Original article

Incidence of and risk factors for incisional hernia after

abdominal surgery
K. Itatsu1,2 , Y. Yokoyama1,2 , G. Sugawara1,2 , H. Kubota7 , Y. Tojima3 , Y. Kurumiya8 , H. Kono4 ,
H. Yamamoto5 , M. Ando6 and M. Nagino1
Divisions of 1 Surgical Oncology and 2 Surgical Infection, Department of Surgery, Nagoya University Graduate School of Medicine, 3 Department of
Surgery, Social Insurance Chukyo Hospital, 4 Department of Surgery, Nagoya Ekisaikai Hospital, 5 Department of Surgery, Tokai Hospital, and 6 Centre
for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, 7 Department of Surgery, Handa City Hospital, Handa, and
8
Department of Surgery, Toyota Kosei Hospital, Toyota, Japan
Correspondence to: Professor M. Nagino, Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine,
65 Tsurumai-cho, Showa-ku, Nagoya 4668550, Japan (e-mail: nagino@med.nagoya-u.ac.jp)

Background: Few larger studies have estimated the incidence of incisional hernia (IH) after abdominal
surgery.
Methods: Patients who had abdominal surgery between November 2009 and February 2011 were
included in the study. The incidence rate and risk factors for IH were monitored for at least 180 days.
Results: A total of 4305 consecutive patients were registered. Of these, 378 were excluded because of
failure to complete follow-up and 3927 patients were analysed. IH was diagnosed in 318 patients. The
estimated incidence rates for IH were 52 per cent at 12 months and 103 per cent at 24 months. In
multivariable analysis, wound classification III and IV (hazard ratio (HR) 226, 95 per cent confidence
interval 152 to 335), body mass index of 25 kg/m2 or higher (HR 176, 135 to 230), midline incision
(HR 174, 128 to 238), incisional surgical-site infection (I-SSI) (HR 168, 124 to 228), preoperative
chemotherapy (HR 161, 108 to 237), blood transfusion (HR 146, 104 to 205), increasing age by 10-year
interval (HR 130, 116 to 145), female sex (HR 126, 101 to 159) and thickness of subcutaneous tissue
for every 1-cm increase (HR 118, 103 to 135) were identified as independent risk factors. Compared
with superficial I-SSI, deep I-SSI was more strongly associated with the development of IH.
Conclusion: Although there are several risk factors for IH, reducing I-SSI is an important step in the
prevention of IH. Registration number: UMIN000004723 (University Hospital Medical Information
Network, http://www.umin.ac.jp/ctr/index.htm).

Paper accepted 3 June 2014

Published online 14 August 2014 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9600

Introduction patients in these studies have been small. As many as 8095

Incisional hernia (IH) is one of the most common postoper-
ative complications following abdominal surgery. Patients
with symptomatic IH have unsatisfactory cosmetic results
and impaired quality of life with serious life-threatening
disorders, including incarceration (615 per cent) and
bowel strangulation (2 per cent)1 5 . The rate of recurrence
after hernia repair is high (1463 per cent)4 7 . The identi-
fication of risk factors is important in the prevention of IH.
In previous reports1 3,8 24 , incidence rates of IH have
varied from zero to 33 per cent. One reason for this may
be retrospective data collection with different definitions of
IH. Only a few prospective observational studies8,9,12,15 17
have analysed the occurrence of IH, and the numbers of
per cent of patients with IH develop this complication
within 6 months to 3 years after the initial operation9,10 ,
so to estimate the incidence of IH, patients should be
monitored for at least 6 months. Approximately 60 per cent
of patients with IH are asymptomatic; thus, in the absence
of common diagnostic criteria, the true incidence rate of
IH may be underestimated1,2 .
Various independent risk factors for IH have been
reported in previous studies, including sex (male11,18,19
and female14 ), advanced age8,11 , co-morbidities (diabetes
mellitus13 and chronic obstructive pulmonary disease10 ),
current smoking11 , systemic use of steroids20 , high body
mass index (BMI)12,13,18 20 , previous laparotomy11,20 ,
emergency surgery21 , laparoscopic surgery15,22 ,

