Minimally Invasive Spigelian Hernia Repair

Introduction:

Spigelian hernia is an uncommon ventral hernia characterized by a defect in the linea semilunaris. Repair of spigelian hernia has traditionally been accomplished via an open transverse incision and primary repair. The purpose of this article is to present 2 case reports of incarcerated spigelian hernia that were successfully repaired laparoscopically using Gortex mesh and to present a review of the literature regarding laparoscopic repair of spigelian hernias.

Methods:

Retrospective chart review and Medline literature search.

Results:

Two patients underwent laparoscopic mesh repair of incarcerated spigelian hernias. Both were started on a regular diet on postoperative day 1 and discharged on postoperative days 2 and 3. One patient developed a seroma that resolved without intervention. There was complete resolution of preoperative symptoms at the 12-month follow-up.

Conclusion:

Minimally invasive repair of spigelian hernias is an alternative to the traditional open surgical technique. Further studies are needed to directly compare the open and the laparoscopic repair.     

Spigelian hernia repair as a day-case procedure

Purpose

Only a few series of patients with a spigelian hernia managed on an outpatient basis have been reported in the literature. The aim of this prospective study was to evaluate the results of the elective spigelian hernia repair as an ambulatory procedure.

Methods

From June 2007 to June 2010, 8 patients with 9 spigelian hernias were electively operated on under local anesthesia as a day case. Four patients had unilateral spigelian hernia, 1 had spigelian and inguinal on the same side, 1 had spigelian and epigastric, 1 had spigelian and umbilical, and 1 patient had bilateral spigelian and umbilical hernia. Spigelian hernia was managed by the “open preperitoneal flat mesh technique.” In patients with several ventral hernias at different sites, “the open preperitoneal flat mesh technique” was performed using one separate flat mesh for each of the hernias; for the patient with inguinal hernia, the Lichtenstein procedure was performed in addition.

Results

No complications and recurrences were recorded during a mean follow-up of 23.5 months (range: 11–35).

Conclusion

The elective spigelian hernia can be successfully repaired under local anesthesia as a day-case procedure. The “open preperitoneal flat mesh technique” provides excellent results under these conditions.     

Laparoscopic repair of incidentally found Spigelian hernia

Background and Objectives:

A Spigelian hernia is a rare type of hernia that occurs through a defect in the anterior abdominal wall adjacent to the linea semilunaris. Estimation of its incidence has been reported as 0.12% of all abdominal wall hernias. Traditionally, the method of repair has been an open approach. Herein, we discuss a series of laparoscopic repairs.

Methods:

Case series and review of the literature.

Cases:

Three patients are presented. All were evaluated and taken to surgery initially for a different disease process, and all were incidentally found to have a spigelian hernia. These patients underwent laparoscopic repair of their hernias; 2 were repaired intraperitoneally and one was repaired totally extraperitoneally. Two patients initially underwent a mesh repair, while the third had an attempted primary repair.

Conclusions:

There is evidence that supports the use of laparoscopy for both diagnosis and repair of spigelian hernias. There are also reports of successful repairs both primarily and with mesh. In our experience with the preceding 3 patients, we found that laparoscopic repair of incidentally discovered spigelian hernias is a viable option, and we also found that implantation of mesh, when possible, resulted in satisfactory results and no recurrence.     

Spigelian hernia: surgical anatomy, embryology, and technique of repair

Spigelian hernia (1-2% of all hernias) is the protrusion of preperitoneal fat, peritoneal sac, or organ(s) through a congenital or acquired defect in the spigelian aponeurosis (i.e., the aponeurosis of the transverse abdominal muscle limited by the linea semilunaris laterally and the lateral edge of the rectus muscle medially). Mostly, these hernias lie in the "spigelian hernia belt," a transverse 6-cm-wide zone above the interspinal plane; lower hernias are rare and should be differentiated from direct inguinal or supravescical hernias. Although named after Adriaan van der Spieghel, he only described the semilunar line (linea Spigeli) in 1645. Josef Klinkosch in 1764 first defined the spigelian hernia as a defect in the semilunar line. Defects in the aponeurosis of transverse abdominal muscle (mainly under the arcuate line and more often in obese individuals) have been considered as the principal etiologic factor. Pediatric cases, especially neonates and infants, are mostly congenital. Embryologically, spigelian hernias may represent the clinical outcome of weak areas in the continuation of aponeuroses of layered abdominal muscles as they develop separately in the mesenchyme of the somatopleura, originating from the invading and fusing myotomes. Traditionally, repair consists of open anterior herniorraphy, using direct muscle approximation, mesh, and prostheses. Laparoscopy, preferably a totally extraperitoneal procedure, or intraperitoneal when other surgical repairs are planned within the same procedure, is currently employed as an adjunct to diagnosis and treatment of spigelian hernias. Care must be taken not to create iatrogenic spigelian hernias when using laparoscopy trocars or classic drains in the spigelian aponeurosis.     

