appeared again after the previous hernia repair - in the same place or nearby.
Pain in the hernia
The hernia started to hurt - see a surgeon the same day. Very strong pain that does not go away is a reason to call 103.
Nausea, vomiting, no gas
This is how entrapment can occur when the intestine in the hernia loses its blood supply. Call 103.
03 / REASONSWhy the hernia occurs
Why the hernia occurs
big or returns.
A meta-analysis of 274 studies identified factors associated with recurrent hernia. Some of them can be changed before the planned operation.
Previous operations
A hernia is formed in the scar after abdominal surgery. Postoperative, not primary, hernia is one of the factors of recurrence.
Hernia has already been operated on
A hernia that has already been operated on is also among the factors that it will return again.
weight
Excess weight is associated with recurrent hernia (in various studies, a body mass index of more than 25, 30, 35, or 40); with obesity, complications after surgery are more frequent.
Smoking and diseases
Smoking, diabetes, chronic lung disease, and steroid use are associated with recurrent hernias.
Complication of healing
Wound infection, accumulation of fluid (seroma), hematoma or wound separation after surgery are among the factors of recurrent hernia.
As operated before
Suturing without mesh, as well as mesh over the muscles or inside the abdomen instead of behind the rectus muscles, are among the factors cited in the same meta-analysis.
04 / SEEK MEDICAL ADVICE
When to seek medical advice?
A large hernia that does not change and does not hurt for years is a planned situation: it usually does not require emergency care. A dangerous complication is entrapment, when the intestine in the hernia loses its blood supply: this is an urgent condition, and surgery is needed as soon as possible. Do not force a painful hernia or drive yourself to the hospital.
103 immediately if:
- very strong pain in the abdomen or in the hernia that does not go away;
- nausea, you vomit or cannot keep food down;
- the hernia, which was previously exercised, has become hard, painful and does not exercise;
- the hernia is swollen more than usual, and the skin above it has changed color;
- no gas and no stool;
- confusion or slurred speech;
- very frequent breathing;
- the skin has become bluish, pale or mottled.
When to the surgeon:
On the same day: to the surgeon or to the reception department if the hernia has started to hurt, the stomach is swollen, the stool is delayed, although the gases are passing, or the temperature has risen to 38 °C and above. Planned: if the hernia grows, interferes with movement or work or has returned after the previous operation, make an appointment for a consultation; take records of previous surgeries and CT scans, if available.
05 / DIAGNOSTICSAs defined,
As defined,
what is needed
- Conversation
When the hernia appeared, what operations on the abdomen have already been performed, whether a mesh was placed, whether there were wound infections; smoking, weight, diabetes, medications.
- Review
The surgeon assesses the size of the hernia, the scar and the skin above it and whether the contents are exercised lying down.
- CT scan of the abdominal wall
Shows the width of the defect lying in the hernia and the ratio of the volume of the hernia to the abdominal cavity. Based on these measurements, it is decided whether training is needed.
- Risk assessment
Before scheduled surgery, weight, blood sugar (glycated hemoglobin), chronic lung and kidney diseases are assessed.
06 / TREATMENTHow we treat
How we treat
large hernia
A large hernia is usually operated on a planned basis. First, the risks are reduced, if necessary, the abdominal wall is prepared, and then the defect is closed - sometimes in several stages. There are few qualitative comparative studies, so the plan is made individually.
01
Follow-up
When the risks of surgery are high.
- Is it possible not to operate?
- In a Danish cohort of 569 people with a postoperative hernia (not just a large one) without surgery, 58% were observed. Among them, based on a 5-year follow-up, approximately 19% underwent surgery later, and 4% required emergency surgery.
- What another study showed
- In a prospective study of 197 people with comorbidities, only those who had immediate surgery had better daily well-being after 5 years. Half (20) of the matched observation group still went to surgery, 3 of them - immediately.
02
Preparation for surgery
Something that can be changed in advance.
- Smoking
- Smokers have more complications, and experts do not advise them to undergo elective surgery. According to a review by the European Hernia Society, quitting smoking reduced the risk of complications after abdominal wall reconstruction.
- weight
- There are more complications with obesity. With a body mass index of 50 and above, experts do not recommend planned surgery, with 30-50 they advise measures to reduce the risk. Data on weight loss are conflicting: in the EHS review, it reduced the risk of complications, but in a meta-analysis of 3 randomized trials (219 patients), the difference was not proven.
- sugar
- With glycated hemoglobin of 6.5% and above, there are more complications; at 8.0% and above, elective surgery is not recommended, at 6.5–8.0%, measures are advised to reduce the risk.
03
Botulinum toxin and pneumoperitoneum
So that the edges of a large defect converge.
