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Bowel complications in the abdominal wall, hernias, fistulae and specialist reconstruction.

From a simple groin lump to a complex enterocutaneous fistula, this guide explains what changes in the bowel and abdominal wall mean, when they are urgent, and how UK specialist teams manage them.

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A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Editorial team

    Written by our editorial team from the UK sources listed on each page.

  • 02

    Sourced from guidance

    Checked against BOMA, AWR consensus, ASGBI, NICE and specialist intestinal-failure unit standards, referenced at the end.

  • 03

    Current for 2026

    Reflects modern UK practice including component separation, biological mesh, SNAP fistula care and specialist intestinal-failure pathways.

Key facts

Bowel and abdominal wall at a glance.

The essentials, in plain English: what these problems are, the main types, and where in the UK they are treated.

  • What it covers

    Bowel complications that involve the abdominal wall: hernias, enterocutaneous and enteroatmospheric fistulae, mesh problems, parastomal hernias and loss of domain.

  • Hernia types

    Inguinal, femoral, umbilical, paraumbilical, epigastric, Spigelian, lumbar, obturator, incisional and parastomal, each with distinct risk profiles.

  • Fistula frameworks

    Classified by output (low under 200 mL/day, moderate 200 to 500, high over 500) and by anatomical origin (gastric, small bowel, colonic).

  • SNAP approach

    Sepsis control, Nutrition, Anatomy definition, Plan. The scaffold behind every UK intestinal-failure unit for complex fistula care.

  • Red flag

    A strangulated or obstructed hernia is a surgical emergency. Sudden severe pain, vomiting, distension or a tender irreducible lump needs A&E.

  • Where care happens

    Complex abdominal-wall reconstruction and enterocutaneous fistula work is centred at specialist UK units: St Mark's, Salford Royal, Leeds, Cambridge, Newcastle Freeman, Nottingham, Birmingham QE and Cardiff.

Why this guide matters

One family of problems, one coordinated plan.

Hernias, fistulae and mesh problems can look like separate issues, but they share the same surgical anatomy and often need the same specialist teams.

  • Elective is safer than emergency

    Planned hernia and abdominal-wall surgery carries far lower morbidity than emergency work on a strangulated or obstructed hernia. Early review matters.

  • SNAP is the scaffold

    For enterocutaneous fistulae, Sepsis, Nutrition, Anatomy and Plan is the framework used across UK intestinal-failure units. It puts safety before speed.

  • Specialist centres exist for a reason

    Complex abdominal-wall reconstruction, mesh removal and enterocutaneous fistula surgery all have better outcomes in dedicated MDT centres.

How the assessment is made

From first review to a definitive plan.

The steps a UK colorectal or complex-hernia team will normally follow, in order, so you know what to expect and why.

  1. 01

    Assessing

    Clinical examination

    A structured look at the hernia orifices, previous incisions, stoma sites, skin and any draining wound. Reducibility, tenderness and cough impulse are recorded.

  2. 02

    Assessing

    Bloods and inflammatory markers

    U and Es, LFTs, albumin, coagulation, CRP and cultures. Nutritional markers guide the intestinal-failure pathway.

  3. 03

    Assessing

    Nutritional assessment

    BMI, unintentional weight loss, prealbumin and dietitian review. Nutrition is a treatment, not an afterthought.

  4. 04

    Confirming

    CT abdomen and pelvis

    With oral or rectal contrast where appropriate, to map hernia contents, fistula tracts, collections and any obstruction.

  5. 05

    Confirming

    Fistulography or endoscopy

    Used to define the tract, identify the source loop of bowel and rule out distal obstruction that would keep a fistula open.

  6. 06

    Planning

    MRI for complex disease

    Preferred in Crohn's-related and perianal fistulae, and for complex pelvic or perineal tracts.

  7. 07

    Planning

    Specialist MDT referral

    Colorectal, upper GI, plastic surgery, stoma nurse, dietitian, interventional radiology and intensive care meet to agree the definitive plan.

Typical pathway: urgent issues in hours, complex reconstruction planned over months.

Presentation

What patients actually notice.