无张力修补术在腹壁疝中的应用

目的探讨腹壁疝的无张力补片修补方法,总结腹壁疝的治疗经验。方法回顾性分析我科2004年10月至2008年11月间收治的25例腹壁疝患者的临床资料。24例手术采用全麻或硬膜外麻醉下的腹膜外补片无张力修补术。1例应用巴德CK补片,置于腹腔内。结果本组患者中,男性9例,女性16例;年龄37～81岁,平均年龄（68±10）岁。其中白线疝1例,半月环疝1例,脐疝6例,切口疝17例。腹壁切口疝疝环直径1～18cm,平均（7±4）em。均采用无张力疝修补术,平均手术时间（116±42）min。平均住院时间（8±3）d。术后1例发生轻微疼痛不适;术后2例发生浆液肿,经穿刺治愈;1例发生上呼吸道感染;随访6～48个月,无复发。结论采用人工补片行腹壁疝无张力修补术是一种安全可靠的手术方式,采用腹膜外修补方式进行手术,避免了补片与腹腔内脏器的直接接触,并发症少,复发率低。     

Laparoscopic ventral and incisional hernia repair: An 11-year experience

Incisional hernias develop in 2%–20% of laparotomy incisions, necessitating approximately 90,000 ventral hernia repairs per year. Although a common general surgical problem, a "best" method for repair has yet to be identified, as evidenced by documented recurrence rates of 25%–52% with primary open repair. The aim of this study was to evaluate the efficacy and safety of laparoscopic ventral and incisional herniorrhaphy. From February 1991 through November 2002, a total of 384 patients were treated by laparoscopic technique for primary and recurrent umbilical hernias, ventral incisional hernias, and spigelian hernias. The technique was essentially the same for each procedure and involved lysis of adhesions, reduction of hernia contents, closure of the defect, and 3–5 cm circumferential mesh coverage of all hernias. Of the 384 patients in our study group, there were 212 females and 172 males with a mean age of 58.3 years (range 27–100 years). Ninety-six percent of the hernia repairs were completed laparoscopically. Mean operating time was 68 min (range 14–405 min), and estimated average blood loss was 25 mL (range 10–200 mL). The mean postoperative hospital stay was 2.9 days and ranged from same-day discharge to 36 days. The overall postoperative complication rate was 10.1%. There have been 11 recurrences (2.9%) during a mean follow-up time of 47.1 months (range 1–141 months). Laparoscopic ventral and incisional hernia repair, based on the Rives-Stoppa technique, is a safe, feasible, and effective alternative to open techniques. More long-term follow-up is still required to further evaluate the true effectiveness of this operation.     

Incidence and outcome of surgical repair of spigelian hernia

BACKGROUND: A spigelian hernia develops through a defect present in a locus minoris resistentiae between abdominal muscles. It is generally considered rare but is probably underdiagnosed. This study was undertaken to characterize the history, presenting features and efficacy of surgical correction of spigelian hernia. METHODS: Medical and surgical charts of 25 patients treated for a spigelian hernia over 22 years were studied retrospectively. Patients were invited for an outpatient interview and physical examination. RESULTS: Dominant symptoms were an intermittent palpable mass (22 patients) and postural pain (16). A quarter of the patients reported a history of other hernias. Two individuals presented with a painful palpable mass and signs of bowel obstruction necessitating emergency small bowel resection. Hernia repair was performed by primary closure in 20 patients and by use of mesh graft in five. During a mean follow-up of 6.1 years, one early recurrence was observed. Two patients reported mild tenderness in the operated area but were not impaired in daily activities. CONCLUSION: Spigelian hernia is commonly encountered and requires surgical treatment because of the risk of strangulation. Operative treatment is simple and effective in the long term.     

