Mesh-free laparoscopic spigelian hernia repair

Varied Spigelian hernia mesh repair techniques have been described, although evidence suggests laparoscopy results in less morbidity and shorter hospitalization compared with open procedures. Laparoscopic suture repair of Spigelian hernias is rarely reported. Two patients with small Spigelian hernias (< or =2 cm) were diagnosed and repaired laparoscopically using a transabdominal suture technique. Under laparoscopic guidance, a suture-passer was used to place two or three transfacial, interrupted 0 polypropylene sutures along the horizontal plane of the defect. Sutures were tied extracorporeally and closure was confirmed laparoscopically. These cases spurred a review of world literature (2001-2007) including clinical characteristics, operative techniques, and urgency of operations in Spigelian hernia patients. Data were compared using Fisher's exact test. One year postoperatively, the patients are without sequelae or recurrence. Literature review demonstrated most patients were females (P < 0.001), ranged in age from 60 to 80 years (P = 0.042), and presented with left-sided hernias (P = 0.026). Open mesh repair (182/392 cases; 47%) was the most common technique; however, increasingly articles describe laparoscopic mesh repair. Mesh-free laparoscopic suture repair is feasible and safe. This novel uncomplicated approach to small Spigelian hernias combines the benefits of laparoscopic localization, reduction, and closure without the morbidity and cost associated with foreign material.     

Spigelian Hernia: a Diagnostic Dilemma and Laparoscopic Management

Spigelian hernias, also called as lateral ventral hernias, are rare hernias to present themselves in clinical practice. The significance of these hernias lies in the fact that they are commonly intraparietal hernias and are, hence, difficult to diagnose clinically. Moreover, the neck of these hernias is usually small, posing a fair risk of strangulation. With the advancement in laparoscopic hernia repair, there is evidence that Spigelian hernias too can be repaired laparoscopically, thereby causing less morbidity and shorter hospital stay. Here, we present a rare case of large Spigelian hernia that posed to us as a diagnostic dilemma. The symptoms, clinical findings, and ultrasound of the patient were not specific, and a CT scan had to be used as the measure to confirm the diagnosis. The patient was then managed successfully with laparoscopic intraperitoneal onlay mesh repair. The details of the case and a brief discussion are included.     

Extraperitoneal laparoscopic approach to Spigelian hernia combined with groin hernias

Spigelian hernia is a rare form of abdominal wall hernia. It occurs when peritoneum with or without organs or preperitoneal fat exists through a defect in the Spigelian fascia. A 63 year old male patient complaint of inguinal hernias and Spigelian hernia treated with laparoscopic approach that has been not previously reported in the literature. The use of the laparoscope has simplified the diagnosis, clarified its localization, and facilitated the subsequent repair of these hernias.     

Single-Incision Laparoscopic Repair of Spigelian Hernia

Introduction:Spigelian hernias represent only 1% to 2% of all abdominal wall hernias. The treatment, however, remains controversial but depends on institutional expertise. This case series reports the first experience with single-incision laparoscopic totally extraperitoneal (SILTEP) repair of Spigelian hernias with telescopic extraperitoneal dissection in combination with inguinal hernia repair.Methods:From February 2013 to April 2014, all patients referred with inguinal or Spigelian hernias, without histories of extraperitoneal intervention, underwent SILTEP repair with telescopic extraperitoneal dissection. A single-port device, 5.5 mm/52 cm/30° angled laparoscope, and conventional straight dissecting instruments were used for all cases. Extraperitoneal dissection was performed under direct vision with preservation of preperitoneal fascia overlying retroperitoneal nerves. Inguinal herniorrhaphy was performed with lightweight mesh that covered low-lying Spigelian defects. High-lying Spigelian defects were repaired with additional mesh.Results:There were 131 patients with 186 (92 direct) inguinal hernias and 7 patients with 8 Spigelian hernias (6 incidental, including 1 bilateral and 2 preoperatively diagnosed), with a mean age of 51.3 years and a mean body mass index of 25.1 kg/m². An additional piece of mesh was used for 3 hernias. All Spigelian hernias were associated with direct inguinal hernias, and 8 combined inguinal and Spigelian hernias were successfully repaired with SILTEP repair with telescopic extraperitoneal dissection as day cases. There were no clinical recurrences during a mean follow-up period of 6 months (range, 1–15 months).Conclusions:Combined Spigelian and inguinal hernias can be successfully treated with SILTEP herniorrhaphy with telescopic extraperitoneal dissection. The high incidence of Spigelian hernias associated with direct inguinal hernias suggests a high index of suspicion for Spigelian hernias during laparoscopic inguinal herniorrhaphy.     

