A patient with an epigastric hernia complains of attacks of pain and sometimes finds a small tender lump, or occasionally more than one lump. His pain can be severe. He is equally likely to be a man or a woman and is often slim. 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 when it is quiescent, although it is more firmly fixed. The key to the diagnosis is its position. Repair is usually straightforward and strangulation unusual.
EPIGASTRIC HERNIAE 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 adranaline (A 6.7).
INCISION Make a small horizontal or longitudinal skin crease incision, reflect upper and lower flaps, and dissect out the lump of fat; it may shell out. Often, there is no real sac and the protrusion is only extraperitoneal fat. Or, there is a sac containing omentum or transvere colon. Reduce the mass by pushing it back inside the abdomen. Repair the hole with a monofilament purse string suture or 2 or 3 interrupted ones.
If you cannot reduce the hernia, enlarge the defect in the 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.