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1440
duration of surgery13,19 , blood transfusion10 , optimal
method and material for abdominal closure1,3,12,19,25 ,
incision type19,20,23 , wound dehiscence26 , and surgical-site
infection (SSI) including incisional SSI (I-SSI)8,11,12,14,18,19,24
and organ/space SSI (OS-SSI)12,13 . Several reports have
shown that I-SSI is one of the most important risk factors
for IH, but no large-scale study has analysed the risk
factors for IH by distinguishing superficial (SI-SSI) and
deep (DI-SSI) I-SSI.
This prospective observational study aimed to evaluate
the rate of IH after abdominal surgery and to assess the
impact of perioperative factors on the risk of IH. Among
perioperative factors, postoperative wound complications,
I-SSI and the depth of I-SSI were analysed specifically.
Methods
Patients who underwent abdominal surgery between
November 2009 and February 2011 at Nagoya University
Hospital and the 19 affiliated hospitals were enrolled. The
eligibility criteria for this study were: age over 20 years;
intra-abdominal surgery; no incision other than in the
abdomen or perineum; and no artificial implant. Patients
who did not have organ resection (for example bypass
surgery of the digestive tract, surgery for bowel obstruc-
tion due to adhesions, and stoma creation and closure)
were included in the study. Emergency surgery other than
for trauma was also included. Patients who had laparo-
scopically assisted operations with small incisions were
included, but those who had purely laparoscopic opera-
tions with only port-site wounds were excluded. Patients
who underwent laparotomy or digestive bypass surgery
for unresectable malignant disease were excluded from the
study, as were patients who had gastric bypass surgery or
banding for morbid obesity. Patients undergoing reoper-
ation because of complete wound dehiscence of all layers
within 30 days of operation were also excluded. Finally,
patients without IH who died or were lost to follow-up
within 180 days of surgery were excluded from the analysis
of IH.
The primary endpoint of this study was the rate of
IH. Risk factors for IH were also analysed. The proto-
col was approved by the institutional review boards of
Nagoya University Graduate School of Medicine and
the participating hospitals, and the study design was
registered with Infrastructure for Academic Activities
with the University Hospital Medical Information Net-
work Identifier (UMIN000004723, http://www.umin.
ac.jp/ctr/index.htm). Informed consent was obtained from
each patient before enrolment in the study.
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K. Itatsu, Y. Yokoyama, G. Sugawara, H. Kubota, Y. Tojima, Y. Kurumiya et al.
Monitored perioperative factors
Data were recorded by the surgeons in charge of data
collection in each hospital. Preoperative clinical data
included age, sex, BMI, American Society of Anesthesi-
ologists grade27 , co-morbidities (hypertension, diabetes
mellitus, chronic obstructive pulmonary disease, collagen
disease and aortic aneurysm), current smoking within
1 month before surgery, previous medical history (such as
laparotomy or chemotherapy), subcutaneous fat thickness,
and indication for surgery. Subcutaneous fat thickness was
measured before surgery by computed tomography (CT)
at the thickest location of the incision.
Intraoperative factors included operative status (elec-
tive or emergency), wound classification (class I, clean;
class II, clean-contaminated; class III, contaminated; class
IV, dirty-infected)27 , duration of operation, blood loss,
intraoperative blood transfusion, open or laparoscopi-
cally assisted laparotomy, operative procedure (gastric,
colorectal, hepatopancreatobiliary or other surgery),
wound length, method of fascial closure and type of
incision.
Postoperative factors included I-SSI, OS-SSI, remote
infection and other postoperative complications27,28 . Post-
operative complications were graded according to the
DindoClavien classification28 . Centers for Disease Con-
trol and Prevention definitions of SSI were employed27 .
Incisional SSI included SI-SSI and DI-SSI. SI-SSI was
diagnosed when the condition occurred within 30 days of
operation and involved the skin and subcutaneous tissue
and one of the following: purulent discharge; organism
isolated from aseptically obtained fluid or tissue; signs or
symptoms of infection, including pain/tenderness, local-
ized swelling, redness/heat and an open wound; or diagno-
sis of SI-SSI by a surgeon or attending physician. DI-SSI
was diagnosed when the infected wound involved fascial
and muscle layers but not the organ/space. The defini-
tion and diagnostic method of DI-SSI were discussed rig-
orously and standardized among the institutions. OS-SSI
was diagnosed when the condition occurred within 30 days
of surgery and involved any organ or space other than
the incision, and at least one of the following: purulent
drainage from a drain that was placed through a stab
wound into the organ or space; organisms isolated from
an aseptically obtained fluid or tissue in the organ/space;
an abscess or other evidence of infection involving the
organ/space that was found on direct examination, during
reoperation, or by histopathological or radiological exam-
ination; or an OS-SSI diagnosed by a surgeon or attend-
ing physician. Remote infection included infections of the
lower respiratory tract, urinary tract or gastrointestinal
tract29 .
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Incidence of incisional hernia after abdominal surgery 1441

