Treatment of Epigastric Hernia

Surgical repair with mesh is the recommended treatment for epigastric hernias to reduce recurrence rates. 1

Diagnosis and Assessment

Epigastric hernias account for 0.35-1.5% of abdominal hernias and 8% of midline hernias, often ranging from small (15-25mm) to large (5-10cm) 2
Approximately 20% of epigastric hernias are multiple, requiring assessment of the entire linea alba 2
Ultrasound scanning shows 100% sensitivity for diagnosing epigastric hernias 2
CT scan or fluoroscopy may be indicated when complications are suspected, particularly in cases of incarceration or strangulation 3

Open approach with preperitoneal flat mesh placement is the primary recommendation for most epigastric hernias 1
For defects that can be closed without tension, primary repair with non-absorbable sutures should be attempted 3
For defects larger than 3 cm, mesh reinforcement is strongly recommended due to high recurrence rates (up to 42%) with primary repair alone 3

In clean surgical fields (CDC wound class I), synthetic mesh is recommended for repair 3
For larger defects (>8 cm or area >20 cm²), mesh should overlap the defect edge by 1.5-2.5 cm 3
In contaminated fields (CDC wound class III or IV), biological or biosynthetic meshes are preferred due to higher resistance to infections 3
Mesh can be fixed using tackers or transfascial sutures, but tackers should be avoided near vital structures 3

For stable patients with uncomplicated epigastric hernias, minimally invasive (laparoscopic) approach may be considered, especially for larger defects 3
For unstable patients or those with suspected strangulation, an open approach is preferred 3
In cases of intestinal strangulation requiring bowel resection, primary repair is recommended when the defect is small (<3 cm) 3

Patients with suspected intestinal strangulation should undergo emergency hernia repair immediately 3
For unstable patients experiencing severe sepsis or septic shock, open management is recommended to prevent abdominal compartment syndrome 3
In cases requiring damage control surgery, delayed closure should be considered after patient stabilization 3

Mesh repair is associated with significantly lower recurrence rates compared to primary suture repair 4, 1
Early complications are slightly more frequent in larger hernias and in patients with type 2 diabetes 4
Recurrence rates increase with older age, increased size of the hernial sac and fascial defect 4

Always open the peritoneal sac during repair to check for and loosen possible adhesions 2
For incarcerated hernias, the constricting ring may need to be enlarged to safely reduce the contents 5
In recurring epigastric hernias, mesh repair is strongly recommended regardless of defect size 2
Local anesthesia can be used for emergency hernia repair in the absence of bowel gangrene, providing effective anesthesia with fewer postoperative complications 3