Combined epigastric hernia repair and mini-abdominoplasty. Case report.

The objectives of abdominal hernia repair are to restore the structural integrity of the abdominal wall. Current techniques include primary closure, staged repair and the use of prosthetic materials. Techniques for mini-abdominoplasty include the use of the transverse lower abdominal incision and the resection of excess skin. We report a case of epigastric hernia repair through a transverse lower abdominal incision with the resection of excess of skin. Our purpose is to evaluate the results of the procedure by incorporating these aspects into an epigastric hernia repair, we found out that the procedures are made safer and the results are improved. Proper indication and details of the technique are described.

Introduction

Epigastric hernia is a type of abdominal wall hernias due to a weakness, gap or opening in the muscles or tendons of the upper abdominal wall, on the alba line between the umbilicus and the xiphoid process. The hernial sac content is usually properitoneal fat, vascular structures and, uncommonly, abdominal viscera. This results in a bulge of intra-abdominal contents and pain or discomfort. Epigastric hernias are usually occult in obese patients, and their symptoms may mimic peptic ulcer or gallbladder disease. Epigastric hernia is quite uncommon and represents 0.5–5% of all hernias. There is a male predominance with a male to female ration of at least 3:1, diagnosis usually occurs in the third to fifth decade. Defects of the fascia may vary in diameter from several centimeters to only a few millimeters. The larger ones usually readily reducible, whereas the smaller often became in-carcerated. Multiple fascial defects are present in between 20% and 25% of individuals. Clinically, the majority of epigastric hernias (75%) are asymptomatic.

Vague upper abdominal pain and nausea associated with epigastric tenderness may be present. Common symptom of epigastric hernias is a painless epigastric swelling or bulge. Incarceration is common, especially in smaller hernias, but strangulation is unusual. Operative management aims at reposition of the hernia sac contents and direct closure of the hernial opening with a continuous suture. Due to high recurrence rates, tension-free hernia repair with mesh is becoming more common. The repair of umbilical and epigastric hernias still represents a challenge to surgeons. Even if is a common and relatively simple procedure, there is no exact protocol today on how the repair should be done. The purpose of epigastric hernia surgery is to repair the weakening area between rectus abdominis and put the hernial sac back into the abdomen. The best way to restore the anatomy of the abdominal wall in a tension free manner, is obtained by the placement of a polypropylene mesh. The Mayo technique and its alterations could not stand the test of time and it shows a recurrence rate of 20% and higher. Although there is no consensus opinion, the anatomic repair without tension and without an artificial enlargement of the defect is clearly the new trend in hernia repair techniques. In 1987 Lichtenstein reported on 6321 cases of inguinal herniorraphy with a tension free repair, and in 1994 Stuart reemphasized that special importance in his editorial in the Lancet. A newer study from Brancato and coworkers in Italy also states the advantage of a tension-free prosthetic repair in 16 patients with epigastric hernia; in their work no recurrence has been recorded. They found the technique simple, safe and absolutely effective, allowing immediate rehabilitation with a low rate of complications (Figs. 1–5).

Small epigastric hernias is usually not a medical emergency and can be healed without surgery. When the symptoms are frequent and the problem affects the quality of life of the patient, surgery is the solution. The traditional approach to incisional hernia repair usually involves a surgical approach via the vertical scar. In young woman midline vertical scar is not well accepted. They would rather prefer not to be operated instead of having such a visible scar. An approach via a low transverse incision may be considered. Techniques developed for the surgical approach to mini-abdominoplasty include the use of the transverse lower abdominal incision and the resection of excess skin above the navel. The laparoscopic access was not the first choice because it did not allow the resection of the excess of skin. We report a case of epigastric hernia repair through a transverse lower abdominal incision with the resection of excess of skin.

Presentation of case

A 37 year-old female patient was diagnosed an epigastric hernia with a little diastasis recti. Patient's symptoms were sense of discomfort, bloat, sometimes associated with dull pain increasing with cough. She had a mild laxity of the skin in the lower part of the abdomen and the position of the navel was 16 cm from the pubic symphysis. She refused classic approach to surgical hernia repair due to the visible midline vertical scar. The general surgeon asked the cooperation of a plastic surgeon who found another technique reliable to solve the functional problem with an esthetic approach combining the hernia repair with a mini-abdominoplasty hiding the scar in the bikini zone. The miniabdominoplasty technique was chosen in accord to the abdominolipoplasty classification system proposed by Mejia JA and Castellanos C and categorized as a type II.

Preoperatory marking was done following the type II abdominoplasty described by Pontes R. because the patient had such criteria in fact this technique is suitable for females with high position of the navel. The patient was placed in the supine position with the “break” in the table at the patient's waist. A standard abdominoplasty incision was used. The lower abdominal incision was first demarcated in the pubic area 6 cm above the anterior vulvar cleft. The incision was made, the flap was elevated, hemostasis was done to avoid any bleeding. The umbilicus was detached from its aponeurotic implantation to prepare the access to the epigastric hernia. The dissection was made cranially creating a subcutaneous tunnel in the midline. Care was taken to elevate the skin flaps only as far as necessary to define the hernial defect and to find surrounding fascia of good quality. The hernia was situated 4 cm beneath the xiphoid process. This area lacks important perforator vessels, and the tunnel was wide enough to expose the medial borders of the rectus muscles. The pannus was raised to the costal margins taking care to avoid undermining laterally to preserve the intercostal perforators to the flap. The navel was released from its insertion on the aponeurosis and left attached to the flap, as described by Psillakis in his paper. This technique allowed us to get to the hernial area to repair the gap. Alba line was opened and the hernial defect was identified, isolated and was safely reduced. It clinically contained only omentum. The edges were dissected to free the hernial sac and identify an intact facial edge. The hernia was reduced and the posterior fascia of rectus abdominis was dissected from its adjacent structures. A polypropylene mesh was placed over the posterior rectus fascia to prevent the recurrence of the hernia. The muscles were sutured together and the anatomy of abdominal wall was restored. A little plication of recti abdominis was made. The navel was reattached 2.5 cm below its original position maintaining 13.5 cm from the pubic symphysis, using a 3/0 absorbable suture. The excess of skin was sectioned after marking the cranial border of the flap with the Pitanguy marker. 4/0 Vicryl was used for subcutaneous sutures and 4/0 monocryl for the intradermal suture.

Discussion

Epigastric hernia repair through a mini-abdominoplasty incision is a reliable method to approach an abdominal wall defect with an esthetic procedure. The use of the mini-abdominoplasty approach isolates the incision from the hernial defect and repair. This technique is safe, with a low risk of postoperative complications. We found a little difficult to access to the epigastric area through the subcutaneous tunnel, but, when the defect is not too big to repair and the flaps are elevated till the xiphoid process, then it is easy to prepare the posterior fascia and to inset the polypropylene mesh.

In conclusion we find this approach suitable for those people who need a surgical repair of an epigastric hernia and have such conditions:

laxity of the skin in the lower part of the abdomen.

high position of the navel.

patients refusing midline vertical scar.

Conflict of interest

None.

Funding

None.

Ethical approval

Written informed consent was obtained from the patient for publication of this case report and accompanying images.

Author contribution

Roberto Grella M.D., Ph.D.: study design, writing the article. Sergio Razzano, M.D.: writing of the article, drawings. Rossella Lamberti, M.D.: analysis and interpretation of data. Trojaniello Biagio, M.D.: data collection and study design. Francesco D’Andrea, M.D.: final approval for the article to be published. Giovanni Francesco Nicoletti, M.D.: review of the article.