Incisional hernia may not dent quality of life after colorectal cancer surgery, trial suggests

For patients recovering from colorectal cancer surgery, few long-term complications are as feared as the incisional hernia, a bulge that forms when the abdominal wall fails to heal fully along the line of the surgical incision. Surgeons have long assumed that this common complication carries a heavy toll on patients’ everyday lives, driving pain, stiffness and body-image distress years after the operation. But a new longitudinal analysis from the Rein4CeTo1 randomized clinical trial, published in the Journal of Abdominal Wall Surgery, challenges that assumption with a finding that is likely to spark debate across surgical departments worldwide: patients who developed an incisional hernia after colorectal cancer surgery reported quality of life and abdominal wall symptoms that were statistically indistinguishable from those who did not.

The study, led by Charlotta L. Wenzelberg and colleagues at Lund University and Skåne University Hospital in Malmö, Sweden, followed patients who had undergone elective open colorectal cancer surgery through a midline incision between 2017 and 2021. The researchers tracked two clinically meaningful time points, one year and three years after the operation, using CT scans performed at 12 plus or minus 3 months and 36 plus or minus 3 months to diagnose incisional hernia with radiological precision rather than relying on physical examination alone. Of the 160 patients originally randomized in the parent trial, 134 were eligible for the one-year follow-up, and 119 of them, or 89 percent, completed the questionnaires. At three years, 81 of the remaining 101 patients, or 80 percent, filled out the same instruments, with 78 patients answering on both occasions.

The technical backbone of the assessment rested on two complementary questionnaires. The first, the EQ-5D-5L developed by the EuroQol Group, is a generic health-related quality of life instrument that probes five dimensions: mobility, self-care, usual activities, pain and discomfort, and anxiety and depression. Each dimension is graded on five levels, from no problems to extreme problems, generating one of 3,125 possible health states that can be converted into a single index value between 1, the best imaginable health, and 0, the worst. The instrument also includes a visual analogue scale on which patients rate their overall health from 0 to 100. The second tool was a slightly modified version of the Ventral Hernia Pain Questionnaire, a disease-specific instrument consisting of 19 questions that cover the intensity, frequency and duration of pain, its impact on daily activities and medication use, work limitation, subsequent operations and patient satisfaction. Pain was graded on a seven-point scale, with grades 1 and 2 defined as ignorable and grade 3 or worse as non-ignorable.

The results were striking in their consistency. At one year, the mean EQ-5D-5L scores showed no significant difference between patients with and without an incisional hernia, with a p-value of 0.276. At three years the picture was the same, with a p-value of 0.404. Mean scores for every dimension hovered between 1 and 1.7, corresponding to problems between none and slight, and the distribution of responses did not deviate from Swedish population characteristics except for a possibly larger share of patients reporting lower levels in the usual activities and pain and discomfort dimensions. The mean EQ-VAS scores, 78 at one year and 77 at three years, matched the Swedish norm of 76.1 almost exactly. Even when the researchers excluded small hernias under 2 centimeters, which lack fascial extrusion and were presumed less clinically significant, the remaining larger hernias were not found to be an independent risk factor for impaired quality of life.

The disease-specific questionnaire told a similarly reassuring story. Non-ignorable pain right now was reported by just 5.0 percent of patients at one year and 1.2 percent at three years, while the corresponding figures for non-ignorable pain over the last week were 3.4 percent and 2.5 percent. Sensation of stiffness in the abdominal wall was present in 11.0 percent at one year and 7.4 percent at three years, and other discomforting symptoms were reported by 11.9 percent and 6.3 percent respectively. Pain was generally occasional or occurred several times a week, lasted minutes to hours, had low impact on daily activities and hardly ever required analgesic medication. No patient was on sick leave because of pain at the time of follow-up, a finding partly explained by the fact that 55 percent of the cohort was retired at one year and 70 percent at three years.

