Open Epigastric Hernia Repair Without Mesh for a 1-cm Incarcerated Hernia

Case Overview

Epigastric hernias, predominantly described in the literature as small defects containing mostly preperitoneal fat, are located in the linea alba between the xiphoid process and the umbilicus. These hernias are relatively common, with an estimated prevalence of up to 10% in the general population.¹ While many epigastric hernias remain asymptomatic, some may become incarcerated, causing pain and discomfort.² Incarceration is a significant concern, often requiring surgical intervention.^3–5

The risk of incarceration in epigastric hernias is influenced by the size of the defect. It has been observed that smaller epigastric hernias, particularly those less than 1 cm in diameter, have a higher risk of incarceration compared to larger ones. This increased risk is attributed to the narrow neck of the hernia, which can more easily trap abdominal contents.⁶

Various treatment options are available for epigastric hernias, including laparoscopic and open surgical approaches. The choice of treatment depends on factors such as hernia size, patient characteristics, and surgeon preference.^7,8 This video describes an open epigastric hernia repair without mesh for a 1-cm incarcerated hernia. The technique demonstrated addresses both the correction of the hernia and the prevention of recurrence, which is crucial given the higher incarceration rates associated with smaller hernias.

The surgery is normally carried out under local anesthesia, with or without sedation, and with the patient lying in the supine position. The surgical field is prepared and draped in a sterile fashion.

The procedure is initiated with the injection of local anesthetic at the surgical site. A small incision is then made over the hernia, and the subcutaneous tissues are carefully dissected. The hernia sac and surrounding fat are identified and excised. In this case, a peritoneal sac was unexpectedly encountered, which is noted to be uncommon for epigastric hernias.

Once the hernia contents are removed, the fascial defect is identified and prepared for closure. The defect is typically observed as a slit in the fascia. The edges of the fascia are carefully delineated and measured. In this procedure, a two-layer closure technique is employed due to the presence of a rectus diastasis.

The first layer of closure is achieved using interrupted sutures. Three to four interrupted sutures are placed, ensuring they are not too close to each other. Following this, a running suture is applied as a second layer to provide additional strength and create a smoother contour. Permanent sutures are utilized for both layers.

After the fascial closure, the subcutaneous fat is approximated to cover the repair site, preventing the patient from feeling the sutures. Interrupted subdermal sutures are then placed to reduce tension on the skin and improve cosmetic outcomes. Finally, a cosmetic skin closure is performed using a no-knot technique. This no-knot technique offers several advantages. The absence of visible knots and minimal external suture material contributes to a more aesthetically pleasing scar. Also, the lack of knots reduces the likelihood of patients feeling or being irritated by suture material under the skin.⁹

Throughout the procedure, meticulous hemostasis is maintained. Any bleeding points, particularly from the peritoneal edge or fat, are carefully addressed. It is emphasized that postoperative care includes the use of ice packs and over-the-counter pain medications. Patients are typically allowed to return to normal activities without restrictions once healing has occurred. 

This video demonstration of an open epigastric hernia repair without mesh for a 1-cm incarcerated hernia provides valuable insights for surgical trainees, general surgeons, and hernia specialists. The technique showcased is particularly useful for small epigastric hernias and in cases where a rectus diastasis is present. The two-layer closure method and attention to cosmetic outcomes make this approach beneficial for patients concerned about visible or palpable sutures. This educational video is a practical guide for surgeons looking to refine their techniques in open epigastric hernia repair, particularly in cases where mesh placement is not necessary or desired.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.