A visible lump, dragging pain, obstructive symptoms or enteric fluid through a scar. And the warning signs that mean it is time to escalate.

  • A visible or reducible lump

    A bulge in the groin, umbilicus, epigastrium or near a previous scar or stoma, often more prominent on standing or straining.

  • Localised pain or dragging

    A pulling or aching sensation, worse on lifting, coughing or at the end of the day, sometimes with skin changes over the sac.

  • Obstructive symptoms

    Colicky abdominal pain, distension, vomiting and absolute constipation suggest the hernia has trapped a loop of bowel.

  • Strangulation red flag

    A tender, irreducible, discoloured lump with severe pain, fever or shock is a surgical emergency. Go straight to A&E.

  • Enteric content through a wound

    Bile, faeculent fluid or gas from a surgical wound or drain site is diagnostic of an enterocutaneous fistula.

  • Skin excoriation and pain

    High-output small-bowel fistulae rapidly damage surrounding skin. Aggressive stoma-nurse-led skin care is central.

  • Dehydration and malnutrition

    Weight loss, thirst, oliguria, electrolyte disturbance and anaemia are common in moderate- and high-output fistulae.

  • Sepsis and peritonitis

    Fever, tachycardia, hypotension, guarding or new confusion point to intra-abdominal sepsis and need urgent hospital assessment.

Management

How these problems are treated in the UK.

Elective hernia repair when possible, urgent surgery when needed, and structured SNAP-based care for fistulae in a specialist intestinal-failure centre.

  • Elective hernia repair

    Laparoscopic, robotic or open mesh repair (TAPP or TEP inguinal, sublay or IPOM ventral). Planned surgery has far lower morbidity than emergency work.

  • Emergency hernia surgery

    Strangulated or obstructed hernias need urgent exploration, reduction and, where bowel is ischaemic, resection with primary anastomosis or stoma.

  • Component separation and AWR

    Transversus abdominis release (TAR) or anterior component separation with synthetic or biological mesh, at specialist abdominal-wall reconstruction centres.

  • Parastomal hernia repair

    Stoma nurse review, support garments and, when indicated, keyhole Sugarbaker or sublay mesh repair to restore function around the stoma.

  • SNAP fistula care

    Sepsis source control, nutritional optimisation, imaging-led anatomy definition and a delayed definitive plan, coordinated by an intestinal-failure unit.

  • Nutrition support

    Enteral feeding where feasible, oral supplements and parenteral nutrition for high-output or proximal fistulae, led by a specialist dietitian.

  • Skin and wound care

    Stoma-nurse-led pouching, barrier films, Manuka or silver dressings and negative-pressure wound therapy (NPWT) to protect and heal surrounding skin.

  • Mesh explantation and reconstruction

    Infected or eroded mesh is removed, sepsis controlled and the wall rebuilt, often with biological mesh, at a complex hernia MDT.

What this guide is based on

The sources behind every claim on this page.

UK national guidance, surgical society standards and specialist intestinal-failure unit consensus, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP or surgeon knows your history and can tell you which parts apply to you. If in doubt, get seen, and for red-flag symptoms go straight to A&E.

  • British Hernia Society and BOMA guidance on abdominal-wall hernia repair.

  • Abdominal Wall Reconstruction (AWR) international consensus statements.

  • ASGBI. Emergency general surgery and complex hernia standards.

  • NICE. Laparoscopic surgery for inguinal hernia repair (TA83) and related guidance.

  • Association of Surgeons of Great Britain and Ireland: Intestinal failure pathways and specialist unit standards.

Red flags

When symptoms need urgent attention.

Many hernias can wait for planned care. These are the situations that cannot, and where hospital assessment must not be delayed.

  • Strangulated hernia

    A tender, irreducible, discoloured lump with vomiting, severe pain or systemic upset is a surgical emergency. Call 999 or go straight to A&E.

  • Small bowel obstruction

    Colicky pain, distension, vomiting and absolute constipation, especially with a previous scar or known hernia, needs urgent hospital assessment.

  • Bowel perforation

    Sudden severe abdominal pain, board-like rigidity and shock, sometimes after NSAIDs, colonoscopy or trauma, is a peritonitis emergency.

