Tricks - Laparoscopic Epigastric Herniorrhaphy
With Dr. Doctor Vanderzee · StayCurrentMD
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
The case involved a 5-year-old girl with swelling and tenderness in the epigastric region that had not been able to be reduced for 6 months.
The technique used a microlaparoscopic approach with a 3 millimeter umbilical port and 2-3 millimeter percutaneous instruments placed 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 and fatty tissue was removed to expose the hernia ring.
The repair was completed with interrupted percutaneous 3-0 PDS suture at 2 separated points.
Combined optics with working channel allow use of only the umbilicus for entrance, with endoclose or percutaneous suture technique for closure.
A true epigastric hernia contains only preperitoneal fat and is extraperitoneal, not full-thickness with omentum protruding.
Working on the anterior abdominal wall through the umbilicus is difficult because of inadequate angle.
Some epigastric hernias observed in 3-4 year old patients have enlarged significantly by age 10, with huge amounts of preperitoneal fat and bigger defects.
The natural history of epigastric hernias is to enlarge over time.
When epigastric hernias are fixed when small, it is a pretty minor procedure.
A huge number of epigastric hernias remain totally asymptomatic and small in size.
Epigastric hernias are not a health concern like inguinal hernias.
The majority of epigastric hernias live quite happily inside the confines of a very small defect.
Several women with epigastric hernias have had significant pain at the time of pregnancy.
Inferior epigastric hernias can be repaired through a periumbilical incision by moving the skin incision up.
Some large adult epigastric hernias require mesh repair.
Oliver Munster presented the same laparoscopic technique at IPEG in Beijing.
Scars grow proportionally as children age, so a scar on a 3-year-old will be twice as big when older.
A periumbilical incision can reach halfway up to the xiphoid process, sufficient for most epigastric hernias.
At least half a dozen patients have been observed with hernias 1-1.5 cm above the umbilicus that were true full-thickness abdominal wall hernias with a sac, not epigastric hernias.
Some epigastric hernias present as Swiss cheese with multiple defects.
Supraumbilical hernias 1 cm above the umbilicus can be managed through a supraumbilical incision hidden through the umbilicus.
In older kids (one year and above) with epigastric hernias in the midline between xiphoid and umbilicus, it is very hard to reach through an umbilical or supraumbilical incision.
Anesthetists are reluctant to anesthetize children under age 5 for truly elective operations due to soft reports about cognitive problems with general anesthesia.
Toddlers tend to recover with less morbidity than 6-7 year olds who associate hospital stay with psychological components and miss school.
Optimal timing for repair of hydroceles and epigastric hernias remains unknown, representing a gap in knowledge.
It is difficult to see the defect laparoscopically in true epiploceles (preperitoneal fat hernias).
There is a risk of adhesion formation to the peritoneal defect that could cause bowel obstruction after laparoscopic repair.
Dr. Abello does not repair all asymptomatic hernias but does repair them in female patients because of pregnancy concerns.
Adult surgeons report needing to take down the falciform ligament and open the peritoneum to visualize epigastric hernias laparoscopically.