Spigelian hernia: An unusual presentation of an uncommon entity

Introduction

Spigelian hernia (SH) is an uncommon defect of the abdominal wall that occurs through the spigelian fascia. SH has varied, non-specific, dubious clinical features which makes diagnosis extremely difficult at times. Pain is common and is invariably associated with the narrow neck of the sac; atypically, our patient had no history of pain at any time.

Case Report

Herein, we present the case of an extremely rare variety of hernia in an 83-year-old male patient. Clinical examination revealed globular, subcutaneous, soft, reducible swelling measuring 6 × 8 cm over the left iliac fossa of this patient with visible cough impulse. Ultrasonography (USG) showed a 2.5 × 2.5 cm muscle defect in the anterior abdominal wall above and lateral to the left inguinal region.

Discussion

SH is a rare form of ventral hernia. The commonest presenting feature is pain, or an anterior abdominal wall lump or incarceration. Real-time USG can easily detect the defect and demonstrate the cough impulse. Both open and laparoscopic approaches have been elected for repair.

Conclusion

Radiological investigations must be undertaken, and surgery should always be performed to avoid risk of strangulation or incarceration of the hernia. Although laparoscopic repair has gained popularity, the open approach remains the gold standard in emergency situations.     

Incarcerated Spigelian hernia mimicking obstructing colon carcinoma

Spigelian hernia is a ventral abdominal hernia that only rarely causes incarceration or strangulation of the bowel. There are few reports in the surgical literature of colonic obstruction secondary to incarcerated Spigelian hernia. In this paper, we present a patient with an incarcerated sigmoid colon in a Spigelian hernia sac, mimicking on contrast enema an obstructing carcinoma. Accurate diagnosis was made pre-operatively by computed tomography (CT), and the hernia was repaired by polypropylene mesh in a tension-free manner.     

Spigelian hernia presenting as an incarcerated incisional hernia

Summary Spigelian hernia, first described at the 18th century, is a rare ventral abdominal hernia occuring through the spigelian fascia. The diagnosis is difficult especially when there is no palpable mass. The case presented here had a spigelian hernia mimicking an incarcerated incisional hernia. This patient had undergone an appendectomy through a right paramedian incision proviously. Three years later she was operated for a suspected incisional hernia. Exploration did not reveal any defects in the external oblique aponeurosis so no further exploration was done. Our operative findings showed also an intact external oblique aponeurosis but when incised a spigelian hernia was observed beneath this structure, which was repaired promptly. A high index of suspicision is necessary for diagnosis both pre and intraoperatively.     

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.     

Spigelian hernia. Diagnosis and surgical treatment

Spigelian hernia (SH) is a rare partial abdominal wall defect; its manifestation is rare. Seven cases were observed--4 females and 3 males with mean age of 56.5 years (range 38-65)--in 857 patients operated for hernia (0.8%) between 1995 and 2003. Ultrasound examination avoid the diagnosis and marked the fascial defect, measuring diameter and sac contents. In all cases a surgical approach with an epicritic incision has be done and the fascia defect closed with properitoneal and subfascial polypropylene mesh (Prolene Hernia System, PHS). All patients underwent to follow-up demonstrating no recurrences or complications like mesh suppuration or dislocation.     

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.     

Spigelian hernia associated with strangulation of the small bowel and appendix

Spigelian hernia is a rare lateral ventral abdominal hernia. These clinically elusive hernias are treacherous and have a real risk of strangulation. We present a patient with a strangulation of the small bowel and appendix in a right spigelian hernia, which was accurately demonstrated by spiral computerised tomography preoperatively and successfully treated with primary suturing reinforced with polypropylene mesh. With a high index of suspicion and the use of modern radiological technique, these "bewildering" hernias can be diagnosed and repaired relatively safely.     

Spigelian hernia: an up-to-date

Nine cases of Spigelian hernia occurred and surgically treated in the years 1992-1997 are reported. Spigelian hernias were observed in 5 females and 3 males with mean age of 62.1 years (range 49-70). In 5 cases prosthetic repair has been done with preperitoneal mesh and a very good outcome. In a 61 years old obese female spigelian hernia was bilateral. Her left sided hernia needed an emergency operation for strangulation. Hernia has been repaired by simple suture and recurred early. For the diagnosis of Spigelian hernia it is essential to remember it inside the "Spigelian belt". The satisfactory results obtained at present by prosthetic repair are underlined.     

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.     

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.     

Postoperative cicatrical hernias of the Spigelian line]

Among 640 patients operated upon due to multiple recurrences of ventral hernias Spigelian hernia was revealed in 11 cases, and primary surgery for Spigelian hernia was performed only in one case. The diagnosis of Spigelian hernias in this category of patients presents considerable difficulties. It is the authors' opinion that operative treatment of Spigelian hernias after repeat operations on abdominal organs should be performed with application of allomaterials. As an alloprosthesis the authors recommend to use a specially manufactured material from Lavsan threads No 200 with 2-3 mm mesh. An examination of patients 10-12 years following herniotomy indicated that neither recurrent hernia nor complications related with the utilization of Lavsan alloprosthesis were noted in any case.     

