Abdominal Wall Hernia: Effects on the Abdominal Wall and Internal Organs

The linea alba is the vertical band of connective tissue running down the center of the abdomen. It extends from the navel to the sternum. The linea alba is formed by the union of the tendons of the lateral abdominal wall muscles.

In an epigastric hernia, a gap (hernia orifice) forms in the abdominal wall along the linea alba. Through this gap, parts of the abdominal cavity protrude outward as hernial contents into a sac-like protrusion of the peritoneum (hernial sac). The hernia most commonly involves connective and fatty tissue, and in rare cases, parts of the small intestine.

Clearly visible linea alba in a slender woman © Mirrorstudio | AdobeStock

The epigastric hernia is thus similar to other external hernias, such as

• an inguinal hernia,
• incisional hernias, or
• an umbilical hernia.

Epigastric hernias are significantly less common than, for example, inguinal hernias or umbilical hernias. They account for only about 1.6 to 3.6 percent of all abdominal wall hernias.

They mostly affect middle-aged people. Men and women are affected by epigastric hernias with roughly equal frequency.

Ultimately, it is crucial for experts to determine the exact location and size of the abdominal wall hernia in order to select the appropriate treatment. Especially when the hernia is located near the navel, precise examinations help to better assess risks and prevent complications early on.

Those affected usually have a congenital weakness in the connective tissue, which causes the abdominal wall to be less firm than it should be. An epigastric hernia develops when this is combined with increased intra-abdominal pressure along the midline of the abdomen.

An increase in intra-abdominal pressure can be caused, among other things, by

• frequent coughing, such as in cases of chronic lung disease,
• frequent and forceful straining during bowel movements, such as in cases of chronic constipation, and
• frequent lifting of heavy loads

.

In addition,

• being overweight,
• pregnancy, and
• abdominal fluid accumulation (ascites)

are among the risk factors that can contribute to the development of an epigastric hernia.

Lifting heavy loads can increase the risk of developing an epigastric hernia in individuals with existing connective tissue weakness © Maria Fuchs | AdobeStock

An epigastric hernia typically manifests as a bulge along the linea alba that is visible and/or palpable from the outside.

Typical symptoms of an epigastric hernia also include severe and sudden pain in the upper abdomen. This pain is caused or exacerbated by an increase in intra-abdominal pressure.

In some cases, a large epigastric hernia can cause the intestines to become trapped in the hernial ring. In such cases, severe, persistent pain may be accompanied by nausea and vomiting.

Furthermore, the causes of an abdominal wall hernia play an important role in determining the severity of the symptoms. Depending on the size of the hernia, the increased pressure in the abdominal cavity can cause tissue to protrude more significantly and become permanently trapped within the body. Similar to an incisional hernia, in severe cases there is a risk that strangulated tissue will no longer receive blood flow and, in the worst-case scenario, will die, necessitating immediate medical treatment.

An epigastric hernia is usually diagnosed through a detailed medical history interview and a physical examination.

During the medical history interview, the patient is asked about their symptoms, lifestyle, and medical history.

As part of the physical examination, the doctor thoroughly palpates the patient’s upper abdomen. During this process, the doctor may already be able to feel the hernial orifice and the protruding hernial sac, thereby confirming the diagnosis of an epigastric hernia.

Illustration of an abdominal wall hernia © blueringmedia | AdobeStock

Following this, imaging tests such as

• ultrasound,
• computed tomography, and
• magnetic resonance imaging

may be used. This allows the doctor to reliably and definitively diagnose the epigastric hernia or to rule out or confirm other conditions.

An epigastric hernia does not resolve on its own. Symptoms worsen over time, and there is also a risk of intestinal obstruction at the hernial orifice. Therefore, an epigastric hernia should always be treated surgically as part of hernia surgery.

For the surgical treatment of an epigastric hernia,

• hernia repair via direct suturing (fascial suture) and
• hernia repair by implanting a synthetic mesh

.

The surgery can be performed either minimally invasively or as an open procedure. The choice of surgical procedure depends on the size of the epigastric hernia and the severity of the symptoms.

When is surgery necessary for an abdominal wall hernia?
As soon as symptoms of an abdominal wall hernia worsen or parts of organs could become trapped in the hernial opening, surgery is usually necessary. Since the hernia does not heal on its own, doctors usually recommend early surgery to prevent complications.

What surgical procedures are available—minimally invasive or open?
Depending on the findings, either minimally invasive laparoscopy or open surgery may be considered. Both procedures are among the most common surgeries performed and have proven effective over the long term.

Is the procedure always performed under general anesthesia?
Usually, yes. Most abdominal wall hernia surgeries are performed under general anesthesia at a specialized clinic to ensure maximum safety.

Can an abdominal wall hernia recur after surgery?
Recurrence is possible, especially in cases of significant pressure in the abdominal cavity or weak connective tissue. However, modern meshes and techniques significantly reduce this risk.

Can an abdominal wall hernia go undetected?
Yes—in cases of small hernias, the hernia may not be visible from the outside. Symptoms often do not appear until straining, coughing, or physical activity puts greater stress on the weak spot.