Spigelian hernia: CT and ultrasonography diagnosis

The diagnostic potential of CT and sonography in detecting clinically unrecognized cases of spigelian hernia is illustrated and discussed. These imaging modalities can promptly and reliably diagnose spigelian hernia based on the following findings: (1) peritoneal and muscular defect along the spigelian line in the lower abdomen; (2) intraparietal location of the hernial sac; and (3) hernial sac containing omentum and/or mesentery and loops of bowel. Two recently diagnosed cases are presented together with a short review of the literature.     

Spigelian hernia: diagnosis by high-resolution real-time sonography

The purpose of this study was to demonstrate the role of high-resolution real-time sonography in the diagnosis of spigelian hernias. The sonographic findings in three patients, two of whom had surgical confirmation, are presented. We also discuss and demonstrate the anatomic and pathologic factors that predispose to these hernias. In all three cases, real-time high-resolution sonography was very helpful in providing detailed images of the abdominal wall defect, the hernial sac and contents, and the relationship of the contents to the spigelian fascia and the rectus, external oblique, and internal oblique muscles. The role of the Valsalva and other provocative maneuvers in demonstrating the "in and out" sliding movement of the contents of the hernia also is discussed. Although the number of cases in our study is small, we think that this modality may be the most effective means for establishing this diagnosis, especially in cases with equivocal clinical findings.     

Preoperative radiographic diagnosis of a Spigelian hernia containing large and small bowel

A case is reported in which the preoperative diagnosis of a Spigelian hernia containing both large and small bowel was made by radiographic means. The anatomy, clinical findings, and radiologic picture of this condition are discussed.     

Sonographic findings in Richter's hernia

Richter's hernia can present as a diagnostic challenge because of its usually small size and eccentric bowel wall involvement with limited luminal compromise. This article describes a case of Richter's hernia in the femoral canal and illustrates its sonographic features.     

Spigelian hernia in laparoscopic surgery

Summary

Objective: To understand the increased frequency of Spigelian hernia, a relatively rare phenomenon, in laparoscopic surgery. Study design: Chart review of five patients in whom Spigelian hernia occurred in the authors' practices in teaching hospitals in Los Angeles, United States, and Vienna, Austria. Results: Spigelian hernia occurred only in conjunction with the use of 10 mm trocar insertion lateral to the rectus muscles. The diagnosis was made by physical examination, palpation, and confirmed by ultrasound. Patients complained of symptoms of bowel obstruction. In no cases was bowel resection necessary. The incidence of this phenomenon was greater than reported in the general population. Conclusions: The rare Spigelian hernia, while not a true hernia, has an increased incidence in surgery using large trocars. While the mechanism is unknown, surgeons should be aware of the potential complication while evaluating patients for abdominal pain following laparoscopic surgery.     

Gangrenous appendicitis in a strangulated obturator hernia

Only two cases of appendicitis in strangulated obturator hernia have been previously reported. In the present case, an 83-year-old woman had fatal anaerobic myonecrosis of the thigh that resulted from gangrenous appendicitis in the right obturator foramen. Early diagnosis, prompt surgical intervention, and perioperative resuscitation are critical for survival in a case of appendicitis in a strangulated obturator hernia with thigh sepsis, especially when it occurs in an elderly, emaciated female patient.     

Spigelian hernia: uncommon or unrecognized?

Spigelian hernia may be a more common clinical entity than previously recognized or reported. We report seven cases, four diagnosed and treated in the past 12 months at a large military hospital. Diagnosis can be difficult because of failure to consider it, incomplete understanding of the anatomy, and the nonpalpable intraparietal nature of the hernia. A careful history and physical examination are essential. Any patient with persistent localized pain in the proper anatomic location--just lateral to the outer border of the rectus muscle and usually below the umbilicus--warrants surgical exploration.     

Spigelian hernia with unusual content

We present a case of a primary tumor of the peritoneum that manifested as a spigelian hernia in a 74-year-old woman. Multidetector computed tomography showed a large heterogeneous mass located subcutaneously on the right spigelian line connected to the abdominal cavity. We found no previous report describing a primary peritoneal tumor in a spigelian hernia.     

Spigelian hernia: CT findings and clinical relevance

Objective

The purpose of our study was to evaluate the clinical relevance of preoperative CT in distinguishing between the two subtypes of spigelian hernia (SH).

Materials and methods

We reviewed retrospectively the CT images of 35 patients. The patients were divided into two groups on the basis of the SH subtype: interstitial SH group (n = 15) and subcutaneous SH group (n = 20). Clinical characteristics of patients and CT findings were analyzed. Bowel ischemia on surgery was also noted.

