Epigastric and Ventral Hernia Repair: Techniques and Recovery

What are epigastric and ventral hernias

A ventral hernia is a gap in the strong tissue, called fascia, that holds the abdominal muscles in place. It happens in the middle of the abdomen, away from the groin area. An epigastric hernia is a type of ventral hernia that appears in the upper midline of the abdomen, between the breastbone and the navel.

These hernias occur when the layers of fascia become weak, allowing abdominal contents such as fat or bowel to push through. A past surgical cut in the abdominal wall will always remain a weak area, which is why incisional hernias are a common form of ventral hernia.

Other factors that weaken the abdominal wall include:

• Obesity
• Injury
• Straining during coughing, urination, or bowel movements

A hernia does not get better on its own and can grow larger over time. Surgery is the only way to fix the defect, though not every hernia needs an operation straight away.

When surgery is recommended

Your surgeon may advise repair if the hernia causes pain, discomfort, or a visible bulge that interferes with daily activities. Surgery becomes urgent if tissue becomes trapped in the hernia defect, a condition called incarceration. If the trapped tissue loses its blood supply, it becomes strangulated, which is a surgical emergency.

Warning signs of strangulation include severe continuous pain, a bulge that is red or tender to touch, and nausea or vomiting. Even without emergency symptoms, a hernia that is growing or causing a dull ache that worsens by the end of the day may be scheduled for elective repair.

Non-operative management carries a low risk of short-term morbidity, but the hernia will not resolve without surgery. The decision balances the risks of the operation against the risk of future complications.

Who is suitable for keyhole or open repair

The choice between keyhole (laparoscopic) and open repair depends on several factors. Keyhole surgery uses small cuts and a camera, but it may not be an option if you have had previous abdominal surgery or have too much scar tissue inside the abdomen.

It is also less suitable if the hernia is very small or very large, or if the surgeon cannot see clearly through the laparoscope. People with severe lung disease may not tolerate the gas used to inflate the abdomen during keyhole surgery. Open repair is typically reserved for very large, complex, or recurrent hernias where a wider exposure is needed.

Elective repair is generally not recommended for patients with a BMI of 50 or above, for current smokers, or for those with HbA1c of 8% or higher. Patients with a BMI between 30 and 50 or HbA1c between 6.5% and 8% require individualised plans to lower surgical risk.

Your surgeon will assess your general health, the hernia size, and your surgical history before advising which technique suits you.

How the repair is done: open surgery

In open repair, the surgeon makes a single larger incision over the hernia, usually a vertical cut in the middle of the abdomen for ventral hernias. The hernia contents are returned to the abdomen, and the surgeon usually tries to close the fascial defect with stitches before placing a mesh to strengthen the repair. Mesh reinforcement is recommended for defects of 2 cm or larger.

The mesh can be placed in different layers:

• Onlay (above the muscle)
• Sublay (behind the rectus muscle, also called retrorectus)
• Underlay (inside the abdomen)

Studies show that sublay placement has lower recurrence and surgical site infection rates than other mesh locations in open ventral hernia repair. For very large hernias, a technique called component separation or transversus abdominis release (TAR) may be needed to bring the muscle layers together without tension. The operation typically takes 30 minutes to 2 hours depending on complexity.

How the repair is done: keyhole (laparoscopic) surgery

Laparoscopic ventral hernia repair is performed through several small incisions, usually 5 to 10 mm each. The surgeon inserts a port and a camera (laparoscope) to view the inside of the abdomen on a screen. The abdomen is inflated with carbon dioxide gas to create working space.

Long instruments are passed through the other ports to pull the hernia contents back and fix a mesh over the defect from inside the abdomen. This is called an intraperitoneal onlay mesh (IPUM) repair. The surgeon may choose to stitch the fascial defect closed before fixing the mesh, a step called closure of the fascial defect (CFD).

Evidence shows that CFD reduces seroma formation and bulging after keyhole repair. If the surgeon cannot complete the repair safely through the keyhole cuts, they will switch to open surgery. General anaesthesia is required for laparoscopic repair. The operation time is typically 30 minutes to 2 hours.

Mesh types and why they are used

Mesh is a sheet of material that reinforces the abdominal wall after the hernia gap is closed. In studies of ventral hernia repair, using mesh was linked to a lower recurrence rate than stitching the tissues together alone; pooled data showed a 2.7 per cent recurrence rate with mesh compared with 8.2 per cent with suture repair.

However, mesh repair was associated with a higher rate of seroma, a fluid collection under the skin, and a slightly higher rate of surgical site infection. Your surgeon will discuss the balance of these risks for your hernia size and health.

The position of the mesh inside the abdominal wall layers affects outcomes. In open ventral hernia repair, placing the mesh in the sublay position — behind the rectus muscle but in front of the posterior sheath — was linked to the lowest recurrence and infection rates across several studies.

