Epigastric hernia, or upper abdominal hernia, is a gap above the umbilicus in the midline (lina alba). Due to a widened midline (rectus diastse), these hernias occur more frequently and fat, and in large hernias, intestinal loops may bulge.
This is a hernia gap in an area above the navel and below the sternum. Therefore, this type of hernia is also called an upper abdominal hernia.
Between the straight abdominal muscles (Musculus rectus abdominus) there is a layer of connective tissue (Linea alba) in which gaps can form preferentially.
This occurs preferentially in rectus diastasis, in which the linea alba can widen over 2cm to as much as 5 or 7cm.
A rectus diastasis is increasingly observed in women who have given birth to 2 or more children or after multiple pregnancies. Men with a so-called "beer belly" also tend to have it and more often have hernias in this region.
For experienced surgeons, a glance is enough for a diagnosis. When standing, a small bump appears above the navel, which recedes when lying down and emerges again when pressing.
If the findings are unclear, an ultrasound examination (sonography) can be performed. In the case of very large hernias or before planning an operation, a computer tomography (CT) or magnetic resonance imaging (MRI) can also be performed. In this case, MRI is always preferable due to the absence of radiation exposure.
We always perform an ultrasound examination before surgery to rule out other hernias and rectus diastasis.
Patients with a new hernia of the abdominal wall who are older than 50 years and who have not yet had a colonoscopy should definitely undergo this examination as a preventive examination before surgery in order to rule out an intestinal tumor.
IMPORTANT: Screening colonoscopy is recommended for men over 50 years of age and for women 55 years of age, and the costs are covered in full by public and private health insurance companies.
Patients often have no complaints, i.e. are asymptomatic. Many are not even aware that a hernia is present. Epigastric hernia is also frequently confused with benign fatty tissue tumors (lipomas) or rectus diastasis.
In addition to the aesthetic problem, there is more often a rather pulling discomfort in the upper abdominal area with radiation into the navel. This can be particularly aggravated during exercise or sports activities.
As with the umbilical hernia, an epigastric hernia can also become stuck (incarceration). When this happens, most of the time some fatty tissue gets stuck and swells a lot, causing inflammation, which is very painful. Because of the pain and inflammation, this is an emergency that should also be operated on quickly because of the pain.
The probability of incarceration is about 6-8% with an existing epigastric hernia during life.
If bowel is incarcerated, it is always a life-threatening emergency that requires surgery within 6 hours. Patients experience severe abdominal pain with nausea and vomiting. Fortunately, this is very rare.
The surgical method is very dependent on the size of the epigastric hernia and any associated hernias.
These epigastric hernias are usually treated with a suture that does not dissolve. A plastic mesh is not necessary. Standard is the outpatient (without overnight stay) surgery in a doctor's office.
For this purpose, a small incision of about 2cm is made in the midline above the navel. The gap in the firm connective tissue (fascia) is closed with several sutures that do not dissolve. The skin is sutured with a thread over it, which dissolves. Stitches do not need to be removed.
According to the guidelines, a mesh should be inserted here for hernias over 1 cm. This can be inserted under the abdominal wall in the abdominal cavity as an IPOM or between the peritoneum and the abdominal wall as a PUMP.
For hernias less than 1.5cm, mesh insertion should always depend on circumstances such as rectus diastasis, age, and the strength of the connective tissue. Standard here is also the outpatient (without overnight stay) operation e.g. in a surgery, in case of risk factors in a hospital.
Here, too, a small longitudinal incision of about 3cm is made above the navel. The mesh is inserted and the gap in the firm connective tissue (fascia) is closed with several sutures that do not dissolve. The skin is sutured with a thread over it, which dissolves. Stitches do not need to be removed.
In the case of mesh inserts, we recommend wearing an abdominal bandage for 4-6 weeks.
A mesh must always be inserted for these hernias. The meshes are considerably larger, up to 20 cm long and 15 cm wide, so that these operations are performed as in-patient operations in hospital.
The meshes are usually placed under the straight abdominal muscle using the sublay method. The MILOS method has become established in experienced centers, in which the meshes are inserted safely through small incisions. There is no contact of the mesh with the abdominal cavity.
In more obese and older patients, the minimally invasive keyhole technique as IPOM is also well possible. Because of the larger wound area, patients stay in the hospital for at least 2 nights.
Wearing an abdominal bandage for 6 weeks is recommended.
In the follow-up treatment of an eigastric hernia, wound healing is usually very good. There are much fewer wound infections compared to umbilical hernias. There is often a small bruise (hematoma) or accumulation of wound fluid (stroma), but this is harmless.
Infection is manifested by pain, swelling, hyperthermia, discharge, smell.
In this case, immediate presentation is required and can usually heal without problems after a small miracle opening and irrigation.
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