A review of spigelian hernias

Although spigelian hernias are rare, they do not appear to be as uncommon as previously thought. Thirty-one cases, one a bilateral hernia, have been documented over the last ten years at a 350 bed community hospital. Spigelian hernias continue to be misdiagnosed preoperatively, often forgotten in the differential diagnosis, as physical examination is usually of little benefit. In this review younger individuals were more commonly affected than previously expected. Treatment continues to be surgical repair.     

Laparoscopic repair of a spigelian hernia: a case report and literature review.

BACKGROUND: We present a case in which laparoscopy was both diagnostic and therapeutic in a patient with a spigelian hernia. CASE REPORT: A 35-year-old man was referred to the General Surgery Service for evaluation of right lower quadrant abdominal pain of approximately 6 months. The pain was not disabling but was a constant discomfort. The patient did not have any significant past medical or surgical history, and the physical examination was significant only for an area of focal tenderness in the right lower quadrant. Ultrasound and CT scans of the patient's abdomen were unremarkable. A laparoscopic exploration of the area revealed a defect in the area of semilunar and semicircular lines consistent with a spigelian hernia. The patient underwent a laparoscopic herniorrhaphy with placement of a polypropylene mesh. CONCLUSION: This case illustrates the role of laparoscopy in the diagnosis and treatment of spigelian hernias.     

Spigelian Hernia

We report on the evolution in concept and techniques that allowed us to improve the treatment of spigelian hernia, operable in day surgery in 90% of cases and through a preperitoneal and recently a preperitoneal and subfascial prosthetic repair (PHS). Background data. We propose an innovative use of the PHS mesh for spigelian hernia repair. With this new implementation, we confront the standard surgical technique and its postoperative period. Methods. From January 1992 to March 2004, we performed 2,500 hernia surgical operations, including 32 spigelian hernia repairs (1.3% of total case series). The first surgical approach used for 20 of these 32 patients (62.5% of total spigelian hernias), all electively operated on, was a classical preperitoneal repair (Wantz), performed when possible by size of defect and weight (Body Mass Index) of the patient, under local anesthesia and on a day-surgery basis. Our new modified technique takes place through the insertion of a PHS large-type mesh, whose bottom underlay portion lies flat in the preperitoneal space with the connector obliterating the hernial orifice and with the overlay portion lying on the internal oblique muscle, covered by the aponeurosis of the external oblique muscle. Results. Our modification to the classical technique consisted only in the application of a product, such as the PHS, in a hernia defect, which presented with an orifice of the size of the connector and, therefore, was easily repairable with the use of the PHS device. This approach is easier than the preperitoneal approach, its always suitable for local anaesthesia, and it gives a more comfortable postoperative period. The surgical approach may be performed completely in day surgery. Conclusions. We believe that spigelian hernia surgical repair should always be performed by means of a preperitoneal prosthesis under local anaesthesia when the patients clinical and physical conditions allow for it, always in day surgery, and using the PHS mesh when the hernia defect size fits with the connector diameter. This last possibility seems to be easier and more comfortable for the patient in the postoperative period.     

Timely Computed Tomography Scan Diagnoses Spigelian Hernia: A Case Study

A spigelian hernia is a rare cause of acute abdominal pain and its diagnosis is often difficult to make. A CT scan of the patient demonstrated an incarcerated spigelian hernia containing small bowel which had subsequently reduced spontaneously. The patient underwent laparoscopic repair of her spigelian hernia the following day and made a fast and uneventful recovery. This case illustrates the importance of imaging a patient whilst symptomatic if the diagnosis of a spigelian hernia is entertained.     

Incarcerated small bowel in a spigelian hernia

We report on a case of a 68-year-old man who was transferred to our department to undergo surgical treatment of intestinal obstruction and a palpable right-sided abdominal mass. The abdominal computed tomography scan revealed a small bowel obstruction with an incarcerated spigelian hernia. A mesh repair was performed by suturing the mesh to the internal oblique muscle and to the rectus sheath. The postoperative course was uneventful, and no recurrence has occurred during the 2-year follow-up. An urgent operation should be performed as soon as an accurate diagnosis of incarcerated spigelian hernia has been made. Computed tomography should be helpful in order to establish an accurate diagnosis of the incarcerated hernia.     