Giant spigelian hernia due to abdominal wall injury: a case report

Spigelian hernia is a rare clinical entity. It is difficult to diagnose due to its location. In this article we report the case of a giant spigelian hernia consequent to abdominal wall injury. The neck of the hernia was 10 cm in diameter. We repaired this hernia with a polypropylene mesh.     

Spigelian hernias: repair and outcome for 81 patients

Spigelian hernia is a rare partial abdominal wall defect. The frequent lack of physical findings along with vague associated abdominal complaints makes the diagnosis elusive. A retrospective review of Mayo Clinic patients was performed to find all patients who had undergone surgical repair of a Spigelian hernia from 1976 to 1997. Patients were scrutinized for presentation, work-up, therapy, and outcome. The goal of this study was to obtain long-term outcome. The study was set in a tertiary referral center. There were 76 patients in whom 81 Spigelian hernias were repaired. Symptoms most commonly included an intermittent mass (n = 29), pain (n = 20), pain with a mass (n = 22), and bowel obstruction (n = 5). Five patients were asymptomatic. Preoperative imaging was performed in 21 patients and correctly diagnosed the hernia in 15. Spigelian hernias were repaired by primary suture closure (n = 75), mesh (n = 5), and laparoscopic (n = 1) techniques. Eight patients (10%) required emergent operations. Thirteen hernias (17%) were found to be incarcerated at the time of the operation. Overall mean follow-up for the 76 patients was 8 years, with three hernia recurrences identified. Spigelian hernia is rare and requires a high index of suspicion given the lack of consistent symptoms and signs. An astute physician may couple a proper history and physical examination with preoperative imaging to secure the diagnosis. Mesh and laparoscopic repairs are viable alternatives to the durable results of standard primary closure. Given the high rate of incarceration/strangulation, the diagnosis of Spigelian hernia is an indication for surgical repair.     

Spigel hernia: a single center experience in a rare hernia entity

Introduction

Spigelian Hernia (SH) is a rare ventral hernia with a high incarceration and obstruction risk. The purpose of this study is to present our experience in diagnosis and treatment of this rare hernia entity.

Materials and Method

Sixteen patients underwent surgery for SH between 2000 and 2010. Analysis parameters included demographic data, location of defect, diagnostic methods, mode of surgery, mode of anesthesia and postoperative outcome.

Results

Mean follow-up was 98?months. The gender bias was 37.5?%: 62.5?% (man: woman) with mean age of 56?years. The SH was right-sided in 56.25?%, left-sided in 37.5?% and bilateral in 6.25?% of the cases. The preoperative diagnosis was correct in 25?% of the cases. Eight patients (50?%) underwent elective surgery, and the other 8 patients (50?%) underwent surgical treatment on emergency basis. Two patients underwent open hernia repair by primary suture, 13 patients underwent open mesh repair and one patient underwent a laparoscopic mesh repair. Neither a major hernia repair-related complication nor mortality could be registered.

Conclusion

SH is a rare entity with a wide clinical spectrum and difficulties in preoperative diagnosis. Once the diagnosis of SH is established, a surgical treatment is indicated because of the high complication risk.     

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.     

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.     

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 a Spigelian hernia: an unusual cause for a tender right iliac fossa mass

Spigelian hernias are a rare type of hernia through the Spigelian aponeurosis, whose contents commonly include omentum or small bowel. In the absence of incarceration or strangulation, they can be difficult to diagnose clinically. In the emergency setting, they can present rarely as a painful abdominal mass and computed tomography provides a reliable diagnostic imaging modality. We report an emergency presentation of a Spigelian hernia containing the appendix.     

Complicated Spigelian hernia: our experience

We present a case of complicated Spigelian hernia presented with symptoms of intestinal occlusion, in a 50 years old woman. Spigelian hernia represents 1-2% of all abdominal hernias and can occur anywhere along the semicircular line of Douglas. The patient underwent emergency surgery followed by polypropylene plastic repair. The postoperative course was uneventful and the patient was discharged on day 8 post intervention in good general conditions. The 2 years follow-up showed no recurrence of the disease. Clinical examination is the foundation of the diagnosis, whereas radiological findings (ultrasonography, TC) allow the exclusion of other pathologies in the differential diagnosis. The preoperative diagnosis is difficult, mainly because of the non-specificity of symptoms as well as the few cases reported in the literature. In conclusion, we remark that the surgery remains the most effective treatment of Spigelian Hernia.