Epigastric Hernia

An epigastric hernia happens when a weakness in the abdominal muscle allows the tissues of the abdomen to protrude through the muscle. An epigastric hernia is usually present at birth, and may heal without treatment as the infant grows and the abdominal muscles strengthen. An epigastric hernia is similar to a umbilical hernia, except the umbilical hernia forms around the belly button and the epigastric hernia is usually between the belly button and the chest.

An epigastric hernia is typically small enough that only the peritoneum, or the lining of the abdominal cavity, pushes through the muscle wall. In severe cases, portions of an organ may move through the rent in the muscle.

Epigastric hernia: Occurring between the navel and the lower part of the rib cage in the midline of the abdomen, epigastric hernias are composed usually of fatty tissue and rarely contain intestine. Formed in an area of relative weakness of the abdominal wall, these hernias are often painless and unable to be pushed back into the abdomen when first discovered.

A linea alba hernia protrudes anywhere between the xiphoid process and the umbilicus, but usually in the midline between these two structures. About 3-5% of people develop epigastric hernias. They are common between the ages of 20 and 50, and occur more often in men than in women. About 20% of the hernias are multiple and 80% occur just off the midline.

The epigastric hernia commences as a protrusion of extra-peritoneal fat where the linea alba is pierced by a small blood vessel. The swelling enlarges and drags a pouch of peritoneum with it. Frequently, the sac is empty or contains a small portion of greater omentum because the mouth of the hernia is usually small.

The patient with an epigastric hernia may be asymptomatic. The abdominal mass is discovered as part of a routine examination.

Clinical Features

The features in a symptomatic patient may include:

• pain - which varies from mild epigastric pain to a deep burning pain radiating to the back or the lower abdomen
• an abdominal mass - which may be palpable and tender
• abdominal bloating
• vomiting
• nausea
• aggravated by eating
• relieved by reclining so that the mass falls away from the anterior abdominal wall

Investigations;-

Diagnosis of an epigastric hernia is confirmed by any manoeuvre which increases intra-abdominal pressure and makes the mass bulge anteriorly. The mass is often difficult to palpate, so that ultrasound or a CT scan may be necessary.

   Epigastric hernia surgery

 Surgery should always be advised and preformed for Epigastric  Herniations of all sizes. Now it should be observed that whatever the size of the defect presents, one should always go for Tension-free repair with prosthesis implant. The days of Fascial Darning are over.

 1.     Anesthesia:- General anesthesia is employed.

2.     Suture material:- Non-absorbable Polypropylene for suture repair and implant fixation.

3.     Procedure:-

·         Draping should be done so as to expose Xiphisternum till umbilicus.( Wide area)

·         Incision:- Two types of incisions can be employed for the surgery viz. Vertical and Transverse. If the surgeon knows the defect of epigastric hernia that it is either solitary or multiple , then vertical incision should be taken. If the surgeon knows that the defect is solitary and small then a transverse incision should be taken as it helps for the cosmetic purpose. The latter heals well and securely.

·         Dissection:- The abdominal fat surrounding the fatty hernia is dissected and the hernia is freed from all directions upto neck. Sometimes the defect in Linea alba needs to be enlarged by incision on it. This should be done in opposite directions in lateral directions. All additional defects should be looked for and extension of incision on linea alba should be made. This is best done in vertical incisions.

·         Sac:- The neck of the sac is opened and the contents of the sac are returned to the abdomen. Now-a-days the whole sac along with the contents are reduced to the abdomen. It is seldom practiced to transfix the sac and excise it. However it should be completely observed that the contents and the sac are completely reduced to abdomen. There should be no constriction on the contents at all.

·         Other defects:- A strict lookout for other corresponding defects should be made and they are reduced effectively as well.

·         Prosthesis implant:- A suitable and available prosthesis should be implanted as INLAY ( in between the pre-peritoneal space ). It should be fixed to the aponeurosis by four anchoring sutures from inside out. The prosthesis should be covering the defect area and it should be at least 4 cms cover after defect line. The preperitneal space should be well prepared for this. There should be no kinking of the mesh material. The light weight mesh which is partly absorbable with large pores is preferred.

·         Closure of defect:- The defect is now closed with simple continuous or interrupted non-absorbable polypropylene sutures in adults and for children the PDS suture is preferred.

·         Drain:- The suction drain is placed so as to absorb the serous collection. This keeps the incision free of discharges.

·         Subcutaneous tissue:- The subcutaneous tissue is closed with absorbable sutures of surgeon’s preference. This is not mandatory. The subcutaneous tissue can be left without suturing.

·         Skin:- Skin is closed with non-absorbable sutures or staples,subcuticular sutures.

The surgery is more or less similar to Umbilical Hernia Surgery.

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