- Botulinum toxin
- About 4 weeks before surgery, botulinum toxin A is injected into the three lateral abdominal muscles on both sides. In a review of 23 studies (995 patients), no serious complications from injections were described; the muscles lengthened by an average of 3.2 cm on each side, and the edges of the defect were more likely to be sutured.
- What is known about the benefits
- The data differ. In another meta-analysis of 5 studies of giant hernias, botulinum toxin reduced the number of postoperative complications but showed no benefit in terms of suturing the edges and recurrent hernias. The authors do not advise to enter it all in a row.
- Pneumoperitoneum
- Air is gradually injected into the abdominal cavity through a thin needle or catheter to stretch it. The method has been known since 1947; it is most often used for a large postoperative hernia with loss of domain. In a review of 53 articles (1216 patients), complications were 12%, mostly minor, but there were 5 deaths.
- caution
- In a review of 20 studies, complications from pneumoperitoneum were described more than from botulinum toxin, and sometimes serious, so it is advised to use it with caution. The quality of research is low, there are no final recommendations.
- Both methods together
- In a review of 7 articles (217 patients with a defect wider than 10 cm), botulinum toxin was administered an average of 29.5 days, and pneumoperitoneum was started 14.8 days before surgery. Complications of pneumoperitoneum had 25.6%, hernia returned in 5.9%.
04
Surgery
Plastic with mesh, if necessary — separation of components.
- grid
- For hernias larger than 2 cm, experts recommend strengthening the plastic with a mesh.
- Component Separation (TAR)
- When the edges of the defect do not converge, the surgeon dissects the deep transversus abdominis muscle; rectus muscles are brought to the middle, and the net is placed behind them. The nerves of the rectus muscles are preserved. In a review of 5 studies (646 patients, average hernia area 509 cm²), complications in the wound area were on average in 15%, repeated hernia in 2 years — in 4%.
- Front or back separation
- In a meta-analysis of 19 studies (3412 patients), complications with a wound, seroma, and hematoma occurred more often after anterior separation, and recurrent hernia, according to the authors, was more common after posterior separation (TAR). There are no direct randomized comparisons yet.
- Emergency surgery
- Emergency operations for hernias cause significantly more complications and deaths than planned ones. If the defect is too large to be closed immediately, the guidelines of the European Hernia Society advise to treat it in several stages: first to stabilize the condition, and to do the final reconstruction later.
07 / AT THE VALIKHNOVSKYI INSTITUTE
How
How
we treat it.
Large and recurrent abdominal hernias are treated at Dr. Valikhnovskyi's Institute of Surgery in the direction of abdominal wall reconstruction — from preparation for surgery to recovery after it.
CLINIC SERVICE
Slender belly
Abdominal wall with umbilical, postoperative and large hernias and diastasis — mostly minimally invasive.
View service
What we do for this condition
- Separation of components of the abdominal wall (TAR) — the transversus abdominis muscle is dissected to reduce its own muscles to the middle and close a large defect.
- Chemical separation with botulinum toxin — a few weeks before the operation, under ultrasound control, botulinum toxin type A is injected into the lateral abdominal muscles to temporarily relax and lengthen them.
- Mesh behind the muscles — the mesh is placed in the space behind the rectus abdominis, where it does not come into contact with the organs.
- Endoscopic and robotic reconstruction — eTEP, TARM — the mesh is installed after several punctures; the method is chosen according to the size of the hernia.
- Mesh implants — self-fixing, composite (IPOM), lightweight and partially resorbable; the type is chosen according to the size of the hernia and its location.
- Phased reconstruction — for large complex hernias, the operation is sometimes divided into several stages.
- Preparation for surgery — weight loss, smoking cessation, sugar control.
Rostislav Valikhnovskyi
Plastic surgeon, candidate of medical sciences, founder of Dr. Valikhnovskyi Institute of Surgery.
How treatment works with us
- Photo and CT scan onlineSend a photo of the abdomen, a CT scan of the abdominal wall, if available, and reports of previous surgeries.
- ConsultationReview of hernias and scars, talk about previous surgeries, smoking, weight, sugar and medications.
- PlanIs training necessary and how long will it take; which method and whether in several stages.
- SurgeryPlastic surgery with a mesh behind the muscles, if necessary - separation of components, open or minimally invasive.
- RecoveryHeavy loads - only after the permission of the surgeon. Don't smoke and keep your weight and sugar in check.
08 / QUESTIONS AND ANSWERSCommon
Common
questions
Short answers. What is right for you, the doctor will tell you during the consultation.
Can you live with a large hernia without surgery?
Sometimes yes, if the risks of the operation are high. In the Danish cohort (569 people with a postoperative hernia), among those who were observed, 5 years later, approximately 19% operated, immediately - 4%. But in another study (197 people with concomitant diseases), those who were operated on immediately had better well-being after 5 years. The decision is made together with the surgeon.
Why the preparation, if the hernia interferes already now?