Table 1 Clinical characteristics

No. of patients (n = 3927)*

Preoperative factors Age (years) 69 (2096)

Sex ratio (M : F) 2506 : 1421
Body mass index (kg/m2 ) 219 (131423)
ASA grade I 1662 (423)
II 2089 (532)
III 158 (40)
IV 18 (05)
Co-morbidity 2265 (577)
Hypertension 1451 (369)
Diabetes mellitus 739 (188)
COPD 126 (32)
Collagen disease 53 (13)
Aortic aneurysm 34 (09)
Current smoking 296 (75)
Previous history of laparotomy 953 (243)
Preoperative chemotherapy 259 (66)
Thickness of subcutaneous fat based on CT (cm) 17 (0170)
Primary disease for surgery Malignant 3742 (953)
Benign 185 (47)
Operative factors Operative status Elective 3778 (962)
Emergency 149 (38)
Surgical approach Open 3286 (837)
Laparoscopically assisted 641 (163)
Operative procedure Gastric resection 1085 (276)
Colorectal resection 1920 (489)
HPB resection 766 (195)
Other 156 (40)
Duration of surgery (min) 196 (291552)
Blood loss (ml) 210 (017 125)
Wound length (cm) 175 (4595)
Intraoperative blood transfusion 367 (93)
Wound classification I 58 (15)
II 3690 (940)
III 104 (26)
IV 75 (19)
Fascial closure Interrupted braid 2479 (631)
Interrupted monofilament 922 (235)
Continuous monofilament 443 (113)
Continuous braid 83 (21)
Type of incision Midline 3041 (774)
Paramedian 313 (80)
Transverse 176 (45)
Inverted L type 322 (82)
Mercedes type 75 (19)
Postoperative factors All complications 1097 (279)
DindoClavien classification I 258 (66)
II 379 (97)
IIIa 424 (108)
IIIb 20 (05)
IVa 15 (05)
IVb 1 (<01)
Surgical-site infection 722 (184)
Incisional 351 (89)
Superficial 290 (74)
Deep 61 (16)
Organ/space 427 (108)
Remote infection 210 (53)

*With percentages in parentheses unless indicated otherwise; values are median (range). ASA, American Society of Anesthesiologists; COPD, chronic
obstructive pulmonary disease; CT, computed tomography; HPB, hepatopancreatobiliary.

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1442 K. Itatsu, Y. Yokoyama, G. Sugawara, H. Kubota, Y. Tojima, Y. Kurumiya et al.

