# Subxiphoid Incisional Hernia Following Cardiac Procedures: A Narrative Review

## TL;DR

This review examines subxiphoid hernias after heart surgery, focusing on risk factors, prevention, and surgical techniques.

## Contribution

The paper provides a comprehensive review of subxiphoid hernia management and highlights the feasibility of minimally invasive techniques.

## Key findings

- Intraperitoneal onlay mesh placement is the most common laparoscopic technique for subxiphoid hernia repair.
- Minimal invasive surgery is a feasible option if proper defect closure and mesh overlap are achieved.
- There is insufficient evidence to confirm the superiority of laparoscopic over open repair techniques.

## Abstract

Subxiphoid hernias are indeed an uncommon type of hernia that tend to present in the caudal aspect of a sternotomy incision, which typically enters the epigastrium. These patients have usually undergone major cardiac surgeries, like heart transplant, coronary artery bypass grafting (CABG), or cardiac valve replacement, representing a high-risk group of patients. The purpose of the study is to identify risk factors, prevention measures, and to explore different techniques for surgical management, including whether minimal invasive surgery is superior than the conventional open approach.

A comprehensive search was performed on Pubmed, Sciencedirect, Scopus, and Cochrane library. The search terms included “subxiphoid hernia” and “post sternotomy hernia.” Articles not in the English literature and duplicates studies were excluded. Studies regarding epigastric hernias were also excluded. All relevant articles published until 28th of February 2025 were included. Relevant references from the identified articles were also searched and included for review.

Particular care should be given to recognizing patient-related risk factors, preventing surgical site infections, and ensuring proper closure of the fascia. Regarding surgical management, seventeen articles were identified with 442 patients overall. 320 patients underwent open repair, while in 122 patients laparoscopic approach was achieved. Intraperitoneal onlay mesh placement was the most popular laparoscopic technique applied. Only 3 studies provided comparable results between the two approaches. A significant variety of techniques concerning both approaches was noticed in the literature.

Excellent knowledge of the anatomical and physiological aspects of the subxiphoid region, and acknowledgement of risk factors, are essential. Minimal invasive repair of subxiphoid hernias is a feasible option, as long as defect closure and adequate mesh overlap are achieved. There are not enough data still to prove the superiority of the laparoscopic approach. Complex cases should be referred to experienced hernia surgeons.