What is the treatment for an asymptomatic epigastric hernia?

Treatment of Asymptomatic Fatty Hernia of Linea Alba (Epigastric Hernia)

Asymptomatic epigastric hernias can be safely managed with watchful waiting, as they have a low risk of complications, but surgical repair is recommended if symptoms develop or the hernia becomes complicated.

Understanding Epigastric Hernias

Epigastric hernias are defects in the linea alba above the umbilicus, representing approximately 0.35-1.5% of all abdominal hernias and 8% of midline hernias 1. These hernias:

• Are often small (15-25mm) but can become larger (5-10cm)
• May contain epiploic appendages or viscera in larger cases
• Can be multiple in about 20% of cases, requiring evaluation of the entire linea alba

Management Approach

Watchful Waiting for Asymptomatic Hernias

For truly asymptomatic epigastric hernias, watchful waiting is a reasonable approach:

• Similar to the management of asymptomatic inguinal hernias, where studies show no significant difference in pain scores and general health status between watchful waiting and surgical groups 2
• The risk of strangulation in asymptomatic hernias is relatively low
• Patient should be educated about potential warning signs that would necessitate medical attention

Indications for Surgical Intervention

Surgery is recommended when:

1. The hernia becomes symptomatic (pain, discomfort)
2. The hernia increases in size
3. Complications develop, such as:
   • Incarceration
   • Strangulation
   • Bowel obstruction

In case of complicated hernia, prompt manual reduction should be attempted, with emergency surgery needed for unsuccessful reduction 3.

Surgical Options

When surgery is indicated, the following approaches are recommended:

1. Open Repair

• Appropriate for small to moderate-sized defects
• Can be performed under local anesthesia in many cases
• Direct reconstruction without mesh may be sufficient for small defects 1
• Mesh augmentation recommended for:
  • Larger defects
  • Recurrent hernias
  • Multiple hernias

2. Minimally Invasive Approaches

For epigastric hernias with concomitant rectus abdominis diastasis, specialized techniques include:

• Endoscopic-assisted linea alba reconstruction (ELAR) with mesh augmentation 4
• Minimal invasive linea alba reconstruction (MILAR) with supraaponeurotic placement of a fully absorbable synthetic mesh 5

These techniques have shown good early results with low complication rates.

3. Prosthetic Repair Considerations

• Prosthetic repair is the treatment of choice for most abdominal wall hernias, including epigastric hernias 3
• In clean cases, non-absorbable mesh is preferred
• In contaminated surgical fields (perforation/bowel resection), suture repair is preferred due to risk of mesh infection 3
• Diagnostic laparoscopy may be useful to assess bowel viability after reduction of complicated hernias 3

Potential Complications and Follow-up

• Postoperative complications may include seroma, hematoma, wound infection, and mesh-related issues
• Two patients (1.4%) in one study required redo surgery for diffuse secondary bleeding 4
• Recurrence rates are generally low with proper technique
• Regular follow-up is recommended to monitor for recurrence or development of other hernias along the linea alba

Key Considerations

• Ultrasound has 100% sensitivity for diagnosing epigastric hernias and should be used to evaluate the entire linea alba 1
• Surgical repair technique should be selected based on hernia size, presence of diastasis recti, and surgeon expertise
• The direction of suture repair is important and should be tailored to the dimensions of the hernial defect 1

Remember that while watchful waiting is appropriate for asymptomatic epigastric hernias, patients should be informed that many will eventually develop symptoms requiring surgery, similar to the pattern observed with inguinal hernias where crossover from watchful waiting to surgery ranges from 23% to 72% 2.