Definition, diagnosis and follow-up of incisional Table 1 shows the clinical characteristics of the patients.
hernia The number of emergency surgeries and laparoscopically
assisted operations was small. The majority of wounds were
After surgery, patients were followed up daily during the
classified as class II. Interrupted braid or monofilament
hospital stay, and perioperative data were recorded in
absorbable sutures were used in the most patients for
a database. All patients were monitored for more than
wound closure. Among patients with I-SSI, 290 (74 per
180 days after the operation. The presence of IH was eval-
cent) had SI-SSI and 61 (16 per cent) had DI-SSI.
uated only for the abdominal wound and not for the per-
The median length of follow-up for IH was 17 (range
ineal incisions, irrespective of symptoms2,25 . After hospital
137) months. Some 3316 (844 per cent) of the 3927
discharge, patients underwent physical examination by the
patients were followed for more than 12 months. Meth-
surgeon every 3 months to assess the presence of IH. Imag-
ods used to diagnose IH were physical examination in all
ing, including CT and ultrasound examination, was used
patients, CT in 3250 (828 per cent) and ultrasound imag-
when necessary. Methods and definitions of IH diagnosis
ing in 572 (146 per cent). No imaging study was performed
were2,11,19,20,23 25,30,31 : physical examination to detect any
in 510 patients (130 per cent). In 233 patients who died
fascial gap or protrusion with a relaxed and tensed abdom-
more than 180 days after surgery, evaluation of IH was per-
inal wall in supine and standing positions; fascial gap or
formed at least once before death. Some 318 patients were
separation in axial images on CT; full-layer defect of fascia
diagnosed with IH (Fig. 1); the KaplanMeier estimated
and muscles of the abdominal wall on ultrasonography. incidence rates of IH were 52 per cent at 12 months and
103 per cent at 24 months (Fig. 1). Of 318 patients with IH,
21 (66 per cent) underwent hernia repair.
Statistical analysis
Differences among categorical variables were evaluated Univariable analysis
using 2 tests. Incidence rates for IH were calculated by
Among 27 possible risk factors (including 14 preoperative,
means of the KaplanMeier method for estimating crude
10 operative and 3 postoperative factors), univariable anal-
risk. The log rank test was used to compare risk factors.
ysis showed 16 factors to be associated with IH (Table 2):
For patients who died after 180 days of follow-up, the
nine preoperative, six operative and one postoperative fac-
date of diagnosis of IH (not the time of death) was used
tor (I-SSI).
for the KaplanMeier analysis. The stepwise forward Cox
regression model was used to calculate hazard ratios (HRs) Multivariable analysis
with 95 per cent confidence interval (c.i.), and to estimate
HRs adjusted for confounding factors. The proportionality All risk factors were included in the multivariable analysis
of hazards was examined graphically using log minus log using a Cox regression analysis. Nine independent risk fac-
survival curves. tors for IH were identified (Table 3), including wound grade
To have 80 per cent power to detect a HR for IH of 133 III/IV (HR 226), BMI 25 kg/m2 or higher (HR 176),
at the 5 per cent significance level between patients with
and those without SSI, at least 3800 patients needed to be 15
accrued for the study under the assumption that 10 per cent
of patients develop SSI.
Incidence rate IH (%)

P < 0050 was considered statistically significant. Data

10
analyses were performed using SPSS statistical software
version 21 (IBM, Armonk, New York, USA).

5
Results

Between November 2009 and February 2011, 4305 con-

secutive patients were registered. Some 378 patients could 0 6 12 18 24
not be followed for up to 180 days owing to death (147 Time after surgery (months)
patients), for unknown reasons (142) or reoperation for rea- No. at risk 3927 3375 3316 1770 1032
sons unrelated to IH (89). Of 17 patients with total wound
dehiscence, three underwent primary wound closure. A Fig. 1 KaplanMeier analysis of the rate of incisional hernia (IH)
total of 3927 patients with complete data were analysed. after abdominal surgery

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Incidence of incisional hernia after abdominal surgery 1443

Table 2 Univariable Cox regression analysis of risk factors for incisional hernia

