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Epigastric hernia

 

  • An epigastric hernia is a protrusion of extraperitoneal fat, with or without a small sac of peritoneum through a defect in the linea alba anywhere between the xiphisternum and the umbilicus.

  • The defect is characteristically small, often about 1 cm in diameter.

  • Patients are frequently fit young males who present with epigastric pain, which may be confused with peptic ulceration or biliary disease.

  • The hernia is usually easier to feel than to see, and is diagnosed by palpation of a small, often very tender, lump in the linea alba.

  • Epigastric hernias are usually irreducible and may be multiple.

 

Treatment

  • Surgery is undertaken to relieve symptoms.

  • The hernia is marked pre-operatively because it may reduce with anaesthesia and the defect may be too small to palpate.

  • If there are multiple hernias, the linea alba is exposed through a vertical incision, the extraperitoneal fat is excised, and each defect is repaired.

  • A ‘keel’ repair of the linea alba is then performed by inserting two or more layers of sutures into the linea alba and anterior rectus sheath, each successive layer covering the previous layer so that the repaired tissue resembles the keel of a boat.

  • If a single defect is present, a transverse incision is usually made, and the defect is repaired with a ‘Mayo’ repair, in which the upper and lower edges of the defect are overlapped with interrupted sutures.

 

Umbilical/para-umbilical hernia

 

  • An umbilical hernia in a child is a congenital defect in which a peritoneal sac protrudes through a patent umbilical ring and is covered by normal skin.

  • About one-third of hernias close within a month of birth, and they rarely persist beyond the age of 3–4 years.

  • Umbilical hernias in children rarely become irreducible or strangulate.

  • A para-umbilical hernia in an adult is an acquired condition and quite distinct from the umbilical hernia of childhood.

  • A para-umbilical hernia protrudes through one side of the umbilical ring, while the umbilicus still retains its fibrous character within the linea alba.

  • Para-umbilical hernias initially contain extraperitoneal fat but, as the hernial orifice enlarges, omentum enters the sac. The contents typically adhere to the sac so that the hernia becomes loculated and irreducible.

  • Para-umbilical hernias occasionally become very large and contain transverse colon and small intestine.

 

Treatment

  • An expectant approach can be adopted for umbilical hernias in children as nearly all hernias close or greatly reduce in size. Repair is recommended for unusually large hernias or if the hernia is still present at school age.

  • Para-umbilical hernias are treated surgically because of the risk of obstruction, strangulation and, rarely, excoriation and ulceration of the skin overlying the hernia. The classic operative procedure is a Mayo repair, but repairs with mesh are performed increasingly.

 

Spigelian Hernia

  • Spigelian hernias are rare.

  • A Spigelian hernia occurs through the transversus abdominis aponeurosis of the anterior abdominal wall, usually below the level of the umbilicus.

  • A Spigelian hernia usually occurs at the widest and weakest point of the aponeurosis, which is about halfway between the umbilicus and the inguinal ligament.

  • Clinically, the diagnosis of a Spigelian hernia may be difficult. The patient, who typically is a middle-aged female, presents with diffuse aching pain in the area of the hernia, which is small and may not be palpable.

  • Pain is often present during the day but may recede at night if the hernia reduces, and may be made worse by raising the arm on the affected side.

  • If a lump is not palpable, the diagnosis may be confirmed by ultrasound or computed tomography scanning.

  • The hernia usually contains omentum but may contain small or large bowel.

  • A Richter’s hernia may occur, and obstruction and strangulation are well-recognised complications.

 

Treatment

  • Spigelian hernias should be treated surgically because of the severity of symptoms and the risk of complications.

  • A skin crease incision is made over the hernia, the sac is excised and the defect in the transversus abdominis aponeurosis is closed with non-absorbable sutures.

 

Lumbar hernia

  • Lumbar hernias are rare.

  • They occur typically in individuals with poor muscle tone, either spontaneously, or following trauma, surgery, or paralysis of paravertebral muscles secondary to poliomyelitis.

  • Differential diagnosis includes a lipoma, lumbar abscess or haematoma.

  • Lumbar hernias occur through two triangular sites of weakness in the lumbar region of the abdominal wall.

 

Treatment

  • Treatment of lumbar hernias is difficult because of their anatomical boundaries, their size, the type of patientnin whom they occur, and because they are bounded in part by muscle rather than tough aponeurotic tissue.

  • Prosthetic mesh repair is required.

 

Obturator hernia

  • An obturator hernia is rare.

  • It protrudes through the obturator canal.

  • When large, the hernial sac passes between the pectineus and adductor longus muscles and protrudes forwards to produce a diffuse bulge in the femoral triangle, where it can be mistaken for a femoral hernia.

  • It is more common on the right side.

  • The hernia occurs most often in elderly females, particularly in those who have become debilitated and lost weight rapidly. Usually, the patient presents with intestinal obstruction of unknown cause, and the hernia is diagnosed at laparotomy.

  • Patients may complain of diffuse pain in the groin together with pain in the medial side of the thigh and knee because of pressure on the obturator nerve.

  • A Richter’s hernia may occur with strangulation of the entrapped part of the intestinal wall.

 

Treatment

  • Laparotomy is performed and the entrapped segment of bowel is released.

  • The hernial defect is often found to be small.

  • Care is taken not to damage the obturator nerve when either closing the defect or covering it with prosthetic mesh.


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