Epigastric Hernia

An epigastric hernia is a primary midline defect through the linea alba between the xiphoid process and umbilicus.

Most are small and contain preperitoneal fat rather than bowel. Multiple small defects may coexist.

Pain can arise from incarceration of preperitoneal fat even when the external swelling is tiny.

Rectus diastasis frequently coexists but is not itself a true hernia because the linea alba remains intact.

Typical presentation is a small midline upper abdominal lump with focal discomfort, particularly during lifting, exercise or increased intra abdominal pressure.

A small painful defect may be easier to palpate while standing or during Valsalva.

Many epigastric hernias are nonreducible because incarcerated preperitoneal fat occupies the defect.

Bowel obstruction is uncommon but can occur in larger defects containing bowel.

Diagnosis is clinical in most patients.

Ultrasound: useful for a small painful midline lesion when examination is uncertain.

CT: reserve for large, recurrent, multiple or anatomically complex defects.

Distinguish a true fascial defect from rectus diastasis.

Repair symptomatic epigastric hernias.

Mesh reinforcement substantially reduces recurrence and is preferred for most clinically significant adult defects. An open preperitoneal flat mesh repair is suitable for many cases.

Small defects can occasionally undergo primary suture repair after considering defect size, tissue quality and recurrence risk.

Large defects or patients with high wound morbidity risk may benefit from minimally invasive repair.

When multiple small defects are present, inspect the surrounding linea alba sufficiently to avoid leaving a second clinically important defect untreated.

Associated rectus diastasis increases recurrence risk after isolated suture closure and should influence repair planning.