Laparoscopic treatment of subxiphoid incisional hernias in cardiac transplant patients

BACKGROUND: Symptomatic subxiphoid incisional hernias present difficult surgical problems, especially in immuno-suppressed cardiac transplant patients. Here, we describe the laparoscopic repair of subxiphoid incisional hernias in patients with a history of cardiac transplantation. METHODS: Four patients with subxiphoid hernias who had previously undergone heart transplantation were identified from a prospective database. Each underwent a laparoscopic repair with mesh implantation. RESULTS: Three patients had a previous open repair. The mean age was 62.5 years, an average of 64.3 months after transplantation. At the time of surgery, all patients were immunosuppressed, and each had a subxiphoid, poststernotomy incisional hernia. Gore dual mesh was used in 2 patients, while Parietex mesh was used in 2. Mean operative time was 122 minutes, and all were completed laparoscopically. The mean length of stay was 6.5 days, and the mean defect size was 286.25 cm(2). There was a significant correlation between hernia size and length of stay (P=0.037). Postoperatively, one patient (25%) developed pulmonary edema, and 1 patient (25%) had a prolonged ileus. CONCLUSION: Symptomatic subxiphoid incisional hernias are a challenging surgical problem in patients with a history of sternotomy. Laparoscopic repair is safe and effective in immunosuppressed patients who have previously undergone cardiac transplantation.     

Recurrent Spigelian hernia: a rare cause of colonic obstruction

Spigelian hernia is considered a surgical rarity. Recent articles describe only six recurrent hernias and a scant number of patients with colonic obstruction resulting from incarceration. A patient with intestinal obstruction resulting from recurrent Spigelian hernia with strangulated colon is described. The patient underwent tension-free repair using a prosthetic mesh. Recent literature suggests that the deficiency of connective tissue in patients with hernias justifies the widespread use of permanent mesh for tissue reinforcement and avoidance of recurrences. The rare case presented should be regarded as an illustrative example for application of the tension-free repair principle in the definitive management of recurrent Spigelian hernia. Electronic Publication     

Multiple concurrent bilateral groin hernias in a single patient; a case report and a review of uncommon groin hernias: A possible source of persistent pain after successful repair

IntroductionThe wide use of laparoscopy for groin hernia repair has unveiled “hidden hernias” silently residing in this area. During the open repair of the presenting hernia, the surgeon was often unaware of these occult hernias. These patients postoperatively may present with unexplained chronic groin or pelvic pain.Presentation of caseRare groin hernias are defined according to their anatomical position. Challenges in the diagnosis and management of occult rare groin hernias are discussed. These problems are illustrated by a unique case report of multiple (six) coexisting groin hernias, whereof five were occult and two were rare.DiscussionRare groin hernias are uncommon because they are difficult to diagnose clinically and are not routinely looked for. They are often occult and may coexist with other inguinal hernias, thus posing a diagnostic and treatment challenge to the surgeon, especially if there is persistent groin pain after “successful” repair. MRI is the most accurate preoperative and postoperative diagnostic tool, if there is a clinical suspicion that the patient might have an occult hernia.ConclusionPreperitoneal endoscopic approach is the recommended method in confirming the diagnosis and management of occult groin hernias. A sound knowledge of groin anatomy and a thorough preperitoneal inspection of all possible sites for rare groin hernias are needed to diagnose and repair all defects. The preperitoneal mesh repair with adequate overlap of all hernia orifices is the recommended treatment of choice.     

