What are the treatments for epigastric hernia?

• Epigastric hernias are hernias that occur 5 cm above the umbilicus, between the lowest edge of the sternum and the umbilicus.
• Epigastric hernias are the least common type of abdominal hernia, but are more common in men.
• To fix an epigastric hernia, hernioplasty surgery with surgical mesh is performed.

The word hernia comes from Latin and means rupture.

A hernia is the protrusion or protrusion of an organ or part of an organ through the wall of the abdominal cavity. A hernia occurs when there is a weakness or tear in the abdominal wall as a result of ageing, injury, an old surgical incision or a congenital condition.

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Hernias have 3 main parts: the hole in the abdominal wall through which the hernia protrudes, the hernia contents that protrude through the hole, and the hernia sac formed by the peritoneum.

Epigastric hernias are hernias that occur 5 cm above the umbilicus between the lowest edge of the sternum and the umbilicus and are caused by the emergence orifices of perforating vessels in the abdominal wall called Rieder's orifices. Fatty tissue or sometimes intra-abdominal structures protrude or protrude through these orifices.

Epigastric hernias are less frequent than the other types of abdominal hernias, accounting for 0.4 to 3.6 % of all hernias. They are more common in men, with a ratio of 3:1 in relation to women. These hernias occur in people between 30 and 60 years of age.

The factors that favour its development are mainly congenital and constitutional, such as diastasis of the anterior rectus abdominis muscles, obesity, diseases in which the volume of the abdomen increases and abnormal width of the vasculonervous orifices of the linea alba.

Normally in the midline of the abdomen above the umbilicus the aponeurotic fibres, i.e. a type of tendon located in this area, are cross-linked giving resistance to the wall in this area. 

People who develop epigastric hernia have a non-uniform and more separated cross-linking of the fibres, making it much easier for herniation to develop. The fragment of fat that is initially introduced into these orifices dilates the orifice and allows the peritoneum and intra-abdominal structures and organs to pass through, thus constituting a true epigastric hernia.

However, increased abdominal pressure also plays an important role in the development of this disease, which is why these hernias develop in individuals of robust build, who exert great bodily effort.

Epigastric hernias have three main types, depending on the content of the hernia:

• Adipose hernia: this is made up of a peloton of peritoneal fat. This form is the most common.
• Epigastric hernia with an uninhabited peritoneal sac, i.e. a sac is already formed but only contains peritoneum.
• Complete epigastric hernia: contains a fragment of omentum or sometimes reaches a larger volume with a segment of stomach, colon or small intestine.

Epigastric hernias present as a mass of variable size in the midline of the upper abdomen accompanied by mild to moderate pain that intensifies with exercise, coughing or by palpation. Adipose hernias are usually asymptomatic. 

Approximately 70-75 % of patients have no symptoms. However, when the hernia is complete, i.e. contains a fragment of omentum, very uncomfortable symptoms such as nausea, vomiting, pain radiating to the precordium and back will occur. The pain may be the result of compression of neighbouring organs.

Occasionally, the tissue or organ within the hernia sac becomes trapped (incarceration), in which case the blood supply to the hernia sac may be compromised (strangulation). The lack of blood supply can lead to tissue necrosis. In these cases there is severe pain in the region and there may be changes in skin colour, swelling and pain to the touch of the region.

When this occurs it is a medical emergency requiring immediate attention and urgent surgical intervention.

During the physical examination a round lump is observed in the supraumbilical midline. This lump shrinks when compressed and the round hernial orifice can be palpated. The patient presents with the characteristic symptoms of epigastric hernia. 

Other diseases can cause similar symptoms, so the differential diagnosis should always be made with a gastrointestinal ulcer, pancreatitis, and cholelithiasis.

The only treatment for epigastric hernia is surgery. Epigastric hernia does not go away on its own and there is no medication or treatment that can repair it. The hernia usually enlarges over time and can damage an abdominal viscera if these organs become trapped (strangulated hernia).

It is much safer to treat a hernia surgically before this happens than to treat it in an emergency situation. When the hernia is small (less than 3 cm) it can be done with sutures only, approximating the edges of the defect. 

In the case of larger hernias, it is advisable to place a mesh (prosthetic material that will cover the defect), thus reducing the possibility of recurrence. Surgery can be performed openly (through an incision in the navel) or laparoscopically (minimally invasive), both with excellent results.

In most cases it is an outpatient surgery, without the need for hospitalisation, and lasts approximately 30-40 minutes. 

Laparoscopic surgery generally lasts longer, approximately 90-120 minutes. 

The operation is performed under local or regional anaesthesia or under general anaesthesia according to the specialist's assessment. After disinfecting the skin of the abdomen, a longitudinal incision is made over the herniated lump. The incision extends deep into the hernia sac.

The contents of the hernia sac are placed back into the abdominal cavity and the hernia sac is resected and ligated. The abdominal wall defect is closed with sutures or, in the case of a large hernia, with the placement of a surgical mesh. If the defect is closed with sutures we speak of herniorrhaphy, and when the surgeon uses a mesh to cover the abdominal wall defect we speak of hernioplasty. 

Once the defect has been repaired, the surgical wound is closed. 

Total recovery time after epigastric hernia surgery is approximately 4 weeks. 

Once this time has elapsed, the patient will be able to resume normal daily activities.

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