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

CHAPTER 1

Hi everyone, I'm Dr. Shirin Towfigh, hernia specialist from the Beverly Hills Hernia Center. We're going to look at an epigastric hernia. This is an incarcerated epigastric hernia, which hurts the patient. She is somewhat elderly, but very, very active, and therefore we're going to make a small scar over this hernia to repair her epigastric hernia. So here's some tips about epigastric hernias. They tend to be like a slit. They're usually not big. They're in the mid upper abdomen. They're almost always fat containing only, but they can bother and they can bulge. In this patient, you'll see how it bulges. When you repair those, you can choose to do them laparoscopically, open directly over the area, or in some cases, open, but through the belly button. In her, she was offered all of these options and she want was okay with a small scar right over the belly button. She had a lot of fat going through it, including a peritoneal sac, which is uncommon for most epigastric hernias. So watch out for that detail. And then lastly, when you fix these, you wanna make sure that they don't feel your knots and that it's a secure repair. In some women, they have had children and the pregnancy separates their abdominal muscles. It's called a diastasis or a rectus diastasis. That thins out the tissue, and so a single repair is not adequate. I will show you how I do a two layer repair, and also in thin women, make it so that they can't feel any knots in the area.

CHAPTER 2

Next one, local anesthetic, please. Another five cc or so. Scalpel.

CHAPTER 3

These epigastrics ones tend to be a little slit.

CHAPTER 4

Kelly, please. Just make this a little bit bigger. And on the side too. Good. All right. See how thin her skin is, and these hernias are... I'm gonna go a little bit deeper actually. There we go. Sometimes these can be lipomas and not actual hernias. Go ahead, cut that. But I think she got actual imaging. Careful with the skin. To confirm the hernia. It's kind of acting like a lipoma where it's all scarred to the edges. Maybe it is a lipoma. See how it's tugging on the skin edges? Okay, Senn please. It's acting like a lipoma. It's got a very fibrous feel to it, which also, you may think it's a lipoma, but see how when you pull, the skin seems to be attached to it. So it's feeling like a lipoma. Buzz that. How satisfying is that? Where's Dr. Pimple Popper when you need her? Right down the street. Down the street. Up the freeway, actually. Where does she practice? Near Fresno. I think. Woo hoo. Oh, that felt really good. Okay. Can we get DeBakey please? See how there's bulging here? Here, take some of that. Where is the wet one? This is all lipomatous fat. There we go. Go ahead and take that. Yeah, that's very lipomatous fat. You see that? Still haven't ruled out a hernia. It's definitely in the right area for one. Okay, go ahead. So you can't just get hernias anywhere. This feels like a hernia coming out. Go ahead and end it. Epigastric is one of them, kind of halfway between the xiphoid and the belly button. That's a hernia sac. So this is a hernia sac. She has definitely a hernia. Go ahead and cut the hernia sac down there. Can't have a lipoma with a hernia sac. Go ahead, cut. So she did have a hernia. Here's your specimen. Trash. Okay. We're not sending any specimens out? No. Thank you. Careful of the skin. Okay.

CHAPTER 5

Where is the defect? Fix the light, please. So now we're looking for the fascia to see where the defect is in the fascia. It's usually a slit in these epigastric ones. Go ahead and open that. And grab it. All right, you see the fascia down there? It's white, shiny white. There's your hole. We found the hole. That's the fascia edge. Let me raise it up so we can see where we're bleeding from. Okay. Get the wet one. So here's our fascial edge. We're bleeding from something small. Sem, please. Here's the fascia. It's just a slit. Hold that there. I think it's the fat in there that's bleeding. Here's the upper edge of the fascia. Lower edge of the fascia. Still oozing. Let's see where it's from. Inside, huh? Okay, why don't you hold this then. Buzz me. It may be the peritoneum. The peritoneal edge always bleeds. The fat bleeds too, so... I feel like we stopped it. Yeah, I don't see it coming up anymore. Okay. Let's regrab this edge. So these are the edges of the hernia. Just grab a ruler. Let's see how big those are. This one, I would run it. Run it? Okay. Also about a centimeter.

CHAPTER 6

All right, put a couple interrupters, and then we'll run it. Ethibond? 3-0. 3-0 Ethibond? Mhm. Can I get another Ethibond, please? So put like three or four interrupters, and then we'll imbricate it by running it as a second layer. We need a couple more. Thank you. So you can run these, or interrupted sutures, you can do a combination. If I feel like we need extra coverage, I usually do the combination. Just tie those, because we're just gonna do three. I'm not gonna do 'em too close to each other, and then we're gonna run on top of it to give her a flatter look. Scissors, please. Not a big bite. No, not a big bite. You need the other portion for her interrupted sutures. Also, if you have a hernia within a diastasis, a two-layer closure helps. There's a lot of different ways of fixing epigastric and umbilical hernias. If it's under one centimeter, I prefer to use suture only and not mesh.

That's good. Mhm. If you have thin patients or you have a diastasis, you may want to have the outer layer being running. Might do two layers if there's a diastasis. I'm just gonna hold this for you. Mhm. Yep. Yeah, that's too big. Yeah, that's better. Beautiful. It's actually coming together. You see that? It's already there for you. I'll take a Senn. Hold on. See that? It's kind of together. Mhm, perfect. The running suture nicely pulls everything together and makes it smooth. That's too big. We'll take that 3-0 after this please. Last one. Last one? Mhm. Tie a knot, and then we'll suture it through. That helps bury the knot.

CHAPTER 7

Okay. Adsons, please. So, cover it with some of the fat so that she doesn't feel the repair. That was a cute one, huh? Mhm. That's enough actually. Okay.

CHAPTER 8

Alrighty. A knotless for this one too? Yeah, a knotless for this too. Actually, why don't you put some interrupted subdermals. Okay. Can I have the Vicryl? This will take the tension off the skin a little bit. Give her a nicer look. Thank you. Okay, that'll look good.

CHAPTER 9

Sometimes when you have such a bulging fat, the skin starts to stretch over that area. It'll learn to stretch back in most patients. Sometimes if it's really chronic, you have to excise the old skin. Okay, that's good. All right, local anesthetic, please. Just add some local at the fascia level. You can feel the fascia with the tip of the needle. All right, just put one this way and we'll... Parallel? Mhm. And I'll cut it. Like the... Yep. All righty. That's it. Thank you everyone.

CHAPTER 10

So you just watched a whopping epigastric hernia, huge amount of fat, including a peritoneal sac. Very unexpected and not very common for this part of the body. She had a nice slit, we closed it in two layers because it was within a thinned out rectus diastasis. We used permanent sutures, and she had a nice cosmetic skin closure. She can go back to her normal activities. I am not going to restrict her. That bandage will come off in a couple days. She may be sore. I use ice packs immediately after surgery, and she can use some simple over-the-counter medications. Narcotics are not indicated in these smaller hernia repairs. She'll do very, very well and can go back to all her athletic efforts once she's healed.