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.     

Laparoscopic diagnosis and repair of Spigelian hernia: A case report and literature review

IntroductionSpigelian hernias are a rare type of hernia which protrude through the abdominal wall at the semilunar line. They are especially difficult to diagnose due to their location and non-specific symptoms and are often overlooked because of their positioning between muscular layers. Patients may present with localized pain which can aid the diagnosis. CT and ultrasound are also helpful.Presentation of case: We present the case of a 75-year-old female patient who presented to Hialeah Hospital with a one-year history of abdominal pain localized to the left lower quadrant.DiscussionA Spigelian hernia containing omentum, was found during a diagnostic laparoscopy. The hernia was reduced, and the abdominal defect was repaired via primary repair, reinforced by mesh. The patient recovered uneventfully.ConclusionNonspecific physical exam findings and inconclusive imaging studies represented a diagnostic challenge. Here we discuss a case of a Spigelian hernia discovered through diagnostic laparoscopy.     

Epiploic appendagitis in a Spiegel hernia: A case report and review of the literature

IntroductionSpigelian hernia is a rare differential diagnosis of abdominal pain. It affects mainly women above the fifth decade of life, more on the left side than on the right side, usually with comorbidities that lead to an increase in intra-abdominal pressure, described as risk factors for the outbreak of ventral hernias. The content of a ventral hernia might be an epiploic appendix and lead to appendagitis.Presentation of caseThis article presents the case of an 82-year-old female patient who presented epiploic appendagitis in a Spigelian hernia.DiscussionSpigelian hernia is a rare type of ventral hernia, especially in association with an epiploic appendagitis. A literature search of this rare entity yielded three publications presenting epiploic appendagitis in a Spigelian hernia. The initial approach after the diagnosis should be adequate analgesia associated with surgical correction of the hernia. There is no gold standard treatment for the repair. European and American societies suggest that if there is no palpable nodule, laparoscopic repair is preferable, always using a mesh.ConclusionEpiploic appendagitis in a Spigelian hernia is a rare condition whose diagnosis is a big challenge. However, the correct diagnosis can lead to a shorter hospital stay, with less cost and avoid the use of unnecessary medications.     

The advantage of laparoscopic surgery in the treatment of Spigelian hernia: A report of two cases

Introduction and importanceThe usefulness of laparoscopic surgery in the treatment of Spigelian hernias and the appropriate insufflation pressure remains unclear.Case presentationCase 1 involved an 81-year-old woman presented with a right abdominal protrusion. CT scan demonstrated a defect in the abdominal wall at the lateral edge of the right rectus abdominis muscle. We diagnosed as Spigelian hernia and performed laparoscopic hernia repair. The insufflation pressure was set at 10 cm H ₂ O, and the IPOM method was selected as the repair method. Case 2 involved a 74-year-old male presented with a right abdominal painful bulging. Strangulation was released and CT scan demonstrated a defect in the abdominal wall at the lateral edge of the right rectus abdominis muscle. We diagnosed as Spigelian hernia and performed laparoscopic hernia repair. The insufflation pressure was set at 10 cmH ₂ O, and the repair was performed by the hybrid method.Clinical discussionIn both cases, the positions of the hernia portals marked preoperatively based on the tender areas and confirmed laparoscopically were not accurate. Although Spigelian hernia is a rare disease and various laparoscopic techniques have been reported in recent years, laparoscopic surgery is very useful to obtain an accurate diagnosis and to observe the abdominal wall from inside the abdominal cavity under insufflation, and it is better to decide the repair method according to the situation of each case and institution.ConclusionLaparoscopic surgery is important for accurate diagnosis in surgery of Spiegel's hernia, and insufflation pressure of 10 cmH2O was sufficient.     

Colonic obstruction secondary to incarcerated Spigelian hernia in a severely obese patient

Spigelian hernia is a rare hernia of the ventral abdominal wall accounting for 1-2% of all hernias. Incarceration of a Spigelian hernia has been reported in 17-24% of the cases. We herein describe an extremely rare case of a colonic obstruction secondary to an incarcerated Spigelian hernia in a severely obese patient. Physical examination was inconclusive and diagnosis was established by computed tomography scans. The patient underwent an open intraperitoneal mesh repair. A high level of suspicion and awareness is required as clinical findings of a Spigelian hernia are often nonspecific especially in obese patients. Computed tomography scan provides detailed information for the surgical planning. Open mesh repair is safe in the emergent surgical intervention of a complicated Spigelian hernia in severely obese patients.     

