Hernia Repair -Epigastric :
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What is an Epigastric Hernia?
An epigastric hernia happens when a weakness in the abdominal muscle allows the tissues of the abdomen to protrude through the muscle. An epigastric hernia is usually present at birth, and may heal without treatment as the infant grows and the abdominal muscles strengthen. An epigastric hernia is similar to a umbilical hernia, except the umbilical hernia forms around the belly button and the epigastric hernia is usually between the belly button and the chest.
An epigastric hernia is typically small enough that only the peritoneum, or the lining of the abdominal cavity, pushes through the muscle wall. In severe cases, portions of an organ may move through the hole in the muscle.
Hernia Symptoms: Epigastric Hernia
Epigastric hernias are located higher on the abdominal wall above the umbilicus and usually in the area just below the breast bone (or sternum).
Epigastric hernias arise because of a small hole between the rectii muscles (often referred to as the "six pack" if you're lucky enough to have one!). The hole or defect is often very small. The hernia sac that comes out between the muscles usually contains fat rather than any bowel.
Epigastric hernias differ from other hernias in that they don't usually disappear when you lie down. This is because the defect is usually too small to allow the herniated sac/fat to go back in.
Repairing an epigastric hernia is usually straightforward involving a small incision and a couple of stiches. Occasionally in larger hernias a mesh may be needed.
The operation is far less painful than an inguinal hernia and recovery and return to work is much quicker. Most patients would expect to be back at work within one week from surgery.
If you notice a bulge or swelling in your groin, abdomen, scrotum, or thigh, you should talk to your doctor. Sometimes a hernia may also cause sharp or dull pain and the pain may worsen when you are standing.
With most types of hernias, including inguinal, umbilical, epigastric, and incisional, your doctor will be able to see and feel the bulge and diagnose you with a hernia.
Types of Hernia
If you have an inguinal hernia, you might be able to see a bulge where your thigh and your groin meet. In guys, the protruding piece of intestine may enter the scrotum, which can cause swelling and pain. Other symptoms of an inguinal hernia might include pain when you cough, lift something heavy, or bend over. These types of hernias require surgery to repair; in fact, inguinal hernia operations are the most common type of surgery performed on kids and teens.
Causes for Inguinal Hernia:
There is no one factor that can be blamed for the creation of an inguinal hernia. The inguinal canal is a tract that is created in embryonal life allowing the testicels to descend from an intra abdominal position to the testicular sac. This tract usually closes after birth can open later in life from a variety of reasons. Heavy physical activity, trauma, obesity, increase in abdominal pressure can cause opening of this canal. Some weakness in the abdominal wall muscles and a possible defect in the quality of the tissues can add to the risks of hernia development. It should be remembered that lack of activity does not exclude the development of a hernia.
Once the diagnosis is made and confirmed by the surgeon the recommendation is to repair it. Otherwise it will grow and it will be more difficult to repair the hernia. We are always trying to perform the operation before any complication can appear.
A femoral hernia is a type of a hernia located in the inguinal region but anatomically somewhat different than the typical inguinal hernia. The repair technique is also somewhat different but can also be done with the mesh and on an outpatient basis. The distinction between a inguinal hernia and a femoral hernia is usually made on a clinical basis.
Umbilical or paraumbilicalhernia
An umbilical hernia is a protrusion of some of the contents of the tummy into
the umbilical area (‘belly-button’). It is a very common problem but only rarely
causes pain. Often the hernia will repair itself as your child becomes older,
but this is much less likely to happen after 4 years of age. Sometimes the
hernia appears to be umbilical but may in fact be immediately alongside the
umbilicus. These hernias are called “Para-umbilical hernias” and, although
very similar to a true umbilical hernia, always need to be repaired as the body
cannot repair them itself.
An epigastric hernia occurs in the middle of the upper abdomen between the breastbone and the umbilicus. It usually consists of fat and seldom contains abdominal organs, as in other types of hernia. An epigastric hernia develops as a result of weakness in the muscles of the upper abdomen, and is caused by increased pressure on the abdomen due to straining and lifting. It is more common in men between 20 and 50, than in women, but can be present at birth. There is a risk that a hernia becomes strangulated, cutting its supply of blood and causing gangrene and peritonitis. If left untreated, it is likely to grow and may cause bowel obstruction. In general, healthcare professionals will recommend an epigastric hernia repair operation.
