Conventional and laparoscopic epigastric hernia repair

Abstract

Primary epigastric hernias are unusual. They are hernias of the linea alba between the xyphoid process and the umbilicus. The incidence of these hernias has been reported to be between 1% and 10%, but because many of them are asymptomatic, and therefore unrecognized,thetrueincidencemaybehigher.Thereispredominanceinmenoverwomenbyafactorofthree.Inonefifth of patients, multiple fascial defects are present at the time of presentation. 1-3 ETIOLOGY For some time, these hernias were believed to be congenital. It is now felt that the majority are acquired lesions resulting from a structural deficiency in the linea alba acted on by mechanical forces. 3 Fibers from the external oblique and internal oblique aponeuroses are bound together to form the anterior rectus sheath in a triple-layer crisscross pattern. A similar triple layer exists for the posterior rectus sheath derived from fibers of the internal oblique aponeurosis and the transversus aponeurosis. Askar has described the patterns of fiber decussation across the midline that form the linea alba. His observations of the linea alba show a decussation of fibers along a single line at the midline in 30% of patients. Seventy percent of patients had an additional line of intersecting fibers on either side of the midline in a triple-decussation arrangement.Hepostulatesthatpatientsinwhomasingle line of decussation exists are prone to develop midline hernias. 4 Another theory suggests that these hernias form at the site of penetration of one of five pairs of neurovascular bundles that pierce the fascia. 3 Still others implicate the ligamentum teres as the site of weakness. 5 Over time,