Preperitoneal mesh repair in Spigelian hernia

The first Spigelian hernia was described in 1764. From April 1995 to April 2004, 29 patients underwent 35 Spigelian hernia repair operations in our department. The choice of primary closure or additional mesh was based on the condition of the local tissue. If the tissue appeared of good quality, primary closure was performed; if the tissue was of weak quality, an additional nonresorbable mesh was implanted to induce a stronger scar tissue. Twenty-one Spigelian hernias were repaired using the primary closure method. There were three radiological recurrences, one of which was symptomatic after 10 months and required reoperation. In 14 cases, an additional preperitoneal mesh was implanted. There was no radiological or clinical recurrence in this group. Spigelian hernia repair may therefore have a lower recurrence rate if a preperitoneal mesh is initially implanted.     

The open mesh repair of Spigelian hernia

BACKGROUND: Spigelian hernias are rare defects of the abdominal wall usually appearing between the abdominal muscles, lateral to the rectus abdominis and through a debilitated Spigelian aponeurosis. Recently, mesh repair has been introduced for the treatment of these types of hernias and different approaches have been proposed. METHODS: Nine patients with Spigelian hernia were prospectively treated by placing a mesh prosthesis between the external oblique and the internal oblique muscles, based on principles of mesh repair established by the Lichtenstein group. RESULTS: Five women and 4 men, mean age 75.7 years, were operated on. In 1 patient the Spigelian hernia was an incidental finding during an inguinal hernia repair. Two patients were operated on an emergency basis. Elective operations were undertaken in ambulatory facilities in 3. Two patients had postoperative ecchymosis with no associated morbidity. No recurrences have been observed during follow-up. CONCLUSIONS: Open mesh repair of Spigelian hernias placing the mesh between the external and internal oblique muscles is a simple and safe approach that can prevent morbidity related to other techniques.     

Concurrent Spigelian hernia and falciform ligament hernia in a 67-year-old female

IntroductionInternal abdominal hernias account for 1% of all hernias but 5.8% of all bowel obstructions and hence are of significant clinical importance. Similarly Spigelian hernias account for only 0.12–2% of all abdominal wall hernias.Case presentationWe present and discuss the management of a case that presented with concurrent falciform ligament internal abdominal hernia and Spigelian hernia. We believe this is the first reported case of such an occurrence in the literature.ConclusionDue to the advancements in computer topography (CT) imaging many internal and Spigelian hernias are diagnosed pre-operatively though these scan are not always available or indicated in cases of suspected small bowel obstruction. Due to the high mortality rate of undiagnosed internal hernias a high clinical suspicion must be maintained. The authors recommend laparoscopic trans-abdominal repair of Spigelian hernias in order to examine the abdominal contents and exclude rare, though potentially serious internal hernias.     

Incidence of occult inguinal and Spigelian hernias during laparoscopy of other reasons

BACKGROUND: A true incidence of occult inguinal and Spigelian hernias in adult population is unknown. The frequency of incipient hernias was studied during laparoscopy of other abdominal diseases. METHODS: The 201 laparoscopic procedures included 104 cholecystectomies, 55 fundoplications, 36 diagnostic, and 6 miscellaneous operations. There were 133 females and 68 males with a mean age of 53 +/- 14 years. The orifices of all inguinal and Spigelian hernias were carefully recorded at the beginning of laparoscopy by using 30 degrees optic. RESULTS: The overall frequency of unexpected hernias was 43 of 201 (21%) including 36 (18%) inguinal hernias, 5 (2%) Spigelian hernias and 2 (1%) ventral hernias. The number of hernias was higher in males than in females (P = .003). The most common finding was indirect inguinal hernia in 27 (13%) subjects. Usually hernia orifices were insignificant and only 5 of 201 laparoscopic hernioplasties were undertaken without any complications. CONCLUSIONS: Occult hernia orifices are commonly found in laparoscopic operation. Usually the defects are asymptomatic and hernioplasty is not needed. Herniation of Spigelian fascia is rare (<2%) in adults during laparoscopy.     

