Management of Reducible Epigastric Hernia Causing Nausea and Vomiting
A reducible epigastric hernia causing symptomatic nausea and vomiting requires elective surgical repair, as these symptoms indicate the hernia is clinically significant and at risk for future incarceration or strangulation, even though it is currently reducible.
Initial Assessment and Stabilization
Confirm reducibility through physical examination by attempting manual reduction of the hernia with the patient in supine position, which distinguishes this from an incarcerated hernia requiring urgent intervention 1
Assess for signs of strangulation including severe pain, fever, elevated white blood cell count (>11,000), elevated lactate (≥2.0 mmol/L), or CT findings of reduced bowel wall enhancement, which would change management to emergent surgery 1
Obtain imaging with ultrasound or CT scan to evaluate the hernia defect size, contents (preperitoneal fat, omentum, or bowel), and to identify multiple defects along the linea alba, which occur in 20% of epigastric hernias 2
Symptomatic Management Prior to Surgery
Treat nausea and vomiting symptomatically with antiemetics such as dopamine receptor antagonists (metoclopramide, prochlorperazine) or serotonin antagonists, as these symptoms indicate the hernia is causing gastric outlet irritation or partial obstruction 1, 3
Provide dietary modifications including small, frequent meals and avoidance of foods that increase intra-abdominal pressure 3
Avoid manual reduction attempts in the outpatient setting if the hernia spontaneously reduces, as repeated incarceration and reduction can lead to bowel injury 1
Definitive Surgical Management
The presence of nausea and vomiting from a reducible epigastric hernia is an indication for elective surgical repair rather than watchful waiting, as symptomatic hernias have higher rates of future complications 1, 2
Surgical Approach:
Perform open repair under general anesthesia with exploration of the entire linea alba to identify multiple defects, opening the peritoneal sac to release any adhesions 2
Use mesh reinforcement for larger defects (>5 cm) or recurrent hernias with polypropylene mesh placed in the preperitoneal position, while smaller primary hernias can undergo direct anatomical repair with proper suture technique 2
Laparoscopic repair is an acceptable alternative for incarcerated ventral hernias in the absence of suspected bowel necrosis, with careful bowel reduction and adhesiolysis using a 5-cm mesh overlap 1
Critical Pitfalls to Avoid
Do not delay surgical referral in symptomatic patients, as the presence of nausea and vomiting indicates the hernia is causing functional obstruction and is at higher risk for future incarceration with potential bowel compromise 4
Do not assume small size equals low risk, as epigastric hernias are typically small (15-25 mm) but can still incarcerate bowel loops, particularly when symptomatic 2, 4
Do not miss concomitant pathology such as peptic ulcer disease or gastritis that may coexist with the hernia and contribute to symptoms; consider upper endoscopy if symptoms persist post-reduction 1, 5
Timing of Surgery
Schedule elective repair within 2-4 weeks for symptomatic reducible hernias to prevent progression to incarceration, which would require emergency surgery with higher morbidity and mortality rates (up to 30% for perforated bowel) 1