  • Acute mesenteric ischaemia

    Severe pain out of proportion to examination findings, especially in older patients with atrial fibrillation, is a time-critical vascular emergency.

  • Enterocutaneous fistula with sepsis

    Enteric fluid through a wound alongside fever, tachycardia or confusion means undrained sepsis. Admission and source control are urgent.

  • Enteroatmospheric fistula

    Exposed bowel in an open abdomen after major surgery needs specialist intestinal-failure unit management from the outset.

  • Mesh infection or erosion

    Chronic sinus, discharging wound, fistulisation or unexplained pain after previous mesh repair warrants urgent surgical review.

  • Diverticular perforation and fistula

    Faeculent peritonitis, or new pneumaturia, faecaluria or vaginal passage of stool, points to a colovesical or colovaginal fistula and needs specialist input.

  • Loss of domain

    A chronic large ventral hernia containing much of the bowel outside the abdominal cavity needs planned assessment at an AWR centre before attempted repair.

Living with it

A treatable set of problems, with a clear pathway.

Four things that make the biggest difference: prehab, nutrition, skin care and knowing when to seek help.

A quiet reminder

Consistency beats intensity, every time.

Small, steady habits, kept up for months, do more than a heroic week that does not last.

  1. 01 Prehab

    Optimise before planned surgery

    Weight, smoking, glycaemic control and nutrition are all modifiable. Even a few focused weeks of prehab lowers complication rates.

  2. 02 Nutrition

    Treat food as medicine

    Adequate protein, energy and micronutrients drive healing. Work with a dietitian for enteral, oral or parenteral support as needed.

  3. 03 Skin

    Protect the skin around a stoma or wound

    Well-fitted pouching, barrier films and stoma-nurse review prevent excoriation and pain around stomas, fistulae and wounds.

  4. 04 Escalate

    Know when to seek help

    New pain, a change in a lump, obstructive symptoms or discharge from a scar should never be ignored. Early review is safer than waiting.

Frequently asked

Everything we get asked about bowel and abdominal wall problems.

Quick answers on hernias, fistulae, parastomal problems, mesh complications and the SNAP framework.

  • What are bowel complications in the abdominal wall?

    A group of conditions where the bowel and the abdominal wall interact abnormally: hernias containing bowel, enterocutaneous and enteroatmospheric fistulae, parastomal hernias, mesh problems after previous repair, loss of domain from chronic large hernias, and complications of diverticular disease, perforation and obstruction that involve the wall.

  • When is a hernia an emergency?

    A hernia becomes a surgical emergency when it is strangulated (blood supply cut off) or obstructed (bowel blocked inside the sac). Warning signs include a suddenly tender, irreducible lump, severe pain, vomiting, distension, absolute constipation, fever or shock. Call 999 or go to A&E rather than waiting.

  • What causes an enterocutaneous fistula?

    The commonest cause is previous abdominal surgery, particularly anastomotic breakdown or unrecognised bowel injury. Other causes include Crohn's disease, previous radiotherapy, malignancy, trauma and retained foreign body. A downstream obstruction, sepsis or malnutrition keeps a fistula open.

  • What is the SNAP approach?

    SNAP stands for Sepsis control, Nutrition, Anatomy and Plan. UK intestinal-failure units use it as the scaffold for complex enterocutaneous fistula care: drain collections and treat infection first, optimise nutrition, image and define the anatomy, and only then plan definitive surgery, usually at six to twelve months.

  • How common is a parastomal hernia?

    Very common. Up to half of patients with a colostomy, ileostomy or urostomy develop a parastomal hernia over time. Many are managed with a support garment and stoma-nurse review. Symptomatic or complicated hernias can be repaired laparoscopically using a Sugarbaker or keyhole mesh technique.

  • What happens if a previous mesh becomes infected?

    Infected or eroded mesh often needs removal, control of any sepsis and delayed reconstruction of the abdominal wall, sometimes with biological mesh. This work is best done in a specialist complex hernia MDT and typically involves colorectal, plastic and reconstructive surgeons alongside stoma and wound-care nurses.

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