Management of Spigelian hernia caused by necrobiotic fibroma of the uterus in a pregnant woman

INTRODUCTIONSpigelian hernias are a rare type of hernia through the Spigelian aponeurosis. Spigelian hernias are very uncommon and constitute only 0.12% of all abdominal wall hernias. These hernias are located in the aponeurosis of the internal oblique muscle and transverse abdominal muscle.PRESENTATION OF CASEA 30-year-old woman at 28 weeks’ gestation was admitted to the obstetrics department due to pain and swelling in the anterior abdominal right region. On inspection, we suspected either a lipoma, a spontaneous hematoma, a tumor of the abdominal wall, or a Spigelian hernia. A Doppler USG and abdominal and pelvic Magnetic Resonance Imaging revealed necrobiotic fibroma of the uterus in Spigelian hernia. The patient was started on dual analgesic and corticotherapy. Overall, the patient improved one week after the acute episode and had no further pain during her gynecologic follow-up.DISCUSSIONWe have reported a first case of Spigelian hernia that was complicated by uterine fibroid. The clinical presentation varies, depending on the contents of the hernial sac and the degree of herniation. MRI is the preferred method for accurately identifying masses of the abdominal wall. Our treatment options were based on the extent of the acute-phase reaction and the venous thrombosis.CONCLUSIONIt is important to differentiate this rare Spigelian hernia from other hernias as the treatment for this hernia is medical rather than surgical. Before the final choice of treatment is made, digestive surgeons should bear this rare hernia in mind.     

Appendicitis in abdominal wall hernia: Case series and literature review

Appendicitis in hernia is a rare disease entity. It usually presents with symptoms and signs of incarcerated hernia, and accurate preoperative diagnosis is difficult. Management includes appendicectomy and hernia repair. Different approaches of appendicectomy have been proposed, including transherniotomy, transabdominal and laparoscopic routes. In this case series, three cases of appendicitis inside different types of abdominal wall hernias, namely incisional, inguinal and Spigelian, are described. A literature review was also performed. Scientific evidence is lacking, and the optimal management remains to be defined.     

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.     

An unusual presentation of an incarcerated Spigelian hernia

Spigelian hernias are rare hernias, occurring through a defect in the Spigelian aponeurosis. Like other hernias, they may contain abdominal contents but are more likely to be incarcerated due to the small size of the fascial defect. Multiple intra-abdominal organs have reportedly been found in Spigelian hernias. A search of the literature showed only nine reported cases in which an appendix has been found within a Spigelian hernia. We present a patient with a history of lower abdominal pain since 10 weeks with a large intra-abdominal mass in the right iliac fossa. Due to abscess formation with spontaneous evacuation through the abdominal wall, drainage and incision were performed and the patient was treated with broad-spectrum antibiotics. An explorative laparoscopy after six weeks showed an incarcerated appendix in a Spigelian hernia.     

Bilateral Spigelian hernia treated by two‐layered prolene mesh

Spigelian hernia is an uncommon variety of abdominal hernias. It has been traditionally treated by tension‐free mesh hernioplasty. We report a rare case of a bilateral Spigelian hernia in an elderly male that was treated by bilateral two‐layeyed prolene mesh hernia system. Rare ventral hernia such as Spigelian hernia with weak abdominal wall can be safely treated by tension‐free mesh repair using bilayered prolene mesh system.     

Repair of giant incisional hernias with polypropylene mesh: a retrospective study.

The aim of the present study was to evaluate the long term results of repair of ventral incisional hernias or of defects in the abdominal wall using polypropylene mesh. Eighty-eight patients were operated on from 1979-1996, inclusive. Abdominal protrusion was found in 78 patients. Fifty-one of these patients had previously had an incisional hernia repaired and the remaining 10 patients had an abdominal wall defect as a result of excision of a malignant tumour. The polypropylene mesh was placed extraperitoneally and sutured with two rows of interrupted stitches, using non-absorbable sutures. Recurrence of the hernia was found in 10 of the 67 patients with incisional hernia. Eight patients had a relaxation of the muscles of the abdominal wall. Perioperative complications consisted of infection (n = 4), embolism (n = 1), haematoma (n = 1), and pneumonia (n = 3, one fatal), and one fatal bowel perforation. Median follow up time was 5.7 years (range 0-17). It is therefore possible to obtain acceptable results after repair of larger incisional hernias even if they had been repaired before.