Results

Sixteen right hernias and 19 left hernias were observed. Fifteen interstitial SH (43%) and 20 subcutaneous SH (57%) were found. No type of content showed a statistically significant association with one or other subtype of SH. Nine of the 26 patients presenting with SH with SB content showed signs of SBO on CT. Closed-loop SBO on CT was present in 5 of the 26 patients with SB content. An interstitial SH was observed in all of these 5 patients (p = 0.039). Surgery was performed on 10 patients. Bowel ischemia was found on surgery in 4 patients and showed no statistically significant association with a particular subtype of SH (p = 0.6).

Conclusion

Our study shows the importance of performing CT in SH. CT provides the diagnosis of SH, shows SH content, and demonstrates the presence of SBO or closed-loop SBO. Moreover, the distinction between the two subtypes of SH on CT appears to be of clinical relevance since closed-loop SBO is statistically associated with interstitial SH and the optimal surgical approach may differ.     

A case of Spigelian hernia after laparoscopic incisional hernia repair

Laparoscopic ventral hernia repair with intraperitoneal onlay mesh reinforcement is often performed in clinical practice. We herein describe a patient who developed a Spigelian hernia at the edge of the mesh due to rupture of the muscular layer in the abdominal wall. A 69-year-old woman developed a left-sided abdominal bulge 15 months after laparoscopic ventral hernia repair. CT showed a 33-mm defect in the abdominal wall at the lateral edge of the left abdominal rectus muscle with an intestinal prolapse through the defect. She was diagnosed with a Spigelian hernia and underwent operation. The hernia orifice was located at the aponeurosis of the transverse abdominal muscle where the thread had been used to fix the mesh through all layers of the abdominal wall. This report details a case of a Spigelian hernia after laparoscopic ventral hernia repair.     

超声诊断右侧腹股沟疝卵巢嵌顿1例

<正>患儿女,40 d,因触及右侧腹股沟区包块2 d就诊。超声检查:右侧腹股沟区探及大小约18 mm×13 mm团块状弱回声,与腹腔相通(图1),相通处约5 mm;内见多个囊泡状结构,最大者约8 mm×8 mm(图2),CDFI示其内可见短条样血流信号(图3)。缺损向体表突出而成,是外科常见疾病之一。由于卵巢输卵管位置前倾,可达腹前壁腹股沟管处,因此疝内容物除小肠、大网膜外,还可以是卵巢、输卵管及子宫,而且常常不易回纳,出现嵌顿,引起坏死。本例患儿疝内容物即为卵巢。当超声发现疝内容     

Spigelian hernia presenting as an appendicular mass

Incarcerated spigelian hernias are a rare cause of acute abdomen. The clinical diagnosis of incarcerated spigelian hernia can be a challenge in the absence of definite signs. Reported here is a case of a strangulated spigelian hernia that mimicked an appendicular mass and was discovered on CT scan of the abdomen and pelvis.     

Ultrasound-guided reduction of an incarcerated Spigelian hernia

Spigelian hernia is a rare abdominal hernia. We report a case in which its diagnosis proved ultrasonography to be an effective tool, not only to diagnose an incarcerated Spigelian hernia but, moreover, to reduce it by echo-probe palpation. Ultrasound (US) is an aid for therapy of various diseases. In our experience, US-guidance prevented possible damage related to forced and wrongly applied compression during the hernia reduction, and allowed us to perform surgical repair on an elective basis. In conclusion, if an incarcerated Spigelian hernia is suspected, a US examination should be done on an emergency basis to confirm the diagnosis and to attempt US-guided reduction.     

Richter's hernia after an intraperitoneal mesh repair

For ventral hernia repair, laparoscopic surgery offers various advantages, including the application of a large mesh using the intraperitoneal approach. However, improper closure of the port site may lead to serious complications. Port‐site hernia is a rare outcome of inadequate repair of the fascial or peritoneal layer, and Richter's hernia in a high risk patient, in the presence of an intraperitoneal mesh, is a particularly challenging scenario. Herein, we present a 58‐year‐old woman who, after a ventral hernia repair, was diagnosed with a small bowel hernia through a 10‐mm port site. The patient complained of pain and mild swelling at the port site in the postoperative period, and her symptoms indicated intestinal obstruction. Clinical evaluation and abdominal X‐ray confirmed the diagnosis, and early laparoscopic re‐exploration and management were the key to a favorable outcome.