A patient with an epigastric hernia complains of attacks of pain and a lump, or occasionally more than one lump, which may be surprisingly painful. You find a small, soft, rubbery, globular, and sometimes lobulated lump, somewhere along his linea alba, between his xiphoid process and his umbilicus. Extraperitoneal fat has bulged through a small (10 mm or less) cleanly punched- out hole. It may be so close to his umbilicus as to resemble an umbilical hernia. Because the fat in it is tightly wedged, it has no cough impulse, and you cannot reduce it. You can easily mistake it for a lipoma, although it is more firmly fixed. The key to the diagnosis is its position. Repair is usually straightforward.
EPIGASTRIC HERNIAS If the patient's hernia is small, and his symptoms mild, leave it. If the lump is more then 3 or 4 cm, or is causing symptoms, consider repairing it.
ANAESTHESIA. Infiltrate the tissues with 0.5% lignocaine with adrenalin (A 6.7).
INCISION. Make a small horizontal skin-crease incision, reflect upper and lower flaps, and dissect out the mass. Clean and mobilize the sac. It will probably shell out. The contents are usually omentum or transverse colon or both, and rarely small gut. Reduce the mass by poking it back inside his abdomen with tissue forceps. Repair the hole with a monofilament purse string suture.
If you cannot reduce his hernia, enlarge the defect in his linea alba by extending it at the 3 and 9 o'clock positions. Replace the mass, and repair the hole with interrupted monofilament sutures on a cutting needle. Overlapping the linea alba is rarely necessary.