Refer All Confirmed Epigastric Hernias to a General Surgeon
All patients with a confirmed epigastric hernia should be referred to a general surgeon for evaluation and surgical management, regardless of hernia size or symptoms. This is the standard of care for abdominal wall hernias requiring operative intervention 1, 2.
Why Immediate Surgical Referral is Essential
The evidence strongly supports prompt surgical referral for several critical reasons:
Risk of strangulation: Even asymptomatic hernias carry a risk of incarceration and strangulation, which can lead to bowel resection (28% of cases) and mortality (4%) when delayed 1. Patients are often unaware of these risks—in one study, 75% of patients who developed strangulation had never been warned about this complication 1.
Misdiagnosis is common: Strangulated epigastric hernias are misdiagnosed by general practitioners in 33% of cases and by hospital registrars in 15% of cases, leading to dangerous delays in treatment 1. This underscores the importance of specialist evaluation.
Surgical expertise is required: Epigastric hernia repair has evolved significantly, with multiple surgical approaches available (open sublay, laparoscopic IPOM, eTEP, MILOS, preperitoneal flat mesh) depending on defect size, patient factors, and surgeon expertise 3, 2, 4.
Key Clinical Pitfalls to Avoid
Do not delay referral based on:
- Small hernia size (even 15-25 mm hernias require surgical evaluation) 5
- Lack of symptoms (the patient in one case had an asymptomatic hernia for 30 years before it incarcerated) 6
- Patient reluctance (37% of patients with strangulation were previously aware of their hernia but didn't understand the risks) 1
Critical warning: 20% of epigastric hernias are multiple, and the entire linea alba must be evaluated—something best assessed by a surgeon with appropriate imaging 5.
The Referral Should Be:
- Timely: Do not adopt a "watchful waiting" approach once the hernia is confirmed
- To a general surgeon: This is the appropriate specialist for all abdominal wall hernias 1, 2
- With clear documentation: Include hernia size, symptoms, and any imaging results (ultrasound has 100% sensitivity for epigastric hernias) 5
The surgeon will determine the optimal timing and technique for repair based on defect size, patient comorbidities, and institutional expertise 3, 2.