Hazard ratio P

Preoperative factors Age (for every 10-year increase) 128 (115, 143) < 0001
Sex ratio (M : F) 135 (108, 168) < 0001
Body mass index (kg/m2 ) < 0001
< 185 100 (reference)
185 to < 25 126 (085, 188) 0245
25 to < 30 229 (150, 351) < 0001
30 281 (142, 552) 0002
ASA grade (III/IV versus I/II) 167 (107, 261) 0022
Hypertension 126 (101, 157) 0042
Diabetes mellitus 134 (104, 174) 0024
COPD 142 (083, 242) 0199
Collagen disease 047 (011, 190) 0294
Aortic aneurysm 085 (027, 267) 0787
Current smoking 092 (060, 142) 0728
Previous history of laparotomy 121 (094, 154) 0125
Preoperative chemotherapy 146 (101, 214) 0049
Thickness of subcutaneous fat based on CT (for every 1-cm increase) 133 (118, 150) < 0001
Primary disease for surgery (benign versus malignant) 133 (118, 150) < 0001
Operative factors Operative status (emergency versus elective) 231 (154, 348) < 0001
Wound classification (III/IV versus I/II) 229 (156, 336) < 0001
Duration of surgery (for every 2-h increase) 100 (090, 110) 0128
Blood loss (for every 500-ml increase) 104 (099, 111) 0102
Intraoperative blood transfusion 159 (114, 221) 0005
Surgical method (open versus laparoscopically assisted) 137 (098, 190) 0059
Operative procedure < 0001
Gastric resection 100 (reference)
Colorectal resection 183 (136, 246) < 0001
HPB resection 142 (098, 206) 0059
Other 237 (141, 399) < 0001
Wound length (for every 10-cm increase) 116 (103, 131) 0013
Fascial closure 0087
Continuous monofilament 100 (reference)
Continuous braid 097 (043, 218) 0950
Interrupted monofilament 139 (095, 205) 0089
Interrupted braid 101 (071, 143) 0950
Type of incision 0026
Midline 100 (reference)
Paramedian 068 (043, 107) 0097
Transverse 045 (021, 097) 0041
Inverted L type 060 (037, 098) 0042
Mercedes type 057 (021, 153) 0268
Postoperative factors Incisional SSI 195 (145, 264) < 0001
Organ/space SSI 127 (091, 177) 0157
Remote infection 140 (092, 215) 0115

Values in parentheses are 95 per cent confidence intervals. ASA, American Society of Anesthesiologists; COPD, chronic obstructive pulmonary disease;
CT, computed tomography; HPB, hepatopancreatobiliary; SSI, surgical-site infection.

midline incision (HR 174), postoperative I-SSI (HR
168), preoperative chemotherapy (HR 161), intraopera-
tive blood transfusion (HR 146), greater age by 10-year
increase (HR 130), female sex (HR 126) and the thickness
of subcutaneous fat based on CT for every 1-cm increase
(HR 118).
Impact of depth of incisional surgical-site infection
When I-SSI was separated into SI-SSI and DI-SSI, the
incidence of IH was significantly greater in patients with
DI-SSI than in patients with SI-SSI (P = 0001) (Fig. 2).
The estimated IH incidence rates in patients without I-SSI,

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1444 K. Itatsu, Y. Yokoyama, G. Sugawara, H. Kubota, Y. Tojima, Y. Kurumiya et al.

