Management of 16.8mm Epigastric Hernia with Fat Content
Elective surgical repair with mesh is recommended for this 16.8mm epigastric hernia to prevent recurrence, using an open approach with preperitoneal flat mesh placement as the preferred technique. 1
Rationale for Surgical Intervention
Mesh repair is superior to simple suture repair for epigastric hernias, particularly for defects larger than 10mm, as it significantly reduces recurrence rates from 20% or higher down to single digits. 2, 1
The 16.8mm defect size places this hernia well above the 10mm threshold where mesh becomes essential—simple suture repair would create unacceptable tension and dramatically increase recurrence risk. 3, 1
Even though the hernia currently contains only preperitoneal fat, surgical correction prevents future complications including incarceration, strangulation, and the need for emergency surgery with significantly higher mortality risk. 4
Optimal Surgical Technique
Open Preperitoneal Mesh Repair (Preferred Approach)
The open approach with preperitoneal flat mesh placement is the gold standard for umbilical and epigastric hernias of this size, offering excellent outcomes with low complication rates. 1
The peritoneal sac should be opened during repair to release any adhesions, even when only fat is present, as this reduces the risk of postoperative complications. 5
Polypropylene mesh should be placed in the preperitoneal space without artificially enlarging the fascial defect, using a tension-free repair technique. 2, 5
The mesh should be customized to the patient's defect size and secured with a one-layer running suture to avoid creating unnecessary tension. 2
Laparoscopic Approach (Alternative)
Laparoscopic repair may be considered if the patient has increased risk factors for wound morbidity (obesity, diabetes, immunosuppression) or if there are concerns about wound healing. 1
Recent evidence suggests fibrin sealant fixation may be superior to traditional fixation methods in laparoscopic repair, and fascial defect closure is recommended. 3
Critical Preoperative Considerations
The entire linea alba must be evaluated because 20% of epigastric hernias are multiple—ultrasound has 100% sensitivity for detecting additional defects and should be performed preoperatively. 5
The patient should be medically optimized before elective surgery, with particular attention to controlling diabetes, achieving weight optimization, smoking cessation, and managing any immunosuppression. 4
General anesthesia is recommended for this repair to allow proper exploration of the peritoneal cavity and adequate mesh placement. 5
Why Simple Suture Repair is Inadequate
Simple suture repair for a 16.8mm defect would result in unacceptable recurrence rates of 20% or higher, as the Mayo technique and its variations have failed the test of time. 2
For defects smaller than 10mm, suture repair may be acceptable, but this 16.8mm hernia clearly exceeds that threshold. 3, 1
The recurrence rate after simple suture in umbilical/epigastric hernias ranges from 3-21%, compared to significantly lower rates with mesh repair. 6
Expected Outcomes and Follow-up
Mesh repair of epigastric hernias shows excellent safety profiles with very rare and minor complications when performed electively. 2
Early postoperative complications occur in approximately 4-6% of mesh repairs, which is comparable to or lower than simple suture techniques. 6
The patient must be educated to seek immediate surgical attention if signs of incarceration develop (irreducible hernia, severe pain, obstipation) or strangulation (severe pain, discoloration, systemic symptoms), as these require emergency intervention. 7, 4
Common Pitfalls to Avoid
Never perform simple suture repair for defects larger than 10mm—this creates excessive tension and virtually guarantees recurrence. 3, 1
Do not artificially enlarge the fascial defect during repair, as this increases the size of the area requiring mesh coverage and may compromise outcomes. 2
Ensure complete evaluation of the linea alba to avoid missing additional hernias that would lead to apparent "recurrence" at a different site. 5
Avoid delaying repair in symptomatic patients, as emergency repair carries significantly higher morbidity and mortality compared to elective intervention. 4