One network meta-analysis of 5,891 patients found sublay mesh had an odds ratio of 0.218 for recurrence and 0.449 for surgical site infection compared with other positions. For keyhole repairs, the mesh is usually placed inside the abdomen against the muscle wall (intraperitoneal onlay) and fixed with tacks, sutures or glue.

The choice of mesh type — lightweight synthetic, heavyweight or composite — depends on the defect size, whether the mesh contacts bowel, and surgeon preference.

Mesh reinforcement is generally recommended for defects of 2 cm or larger. For very small defects, some surgeons may offer a suture-only repair to avoid mesh-related complications, though the chance of the hernia returning is higher. The mesh becomes incorporated into your own tissue over time, providing long-term strength. If a mesh infection occurs, which is uncommon, the mesh may need to be removed or replaced.

Recovery timeline and what to expect at home

Most ventral and epigastric hernia repairs are done under general anaesthesia. After surgery you will spend one to two hours in the recovery room until you are fully awake. Many patients go home the same day, especially after keyhole surgery for smaller hernias.

Larger or complex repairs, or those done by open surgery, may need an overnight stay or a few days in hospital for pain control and monitoring. The typical hospital stay for laparoscopic repair is one to two days versus two to four days for open repair.

Pain is expected after any hernia repair and varies by person and technique. Keyhole surgery is consistently linked with less pain in the first days and weeks; patients having laparoscopic repair used 42 per cent fewer painkillers in the first 48 hours and reported lower pain scores for up to a year.

You will be given pain medicine to take at home, usually simple tablets like paracetamol or ibuprofen, and sometimes a stronger prescription for a few days. Putting an ice pack on the wounds for short periods can also help.

You can walk and do light activities such as showering and climbing stairs from the first day at home. Desk work can usually be resumed within one to two weeks. Heavy lifting and strenuous exercise should wait until four to six weeks after surgery, or until your surgeon clears you.

Driving is allowed once you can do an emergency stop comfortably and are not taking strong painkillers. A follow-up visit is usually scheduled one to four weeks after discharge.

Risks, complications, and long-term results

Seroma — a collection of clear fluid under the skin — is one of the most common events after ventral hernia repair, especially after keyhole surgery. In studies, seroma rates after laparoscopic repair ranged from about 16 to 22 per cent. Most seromas are small, cause little discomfort, and absorb on their own over weeks to months.

Larger or persistent seromas may need drainage with a needle in the clinic. Closing the fascial defect during keyhole repair can reduce seroma formation.

Wound infection occurs in about 7 per cent of mesh repairs in pooled data. Keyhole surgery is associated with lower wound infection rates than open surgery.

Risk factors for complications include:

• Obesity
• Smoking
• Diabetes with HbA1c of 6.5 per cent or higher

Smoking also raises the chance of recurrence. Bowel injury is a recognised but uncommon risk of keyhole surgery, reported more often than with open repair. General anaesthesia carries rare risks such as allergy, heart or lung problems.

Recurrence rates after ventral hernia repair are reported between 15 and 40 per cent in long-term studies, though modern mesh techniques aim to lower this. In a large meta-analysis, laparoscopic repair had significantly lower odds of recurrence than open repair (odds ratio 0.76).

Factors that increase recurrence include a defect wider than 5 cm, incisional or recurrent hernias, BMI over 30, smoking, diabetes, COPD, and steroid use. Bridged repairs — where the mesh spans the gap without the muscles being stitched together — carry a much higher recurrence risk than repairs with primary fascial closure. Maintaining a healthy weight and not smoking improve long-term success.

When to see your surgeon and questions to ask

Contact your surgeon or go to the emergency department if you develop any of the following after discharge: severe continuous pain that is not relieved by prescribed medicine; a bulge that becomes red, tender or hot to touch; fever above 38°C; nausea or vomiting; or inability to pass urine or stool.

These can signal infection, bowel obstruction, or other urgent problems. A lump or swelling at the wound that grows or becomes painful should also be reviewed, as it may be a seroma needing drainage or, rarely, a recurrence.

At your preoperative consultation, ask your surgeon which technique — open or keyhole — they recommend for your hernia and why. Questions that help you understand the plan include: What size is the defect, and will the muscles be stitched together before the mesh is placed? Where will the mesh be positioned (sublay, onlay, or intraperitoneal)?

What type of mesh will be used, and does it contact the bowel? What is the expected hospital stay and when can I return to my usual work? How will pain be managed, and what are the specific risks for me given my weight, smoking status, or diabetes control?

If you smoke, stopping at least four weeks before surgery lowers complication and recurrence risks. If you have diabetes, improving blood sugar control before surgery is advised. For patients with BMI between 30 and 50 or HbA1c between 6.5 and 8.0 per cent, individualised risk-reduction plans are recommended.

Elective repair is generally not offered if:

• BMI is 50 or above
• HbA1c is 8.0 per cent or above
• You are a current smoker

Ask about the typical cost range for your procedure and what is included, as prices vary with technique, mesh type, and hospital stay.