What are the symptoms and treatment options for an epigastric ventral hernia?

Epigastric Ventral Hernia: Symptoms and Treatment

Clinical Presentation and Symptoms

Epigastric hernias often present with non-distinct symptomatology, making clinical diagnosis challenging, though they may manifest with epigastric pain, a palpable mass, or remain asymptomatic until complications develop. 1

Common Presentations:

• Epigastric pain or discomfort - the most frequent presenting symptom 1, 2
• Palpable midline mass above the umbilicus, though small hernias (15-25 mm) may be difficult to detect on physical examination 1
• Asymptomatic discovery during imaging for other conditions 1
• Multiple hernias occur in 20% of cases, requiring evaluation of the entire linea alba 1

Complicated Presentations Requiring Urgent Attention:

• Incarceration symptoms: irreducible swelling, increasing pain, nausea/vomiting 3, 4
• Strangulation indicators: severe pain, systemic inflammatory response syndrome (SIRS), skin changes over the hernia (redness, discoloration) 3
• Laboratory abnormalities: elevated lactate (≥2.0 mmol/L), elevated WBC, elevated fibrinogen, elevated CPK, elevated D-dimer 5, 3
• Symptoms persisting >8 hours are associated with significantly higher morbidity 3

Diagnostic Approach:

• Ultrasound demonstrates 100% sensitivity for detecting epigastric hernias and is extremely effective for evaluating the entire linea alba 1
• CT scanning with contrast is the gold standard for complicated cases, with reduced wall enhancement being the most significant predictor of bowel strangulation (56% sensitivity, 94% specificity) 5

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Treatment Strategy

Surgical repair is the definitive treatment for epigastric hernias, with mesh reinforcement significantly reducing recurrence rates compared to primary tissue repair, though the approach must be tailored to hernia size, complexity, and presence of complications. 3, 6

Uncomplicated Epigastric Hernias:

Small Hernias (<3 cm):

• Direct anatomical repair without mesh is acceptable for small, simple defects when sutures are placed in the correct direction 1
• Mesh reinforcement is preferred even for small defects to minimize recurrence risk 3, 6
• General anesthesia with opening of the peritoneal sac to lyse adhesions is recommended 1

Large or Voluminous Hernias (5-10 cm):

• Properitoneal mesh placement (polypropylene) is indicated for large, multiple, or recurrent hernias 1
• Mesh should overlap the defect edge by 1.5-2.5 cm for adequate coverage 5
• Laparoscopic or robotic approaches provide unique technical advantages for mesh placement 6

Complicated Epigastric Hernias:

Incarcerated Hernias (Without Strangulation):

• Laparoscopic repair is feasible and safe with lower wound infection rates and shorter hospital stays 5, 3
• Synthetic mesh can be safely used in clean-contaminated fields (CDC Class II) without increased 30-day morbidity 5, 3
• Manual reduction may be considered if onset is recent (<24 hours), no signs of strangulation present, and minimal pain 3

Strangulated Hernias Requiring Bowel Resection:

Emergency surgical repair is mandatory immediately upon diagnosis, as delayed treatment beyond 24 hours significantly increases mortality. 3

• Clean-contaminated fields (CDC Class II): Synthetic mesh can be safely used even with intestinal resection if there is no gross enteric spillage 5, 3
• Contaminated/dirty fields (CDC Class III-IV):
  • Primary repair for small defects (<3 cm) with bowel necrosis or gross spillage 3
  • Biological mesh (preferably cross-linked) for larger defects when direct suture is not feasible 5, 3
  • Polyglactin mesh as alternative when biological mesh unavailable 3
• Open preperitoneal approach is preferable when bowel resection is anticipated 5
• Diagnostic laparoscopy (hernioscopy) is useful for assessing bowel viability after spontaneous reduction 5, 3

Unstable Patients:

• Open management with damage control principles to prevent abdominal compartment syndrome 5
• Intraoperative intra-abdominal pressure monitoring may be measured to assess clinical severity 5

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Critical Pitfalls to Avoid

• Never use absorbable prosthetic materials as they lead to inevitable hernia recurrence due to complete dissolution 3
• Do not delay surgery in strangulated cases - elapsed time from symptom onset to surgery is the most important prognostic factor (P<0.005) 3
• Avoid synthetic mesh in contaminated fields (CDC Class III) where infection rates can reach 21% 3
• Always evaluate the entire linea alba as 20% of epigastric hernias are multiple 1
• Do not assume small hernias are benign - even small defects can incarcerate bowel loops, though this is rare 4

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Watchful Waiting Considerations

For asymptomatic or minimally symptomatic uncomplicated epigastric hernias, watchful waiting appears to be a safe strategy with only 16% requiring surgical repair and 4% requiring emergency repair after 5 years. 7

• Patients must be educated on red flag symptoms requiring immediate return: increasing pain, irreducibility, vomiting 3
• This approach is only appropriate for uncomplicated hernias without signs of incarceration or strangulation 7