Incisional Hernia forms along the site of a surgical incision.
Epigastric Hernia Surgery
Epigastric hernia surgery is typically performed using general anesthesia and can be done on an inpatient or outpatient basis. Special care should be taken to adequately prepare children for the surgery. Surgery is performed by a pediatric general surgeon or a pediatric colon-rectal specialist.
Once anesthesia is given, surgery begins with an incision on either side of the hernia. A laparoscope is inserted into one incision, and the other incision is used for additional surgical instruments. The surgeon then isolates the portion of the abdominal lining that is pushing through the muscle. This tissue is called the “hernia sac.” The surgeon returns the hernia sac to its proper position, then begins to repair the muscle defect.
If the defect in the muscle is small, it may be sutured closed. The sutures will remain in place permanently, preventing the hernia from returning. For large defects, the surgeon may feel that suturing is not adequate. In this case, a mesh graft will be used to cover the hole. The mesh is permanent and prevents the hernia from returning, even though the defect remains open.
If the suture method is used with larger muscle defects (approximately the size of a quarter or larger), the chance of reoccurrence is increased. The use of mesh in larger hernias is the standard of treatment, but it may not be appropriate if the patient has a history of rejecting surgical implants or a condition that prevents the use of mesh.
Once the mesh is in place or the muscle has been sewn, the laparoscope is removed and the incision can be closed. The incision can be closed in one of several ways. It can be closed with sutures that are removed at a follow-up visit with the surgeon, a special form of glue that is used to hold the incision closed without sutures, or small sticky bandages called steri-strips.
You can be given a local or a general anaesthetic. The choice depends partly on which you prefer, and partly on what your anaesthetist and surgeon think is best. The vast majority of operations for hernia repair are carried out under general anaesthetic. In some cases when the hernia is relatively small and your general medical condition does not allow you to tolerate the stress of a general anaesthetic, the operation can be done under local anaesthetic. Having a general anaesthetic means that you will be completely asleep during the operation. Having a local anaesthetic means that you will be awake during the operation, you will feel that something is being done at the area of the operation but will not feel pain.
A cut is made into the skin overlying the hernia. The bulge is pushed back or is cut off. The weak part is mended/closed and strengthened, usually with strong stitches. Another alternative is to patch the weak spot with a piece of synthetic material. This is usually done when the tissues around the weak spot are not strong enough to be stitched up together with strong stitches or when the weak spot is so big that it is impossible to close it just by using stitches. The synthetic patch is placed on top of the weak spot and is stitched to the healthy tissues around it. Soon, a lot of scarred tissue develops above and under the patch which makes it very strong and doesn’t allow the hernia to come back again. The cut in the skin is then closed up.
Keyhole surgery for hernia repair is only carried out in some specialised centres and for selective cases. There is no clear evidence at the moment that it offers a significant advantage compared to the traditionally performed operations.
The operation can either be done as a daycase, which means that you come into hospital on the day of the operation and go home the same day, or as an inpatient case, which means spending one or two nights in hospital. Your doctor will have discussed with you which operation you will be having
These hernias may be repaired with you asleep (under general anaesthetic), or with you awake (under local anaesthetic). The method of repair and anaesthetic will be discussed by your specialist at the time of your outpatient consultation.
Before your operation you will meet your surgeon. They will examined you, mark your hernia, and explain the operation in detail.
Once anaesthetised, using a small cut in the skin over the hernia, the hole in the muscle wall is identified. The hernia defect may be closed using stitches or even a mesh, depending on the size of the hernia. Dissolving stitches are usually used for the skin.
Risks or Complications
The risk of the hernia recurring is less than 2%. Hernia operations may cause some bleeding and bruising near the scar. There is a small risk of a wound infection and antibiotics may be given.
General anaesthetics are very safe although all operations do carry a small risk. If you are concerned about an anaesthetic please speak to your specialist.
Q. How do hernias occur?
Ans : Epigastric hernias are most common in young adults. They may develop after a period of lifting, straining or
coughing. This can weaken the abdominal muscles, cause pain and allow a hernia to bulge through. Hernias are
more common in people with heavy manual jobs.
Q. What is a strangulated hernia?
Ans : If bowel becomes stuck in the hernia it may become blocked and trapped. If this happens the hernia bulge may
become warm, red and painful to touch. You may also feel sick or vomit. This is a medical emergency and you
should contact your GP or attend the Accident and Emergency department.
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