Perhaps most intriguingly, patients were largely content with the outcome of their operation despite visible reminders of the surgery. About 23.5 percent regarded their scar as cosmetically disturbing at one year and 19.8 percent at three years, and roughly 10 percent experienced the appearance of their abdominal wall as somehow socially limiting at both time points. Yet 87.1 percent were satisfied with the result of their operation at one year, rising to 92.5 percent at three years. There were no differences at any follow-up occasion between the two surgical closure groups in the parent trial, one closed with a Reinforced Tension Line suture combined with the small bite 4:1 technique using polypropylene, the other with standard small bite 4:1 closure using polydioxanone, nor between patients with and without hernia.

The risk factor analysis, conducted with multivariable linear regression using the EQ-5D index as the outcome, produced the study’s most consequential finding. Incisional hernia, recurrence of colorectal cancer or new malignant disease, and the presence of a stoma were included as predefined potential risk factors. None emerged as an independent risk factor at one year. But at three years, the presence of a stoma was identified as an independent risk factor for impaired general quality of life, with a regression coefficient of minus 0.070, a 95 percent confidence interval of minus 0.117 to minus 0.022, and a p-value of 0.004. In the cohort, 68 of 119 patients, or 57 percent, had a stoma at one year and 40 of 78, or 51 percent, at three years. This aligns with a systematic review concluding that living with a colostomy negatively influences overall quality of life among colorectal cancer ostomates.

The findings contradict a body of previous research suggesting that incisional hernia does impair quality of life. A Danish register study indicated an additional decrease in quality of life among colorectal cancer patients who developed a hernia, measured with the disease-specific EORTC QLQ-C30 questionnaire. Other studies using the SF-36 instrument found reduced physical function in hernia patients, though not reduced general health, possibly due to limited statistical power. Randomized trials of hernia repair have shown improved and normalized quality of life after surgical correction, and abdominal wall reconstruction has been associated with significant overall improvement measured with the EQ-5D-5L. The Swedish authors suggest a possible explanation: general quality of life is a broad construct covering far more than abdominal wall symptoms, and colorectal cancer patients carry many other factors that affect their overall perception of health, so the presence or absence of a hernia may simply not dominate in this respect.

The study’s strengths include its prospective design, standardized inclusion criteria within a randomized controlled trial, and two recruiting centres, with ethics approval from the Regional Ethics Committee at Lund University and registration at ClinicalTrials.gov under NCT03390764. But the authors are candid about limitations. Quality of life and abdominal wall symptoms were secondary aims of the parent trial, and no power calculation was performed for these outcomes, raising the risk that the analysis was under-powered. A significant portion of patients were lost to follow-up, partly due to pandemic travel restrictions. And no preoperative questionnaire data exist, preventing evaluation of changes in quality of life from before surgery, a deliberate choice made because patients were enrolled the day before their operation, when preoperative anxiety was believed to distort questionnaire results.

The broader implication is that the surgical community may need to recalibrate how it weighs the incisional hernia threat in colorectal cancer patients, at least when it comes to patient-reported outcomes. The authors conclude that further studies are warranted in which quality of life assessment constitutes the primary aim, ideally with a single widely accepted assessment tool, which a 2021 systematic review noted is still lacking for abdominal wall hernia patients. Until then, the Rein4CeTo1 data suggest that for patients facing colorectal cancer surgery, the hernia that so often follows may be less of a burden on daily life than convention holds, while the stoma that many must live with remains the more decisive factor in how they feel three years on.

Subject of Research: Quality of life after incisional hernia following colorectal cancer surgery

Article Title: Impact of incisional hernia on quality of life after colorectal cancer surgery – results of the Rein4CeTo1 randomized clinical trial

Article References: Wenzelberg, C. L., Rönnow, C.-F., Petersson, U., & Rogmark, P. (2026). Impact of incisional hernia on quality of life after colorectal cancer surgery – results of the Rein4CeTo1 randomized clinical trial. Journal of Abdominal Wall Surgery, 5, Article 17039. https://doi.org/10.3389/jaws.2026.17039

Image Credits: AI Generated

DOI: 10.3389/jaws.2026.17039

Keywords: colorectal cancer, incisional hernia, quality of life, stoma, abdominal wall surgery, patient-reported outcomes, Rein4CeTo1, surgical complications, Impact, incisional, hernia, quality