Laparoscopic management of paraduodenal hernias: mesh and mesh-less repairs. A report of four cases

Background  Paraduodenal hernias are the most common form of internal hernias. There are few reports in the literature, with the total number of reported cases being less than 500. We report four patients with paraduodenal hernias causing intestinal obstruction. Materials and methods  All of the four patients with paraduodenal hernias presented with features of intestinal obstruction. A clinical diagnosis was not made in any of the cases, and computed tomography (CT) scanning was performed to confirm this. They were all successfully managed by a laparoscopic repair. Results  The operating time was 55–72 mins. Postoperatively, three patients recovered uneventfully, while one patient had ileus for 3 days and, thereafter, recovered spontaneously. Hospital stay was in the range 2–6 days. There were no conversions. One patient had recurrent paraduodenal hernia, for which a laparoscopic mesh repair was successfully performed. Discussion  The mechanism of the herniation is thought to be a defective rotation of the superior mesenteric vein during embryonic development. Paraduodenal hernias are not high on the list of differentials for bowel obstruction. Some form of surgery is mandatory for all cases. The inferior mesenteric vein has to be sacrificed in some cases to facilitate reduction of the hernia contents. A mesh repair is reserved for large defects and recurrent hernias. Laparoscopic repair has been infrequently reported in the literature. Based on our experience, the laparoscopic approach seems to be effective in the repair of paraduodenal hernias. It carries all of the benefits of minimal access surgery, while providing a sound repair.     

Laparoscopic repair of Morgagni hernia

Background Foramen of Morgagni hernias are rare diaphragmatic hernias. They account for 3–5% of all diaphragmatic hernias and the majority of the cases are asymptomatic. They are caused by trauma, obesity or pregnancy. With the advancements of laparoscopic surgery, laparoscopic repair has become an excellent alternative to open repair for Morgagni hernias. We report five cases of Morgagni hernia repaired with the laparoscopic approach in conjunction with a review of the literature. Patients A retrospective review comprised five patients who had a Morgagni hernia repaired with a laparoscopic approach. Data from these patients were collected for the period between February 2001 and May 2005. Results The average age at operation was 61. The anatomic pathology was detected preoperatively using X-rays and computerized tomography (CT) scans in four of our patients. Hernia was detected incidentally in one patient during an elective cholecysectomy. Three hernias were right-sided and two were left-sided. The contents of the hernias were omentum and transverse colon in the majority of the patients. The hernia was repaired with a laparoscopic approach in all patients. Four patients had composite mesh repair and one patient had primary closure with nonabsorbable sutures. There were no postoperative complications and all patients tolerated laparoscopic repair. There were also no recurrences during follow-up. Conclusions Laparoscopic repair is a candidate to be a standard treatment for Morgagni-type hernias. It is an effective and safe technique and can be performed by all compotent general surgeons with a certain learning curve. It has several advantages relative to the open operation.     

Spigelian hernia in children: low versus classical

Purpose

Pediatric spigelian hernias are very rare. They are often missed or misdiagnosed. A series of cases with spigelian hernia, presented to a tertiary care center are presented here with emphasis on different anatomy of spigelian hernias with cryptorchidism and those without associated cryptorchidism.

Incisional hernia repair in Sweden 2002

Incisional hernia is a common problem after abdominal surgery. The complication and recurrence rates following the different repair techniques are a matter of great concern. Our aim was to study the results of incisional hernia repair in Sweden. A questionnaire was sent to all surgical departments in Sweden requesting data concerning incisional hernia repair performed during the year 2002. Eight hundred and sixty-nine incisional hernia repairs were reported from 40 hospitals. Specialist surgeons performed the repair in 782 (83.8%) patients. The incisional hernia was a recurrence in 148 (17.0%) patients. Thirty-three per cent of the hernias were subsequent to transverse, subcostal or muscle-splitting incisions or laparoscopic procedures. Suture repair was performed in 349 (40.2%) hernias. Onlay mesh repair was more common than a sublay technique. The rate of wound infection was 9.6% after suture repair and 8.1% after mesh repair. The recurrence rate was 29.1% with suture repair, 19.3% with onlay mesh repair, and 7.3% with sublay mesh repair. This survey revealed that there is room for improvement regarding the incisional hernia surgery in Sweden. Suture repair, with its unacceptable results, is common and mesh techniques employed may not be optimal. This study has led to the instigation of a national incisional hernia register.     

Laparoscopic repair of bilateral spigelian and inguinal hernias

Spigelian hernias are rare and difficult to diagnose. Treatment has previously been limited to open surgical repair. We report the successful laparoscopic repair of bilateral spigelian and inguinal hernias using mesh. Received: 14 January 1997/Accepted: 11 April 1997