Chapter 364 Epigastric Hernia
Epigastric hernias are ventral hernias in the midline of the abdominal wall between the xyphoid and the umbilicus. Epigastric hernias result from defects in the decussating fibers of the linea alba and are more likely congenital than acquired. Most epigastric hernias are small and asymptomatic; therefore, the true incidence is unknown, but the reported incidence in childhood varies from <1% to as high as 5%. Epigastric hernias may be single or multiple and are 2-3 times more common in males than females. The defect typically contains only preperitoneal fat without a peritoneal sac or abdominal viscera. Epigastric (incisional) hernias can occur in a previous incision site or be associated with ventricular-peritoneal shunts.
Epigastric hernias typically appear in young children as a visible or palpable mass in the midline, between the umbilicus and the xyphoid, noted by the parents or primary care practitioner. The mass is almost always small (<1 cm) and asymptomatic. The mass is typically present at all times but most apparent at times of irritability or straining. Occasionally, the mass is intermittent and the child relates pain localized to the site of the hernia. Physical examination demonstrates a firm mass, directly in the midline, anywhere between the umbilicus and the xyphoid. Epigastric hernias typically contain only preperitoneal fat and are not reducible due to the small size of the fascial defect. Rarely, a fascial defect is noted without a palpable mass. The mass may be intermittent if the fat reduces with relaxation of the abdominal muscles. Herniation of intestines or abdominal viscera in an epigastric hernia would be exceptionally rare. The mass may be tender to examination, but strangulation of the hernia contents is uncommon. Physical examination is almost always diagnostic and imaging studies are unnecessary.
The natural history of epigastric hernias is for gradual enlargement over time as intermittently more preperitoneal fat is extruded through the defect at times of straining or increased intra-abdominal pressure. Left untreated, the defect can enlarge and allow herniation of intra-abdominal viscera within a peritoneal sac. Epigastric hernias do not resolve spontaneously, and therefore operative repair is the recommended treatment.
The site should be carefully marked preoperatively because the mass and defect can be difficult to localize after induction of anesthesia. A limited transverse incision is made over the mass and dissection is performed to delineate the edges of the fascial defect. If herniated fat is present, it is dissected free of the subcutaneous tissues and can be reduced or ligated and excised. The defect is closed using absorbable suture. The skin is closed with an absorbable subcuticular suture. Postoperative complications are rare and the recurrence rate is low.
364.1 Incisional Hernia
Hernia formation at the site of a previous laparotomy is uncommon in childhood. Factors associated with an increased risk of incisional hernia include increased intra-abdominal pressure, wound infection, and midline incision. Transverse abdominal incisions are favored because of their increased strength and blood supply, which reduce the likelihood of wound infection and incisional hernia. Although most incisional hernias require repair, operation should be deferred until the child is in optimal medical condition. Some incisional hernias resolve, especially those occurring in infants. Some recommend elastic bandaging to discourage enlargement of the hernia and to promote spontaneous healing. Newborns with abdominal wall defects represent the largest group of children with incisional hernias. Initial management should be conservative, with repair deferred until about 1 yr of age. Incarceration is very uncommon but is an indication for prompt repair.
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