Table 3 Multivariable Cox regression analysis of independent Discussion

risk factors for incisional hernia
This observational study included approximately 4000
Hazard ratio P patients who were investigated for IH after abdominal
surgery. IH incidence rates were 52 and 103 per cent
Age (for every 10-year increase) 130 (116, 145) < 0001
Sex (F versus M) 126 (101, 159) 0042
after 12 and 24 months respectively. Independent peri-
Body mass index ( 25 versus < 25 kg/m2 ) 176 (135, 230) < 0001 operative risk factors identified for IH were wound clas-
Preoperative chemotherapy 161 (108, 237) 0017 sification (III/V), high BMI, midline incision, I-SSI,
Thickness of subcutaneous fat based on 118 (103, 135) 0017 preoperative chemotherapy, intraoperative blood trans-
CT (for every 1-cm increase)
Wound classification (III/IV versus I/II) 226 (152, 335) < 0001
fusion, older age, female sex and the thickness of
Intraoperative blood transfusion 146 (104, 205) 0028 subcutaneous fat measured by CT. Patients with DI-SSI
Type of incision (midline versus 174 (128, 238) < 0001 had a higher incidence rate than the patients without I-SSI
non-midline)
or those with SI-SSI.
Incisional surgical-site infection 168 (124, 228) < 0001
Although previous investigations have reported inci-
Values in parentheses are 95 per cent confidence intervals. CT, computed dence rates and risk factors for IH, only a few studies
tomography.
were prospective and followed patients for a longer time
period8,9,12,15 17 . The present study included a large cohort
of patients, approximately equal to the numbers reported in
DI-SSI
30 previous meta-analyses1,3 , and used clear diagnostic crite-
SI-SSI
ria and follow-up for IH. The incidence rates of IH in this
No I-SSI
study at 12 and 24 months may represent the realistic rates
of IH after abdominal surgery in the Japanese population.
Several reports8,11,14,18,19,24 have shown that I-SSI is an
Incidence rate IH (%)

20
important risk factor for IH. However, no large-scale
report has differentiated between SI-SSI and DI-SSI as
risk factors. In the present study, DI-SSI was clearly
defined, and the results demonstrated that SI-SSI and
10 DI-SSI had different impacts on the risk of IH. DI-SSI
has a strong association with IH. I-SSI induces abnor-
mal collagen metabolism, and inhibits and delays the
fascial wound-healing process, especially in the prolif-
erative phase1,10,32 35 . DI-SSI may directly impair the
0 6 12 18 24 early wound-healing process in fascia by inducing the
Time after surgery (months) wound dehiscence to drain pus with weakening of the
No. at risk
healed wound. Optimal perioperative wound management
DI-SSI 61 54 42 20 14 is therefore recommended to reduce the incidence of I-SSI
SI-SSI 290 282 234 147 93 and minimize the incidence of IH27,36,37 .
No I-SSI 3576 3514 3040 1603 925 The present study showed that BMI and the thickness
of subcutaneous fat, as measured by CT, were independent
Fig. 2KaplanMeier analysis of incisional hernia (IH) in relation
to depth of incisional surgical-site infection (I-SSI). DI-SSI, deep risk factors for IH. Several studies12,13,18 20 have demon-
incisional surgical-site infection; SI-SSI, superficial incisional strated high BMI to be a risk factor for IH. A previous
surgical-site infection. P = 0001 (DI-SSI versus SI-SSI), Japanese study38 on I-SSI indicated that the thickness of
P < 0001 (DI-SSI versus no I-SSI) (log rank test) subcutaneous fat, but not BMI, was an independent risk
factor for I-SSI in elective colorectal surgery. The present
study provides further evidence that thick subcutaneous fat
with SI-SSI and with DI-SSI were 46, 101 and 20 per is significantly associated with IH.
cent respectively at 12 months, and 98, 143 and 24 per For abdominal surgery in general, the type of incision is
cent at 24 months. Compared with patients without I-SSI, chosen according to the surgical philosophy and the sur-
the univariable Cox proportional hazards model for IH geons preference. A midline incision is used most com-
occurrence showed a HR of 171 (95 per cent c.i. 122 to monly, because it allows easy access to the abdominal cav-
241; P = 0002) for patients with SI-SSI and 332 (190 to ity. This study demonstrated that patients operated on
580; P < 0001) for patients with DI-SSI. with a midline incision had a higher incidence of IH than

