Epigastric hernia is a type of ventral hernia that occurs in the upper midline of the abdominal wall, between the umbilicus and the sternum. It results from a defect in the linea alba through which preperitoneal fat or, in larger cases, omentum or bowel may protrude. Patients may present with localized swelling, pain, or discomfort, and in some cases, complications such as incarceration or strangulation. Traditionally treated with open surgery, epigastric hernia repair has evolved significantly with the advent of minimally invasive techniques. Among these, laparoscopic repair using only two ports represents a refinement that minimizes surgical trauma while maintaining the efficacy of hernia repair.

Understanding the Two-Port Approach

Conventional laparoscopic hernia repairs often use three or more ports: one for the camera and two or more for working instruments. The two-port technique reduces the number of access points, thereby minimizing potential complications like port-site bleeding, infection, or hernia. It also decreases postoperative pain, improves cosmetic outcomes, and shortens recovery time. With growing expertise in laparoscopy and the availability of advanced laparoscopic instruments, two-port epigastric hernia repair has become feasible for small and medium-sized hernias.

Indications for Laparoscopic Two-Port Repair

This approach is particularly suited for:

Small to medium-sized epigastric hernias (usually less than 4–5 cm).

Patients with recurrent hernias after open repair.

Patients desiring minimal scarring or faster recovery.

Low-risk patients without extensive adhesions or multiple prior abdominal surgeries.

For very large or complex hernias, a multi-port approach or open repair may still be preferred.

Surgical Technique

Patient Positioning and Anesthesia

The patient is placed supine under general anesthesia.

A Foley catheter and nasogastric tube may be used in selected cases.

Port Placement

A 10 mm port is placed away from the hernia site, usually in the left hypochondrium or periumbilical region, for the laparoscope.

A 5 mm or 10 mm working port is introduced under vision in a position that allows comfortable triangulation and access to the hernia defect.

Exploration and Adhesiolysis

The hernia defect is identified, and any herniated contents (omentum or bowel) are carefully reduced back into the abdominal cavity.

Adhesions, if present, are released using a combination of blunt and energy dissection.

Defect Closure

In selected cases, the defect may be closed primarily with intracorporeal sutures passed through the working port.

Alternatively, closure can be omitted if a sufficiently large mesh is applied with adequate overlap.

Mesh Placement

A composite mesh (dual-layer to prevent adhesions) is introduced through the 10 mm port.

The mesh is spread out to cover the defect with at least 3–5 cm overlap in all directions.

Mesh Fixation

Fixation can be performed with fibrin glue, absorbable tacks, or trans-fascial sutures introduced through the working port.

In small hernias, self-gripping meshes may also be used, further simplifying fixation.

Closure

Ports are removed under direct vision.

Fascial closure of the 10 mm port is performed to prevent port-site hernia. Skin incisions are closed with absorbable sutures or skin adhesive.

Advantages of Two-Port Repair

Reduced Invasiveness: Fewer ports translate to less tissue trauma.

Less Postoperative Pain: Patients often report significantly reduced pain compared to multi-port repair.

Lower Risk of Port-Site Complications: Fewer entry points decrease the risk of port-site bleeding, infection, or hernia.

Cosmetic Benefit: Only two small scars, often hidden in natural folds.

Shorter Recovery: Many patients can be discharged within 24–48 hours and resume normal activities sooner.

Cost Efficiency: Fewer ports and potentially fewer fixation devices lower overall costs.

Challenges and Limitations

Technical Demands: Instrument triangulation and suturing are more restricted with only two ports. This requires advanced laparoscopic skills.

Case Selection: Not suitable for very large epigastric hernias, multiple defects, or patients with extensive adhesions.

Learning Curve: Surgeons must be well trained in minimal-port techniques to perform this safely and efficiently.

Outcomes and Clinical Evidence

Evidence shows that two-port laparoscopic epigastric hernia repair provides outcomes comparable to traditional three-port methods in terms of recurrence and durability. Patients, however, benefit from reduced pain, quicker mobilization, and higher satisfaction with cosmetic results. With proper case selection, recurrence rates remain low, provided mesh overlap and fixation are adequate.

Conclusion

Laparoscopic repair of epigastric hernia using only two ports is an effective and minimally invasive approach that balances surgical efficiency with patient comfort. By minimizing access trauma while ensuring secure mesh placement, it delivers durable results with enhanced cosmetic outcomes and reduced postoperative discomfort. Though technically more demanding, it represents a valuable advancement in the minimally invasive management of epigastric hernias. With growing experience and training, the two-port technique is poised to become an increasingly accepted option for selected patients requiring hernia repair.