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Laparoscopic Epigastric Herniorrhaphy-Case and Discussion: Pediatric Surgery...
With Dr. Todd Ponsky · hosted by Dr. Todd Ponsky
Chapter 1 of 4 · Case-Based Learning
Case presentation
Case presentation: laparoscopic epigastric hernia repair in a 5-year-old
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Combined optics with a working channel allow repair through the umbilicus alone, using endoclose or percutaneous sutures tied subcutaneously.
True epigastric hernias contain only preperitoneal fat and are extraperitoneal, not full-thickness defects with omentum or peritoneal sac.
Working on the anterior abdominal wall through the umbilicus is difficult due to poor working angle.
The surgeon opened the peritoneum from inside, accessed the preperitoneal space, and pulled down preperitoneal fat that was residing in the hernia space.
Finger pressure on the outside pushed the hernia contents inward to aid laparoscopic identification.
For teenage girls with unsightly epigastric hernias, the laparoscopic technique is worth considering for cosmetic reasons.
Some small epigastric hernias in 3-4 year olds enlarge significantly by age 10, with increased preperitoneal fat and larger defects.
The natural history of epigastric hernias is to enlarge over time.
Repairing epigastric hernias when small is a minor procedure.
Asymptomatic epigastric hernias may enlarge into adulthood, especially after pregnancy in females, potentially requiring mesh rather than primary closure.
Many epigastric hernias remain totally asymptomatic and small in size throughout life.
Epigastric hernias are not a significant health concern like inguinal hernias.
Some women with epigastric hernias experience significant pain during pregnancy.
Inferior epigastric hernias can be repaired through a periumbilical incision by moving the skin incision upward.
Some large adult epigastric hernias require mesh repair.
Oliver Munster presented the same laparoscopic technique at IPEG in Beijing.
Scars in young children grow proportionally as the child grows.
Hiding the scar in the umbilicus offers a cosmetic advantage over midline epigastric scars.
A supraumbilical or periumbilical incision can reach epigastric hernias located halfway to the xiphoid process, based on experience with pyloric stenosis operations.
Some abdominal wall hernias 1-1.5 cm above the umbilicus are full-thickness defects with a peritoneal sac, not true epigastric hernias, and may be misdiagnosed.
Multiple small abdominal wall defects (Swiss cheese pattern) can occur in the epigastric region.
Supraumbilical hernias (1 cm above the umbilicus) can be repaired through a supraumbilical incision hidden in the umbilicus.
Epigastric hernias located midway between xiphoid and umbilicus in children over 1 year are difficult to reach through an umbilical or supraumbilical incision.
Anesthesiologists are reluctant to anesthetize children under age 5 for truly elective operations due to soft reports of cognitive problems with general anesthesia.
Most parents requesting epigastric hernia repair report the hernia is symptomatic with pain.
There is a gap in knowledge about the optimal timing for repair of epigastric hernias and hydroceles.
Most surgeons repair hydroceles between 1 and 2 years of age, but the rationale for this timing versus waiting until 3-5 years is unclear.
Toddlers recover from surgery with less morbidity and fewer psychological effects than older children (6-7 years) who associate hospital stays with missing school.
It is difficult to visualize true epigastric hernias (epiplocoeles with preperitoneal fat only) laparoscopically.
There is a risk of future adhesive bowel obstruction from the peritoneal defect created during laparoscopic epigastric hernia repair.
The case involved a 5-year-old girl with epigastric swelling and tenderness that had not reduced for 6 months.
The technique used a 3mm umbilical port and 3mm percutaneous instruments in the left anterior axillary line.
Finger pressure on the abdominal wall hernia bulge was used to identify the hernia site laparoscopically.
The peritoneum was opened, fatty tissue removed, and the hernia ring exposed and closed with interrupted percutaneous 3-0 PDS sutures.
The laparoscopic approach avoids a non-cosmetic incision and scar in the epigastric region.
Dr. Abello confirmed the hernia was a true epigastric hernia with fat, not omentum.
Dr. Abello does not repair all asymptomatic epigastric hernias but does repair them in female patients due to pregnancy concerns.
Adult surgeons report needing to take down the falciform ligament and open the peritoneum to visualize epigastric hernias laparoscopically.