Invisible hernia, visible relief: laparoscopy in atypical epigastric swelling

Abstract

Epigastric hernias are midline abdominal wall defects between the xiphoid and umbilicus, typically small and often asymptomatic. Atypical presentations can pose diagnostic challenges, especially when imaging findings are incongruent with clinical signs. We present a case of a 30-year-old male with persistent epigastric discomfort and a partially reducible swelling for three years. Ultrasound revealed a small defect with herniated fat and bowel loops, but diagnostic laparoscopy found no fascial defect. Instead, preperitoneal fat herniation and localized muscle atrophy were noted. The herniated fat was excised, and a composite intraperitoneal mesh was placed using the IPOM technique (Intraperitoneal Onlay mesh). The patient recovered uneventfully and remained symptom-free at six-month follow-up. This case emphasizes the diagnostic limitations of imaging alone in atypical epigastric hernias and the diagnostic and therapeutic value of laparoscopy. Even in the absence of a visible fascial defect, symptomatic patients may benefit from surgical intervention. Laparoscopic IPOM repair provides a safe and effective approach, particularly in anatomically ambiguous cases. This report contributes to the limited literature on atypical epigastric hernias and reinforces the need for individualized surgical planning and long-term follow-up to monitor outcomes.