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Incidence of incisional hernia after abdominal surgery
those who had a non-midline incision. In support, a recent
meta-analysis39 found that the incidence of IH in patients
with a midline incision was higher than that in patients with
transverse and paramedian incisions. The exact mechanism
for this difference in incidence is unknown.
Preoperative chemotherapy and intraoperative blood
transfusion are known to induce immunosuppression40,41 ,
which may render patients susceptible to infection and
impair the tissue-healing process20,42 . Advanced age is
also associated with delayed wound healing and decreased
collagen synthesis11 . A few Western reports11,18,19 have
shown male sex to be an independent risk factor for IH.
In contrast, a Korean series14 and the present study, indi-
cated that female sex is a significant risk factor. These
discrepancies may be due to different patient populations
with different BMI, different lifestyles, and variations in
gene expression related to the wound-healing process and
collagen metabolism10,34,43 .
The standard for fascial closure is a continuous suture
using absorbable monofilament1,3,19,25 . However, an inter-
rupted absorbable braid suture was used most commonly
in the present study. Nevertheless, the results of this study
suggested that the suture materials and methods had no sig-
nificant impact on the incidence of IH.
A major limitation of the present study was the length
of follow-up. Although all patients were followed for at
least 180 days, the optimal follow-up interval to deter-
mine the incidence of IH is controversial. Follow-up
periods in previous studies12,16,17,19,23,24,31 were variable,
ranging from 3 months to 3 years. A recent prospective
study31 found that the incidence of IH increased in a
time-dependent manner, and the authors concluded that
3 years of follow-up was mandatory when evaluating IH.
Another long-term study15 , which compared laparoscopic
with open surgery for rectal cancer, demonstrated that inci-
dence of IH plateaued within 3 years after surgery. In a
retrospective Japanese study20 with a median follow-up of
52 months, 27 of 48 patients with IH were diagnosed within
9 months of operation, with only five patients being diag-
nosed after 12 months. Based on this study20 , the minimum
follow-up period in the present investigation was set to at
least 180 days.
Other limitations of the present study were that the col-
lected data did not include some potentially important fac-
tors such as nutrition, co-morbidities, use of postoperative
chemotherapy and radiotherapy, and tumour recurrence in
patients with malignant disease. Other important factors
not included were wound complications, such as wound
dehiscence, seroma and haematoma, and the number, loca-
tion and time-dependent growth rate of the abdominal
defects. This study included only Japanese patients, and
2014 BJS Society Ltd
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1445
the Japanese population is known to differ from the West-
ern population in a variety of aspects. Thus, it is uncertain
whether the results of this study can be extrapolated to
Western populations.
This study found several risk factors for IH after abdom-
inal surgery. I-SSI, especially DI-SSI, was strongly associ-
ated with the incidence of IH and is of importance because
this complication is potentially preventable.
Contributors
The following investigators also participated in this
study: A. Ishikawa (Department of Surgery, Chubu Rosai
Hospital); A. Akutagawa (Nagoya Ekisaikai Hospital); A.
Morioka, H. Matsuba and Y. Asaba (Kumiai Kosei Hos-
pital); E. Takeuchi (Japanese Red Cross Nagoya Daiichi
Hospital); H. Hasegawa and S. Komatsu (Japanese Red
Cross Nagoya Daini Hospital); K. Shirai (Yamashita Hos-
pital); M. Kato and A. Okajima (Kamiiida Daiichi General
Hospital); M. Terasaki and K. Suzumura (Shizuoka Sai-
seikai General Hospital); M. Momiyama (Tokai Hospital);
M. Kanai and K. Aizu (Kasugai Municipal Hospital); S.
Kamiya (Tsushima City Hospital); S. Iyomasa, Y. Mokuno
and H. Matsubara (Yachiyo Hospital); S. Ohira (Handa
City Hospital); T. Kato, H. Yamada and T. Aoba (Toyo-
hashi Municipal Hospital); T. Arai and H. Goto (Anjo
Kosei Hospital); Y. Fukami (Toyota Kosei Hospital); Y.
Tanimura and N. Yamaguchi (Social Insurance Chukyo
Hospital); and Y. Kaneoka, K. Shibata, M. Sunagawa and
Y. Yonekawa (Ogaki Municipal Hospital).
Acknowledgements
Ethicon Japan KK gives financial support to Nagoya Uni-
versity Graduate School as the fund of the Division of
Surgical Infection, Nagoya University Graduate School of
Medicine, which employs K.I., Y.Y. and G.S.
Disclosure: The authors declare no conflict of interest.
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