Smoking, obesity, and high blood sugar increase the risk of complications and are associated with recurrent hernias. Experts do not recommend scheduled surgery to smokers with a body mass index of 50 or higher or glycated hemoglobin of 8.0% or higher.
What gives botulinum toxin before surgery?
It temporarily relaxes and lengthens the lateral abdominal muscles, so the edges of the defect are easier to reduce. It is administered approximately 4 weeks before surgery. Whether you need it, the surgeon decides on CT.
What is pneumoperitoneum?
This is the gradual injection of air into the abdominal cavity before surgery to stretch it. It is used for hernias with loss of domain; complications from it are described more than from botulinum toxin, so the method is used cautiously.
Why did the hernia return after surgery?
Recurrent hernias have been linked to smoking, diabetes, being overweight, steroid use, wound healing complications, and the way the surgery was performed, including non-mesh suturing. Repeated hernia is operated on again; the plan is drawn up after CT.
A hernia has hurt - what to do?
If the pain is very strong and does not go away, you are nauseous or vomiting, the hernia, which used to be exercised, has become hard and cannot be exercised, the hernia is swollen and the skin above it has changed color, or gas does not pass and there is no stool, call 103. If the hernia just started to hurt, go to the surgeon the same day. Do not force a painful hernia.
Is a grid required?
For hernias from 2 cm, experts recommend plastic with a mesh. The surgeon chooses the type of mesh and the place where it is placed based on the size of the hernia.
Sources
18 sources · guidelines and consensus, systematic reviews, meta-analyses and NHSshowCollapse
- Ventral Hernia Management: Expert Consensus Guided by Systematic ReviewAnnals of Surgery, 2017doi:10.1097/SLA.0000000000001701 ↗
- EHS Guidelines on the Management of Primary Ventral and Incisional Hernias Under Emergency ConditionsJournal of Abdominal Wall Surgery, 2026doi:10.3389/jaws.2026.16228 ↗
- Criteria for definition of a complex abdominal wall herniaHernia, 2014doi:10.1007/s10029-013-1168-6 ↗
- The European Hernia Society Prehabilitation Project: a systematic review of patient prehabilitation prior to ventral hernia surgeryHernia, 2022doi:10.1007/s10029-022-02573-2 ↗
- Randomized Controlled Trials of Weight Loss Before Hernia Surgery: A Systematic Review and Meta-AnalysisJournal of Abdominal Wall Surgery, 2025doi:10.3389/jaws.2025.15234 ↗
- A systematic review and meta-analysis of technical aspects and clinical outcomes of botulinum toxin prior to abdominal wall reconstructionHernia, 2021doi:10.1007/s10029-021-02499-1 ↗
- Effect of preoperative botulinum toxin injection in the treatment of giant incisional hernias: a systematic review and meta-analysisHernia, 2025doi:10.1007/s10029-025-03384-x ↗
- Fascial closure in giant ventral hernias after preoperative botulinum toxin a and progressive pneumoperitoneum: A systematic review and meta-analysisSurgery, 2021doi:10.1016/j.surg.2021.03.027 ↗
- A systematic review of the use of progressive preoperative pneumoperitoneum since its inceptionHernia, 2021doi:10.1007/s10029-020-02247-x ↗
- Botulinum Toxin and Progressive Pneumoperitoneum in Loss of Domain Ventral Hernias: A Systematic ReviewJournal of Abdominal Wall Surgery, 2024doi:10.3389/jaws.2024.12650 ↗
- Systematic review of transversus abdominis release in complex abdominal wall reconstructionHernia, 2019doi:10.1007/s10029-018-1870-5 ↗
- The outcomes of open anterior component separation versus posterior component separation with transversus abdominis release for complex incisional hernias: a systematic review and meta-analysisHernia, 2023doi:10.1007/s10029-023-02745-8 ↗
- Identifying predictors of ventral hernia recurrence: systematic review and meta-analysisBJS Open, 2021doi:10.1093/bjsopen/zraa071 ↗
- Watchful waiting as a treatment strategy for patients with a ventral hernia appears to be safeHernia, 2016doi:10.1007/s10029-016-1464-z ↗
- Is expectant management warranted in patients with ventral hernias and co-morbidities? A prospective, 5 year follow-up, patient-centered studyThe American Journal of Surgery, 2022doi:10.1016/j.amjsurg.2022.02.065 ↗
- Umbilical herniaNHS, 2025nhs.uk/conditions/umbilical-hernia ↗
- HerniaNHS, 2026nhs.uk/conditions/hernia ↗
- SepsisNHS, 2026nhs.uk/conditions/sepsis ↗
The figures on the page are from these sources.
Large hernia
did she come back again?
Send photos, CT scans and reports of previous operations. The doctor will tell if preparation is needed and how the defect can be closed.