Richter's hernia through a Spigelian defect of the abdominal wall

A 78-year-old healthy woman with no previous surgeries or history of trauma presented with a painful abdominal mass for 1 day. The computed tomography (CT) scan of the abdomen demonstrated a partial herniation and strangulation of the cecum (Richter's hernia) between the internal and external oblique muscles through the linea semilunaris (Spigelian hernia). The challenging clinical diagnosis of Spigelian hernias and their surgical treatment options are discussed.     

A differential diagnosis in chronic lower abdominal pain

INTRODUCTIONSpigelian hernias represent 0.12–2.4% of all abdominal wall hernias. Its diagnosis is elusive and requires a high level of conjecture given the disease rarity, vague associated abdominal complaints and frequent lack of consistent physical findings.PRESENTATION OF CASEA 60-year-old woman presented with a history of chronic pain in the left lower side of the abdomen. The patient was treated for several diseases with no relief of symptoms. Abdominal ultrasound showed a Spigelian hernia in the lower left abdomen and surgery was scheduled for treatment.DISCUSSIONA SH is generally an inter-parietal hernia, meaning that the pre-peritoneal fat and the hernia sac penetrate the trasnversus abdominis and internal oblique muscles but remain behind the external oblique aponeurosis. In most of the patients the lack of clinical signs demands radiological investigation. That's the importance of the high grade of suspicious of the disease during the physical exam. The surgical repair is necessary due to the high risk of incarceration-related complications which can occur in up to 21% of cases.CONCLUSIONIt's important to think in the Spigelian hernia as cause of lower abdominal pain to prompt indicate surgical repair and provide the patient's symptom relief. Also the type of repair is dependent on the surgeon's choice and also the means available in each center.     

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.     

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.     

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.     

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.     

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.     

Modifications to Rives technique for midline incisional hernia repair

Between 1990 and 1997, 284 patients were treated in our hospital for abdominal hernias. In the original group, 239 patients (84.15%) had midline hernia, and 45 (15.8%) had lateral hernia. A total of 152 midline hernia patients (63.5%) were treated using our variant of Rives technique. In all these cases, preperitoneal and retromuscular polypropylene mesh was used as a reinforcement and was subsequently attached by means of absorbable sutures to the external border of the rectus muscles. There were no deaths. A total of 42 of all patients operated on (27.6%) suffered from long-term postoperative pain. In seven cases (4.6%) it was necessary to remove the prosthesis because of chronic infection, and there were two recurrences in patients in whom the prosthesis had to be removed. In our experience, the Rives technique is a suitable and safe treatment for the repair of midline incisional hernias. The use of absorbable sutures and fixation of the mesh to the external oblique aponeurosis can reduce the original problems of abdominal pain and unaesthetic skin scars. Electronic Publication     

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.     

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.     

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.     

The use of an underlay polypropylene mesh in complicated incisional hernias: sucessful French surgical technique

BACKGROUND: Incisional hernia repair with conventional techniques is associated with high recurrence rates of 30-50%. Surgical repair using different prosthetic biomaterials is becoming increasingly popular. On the basis of the favourable results by French surgeons, the results of underlay prosthetic mesh repair using polypropylene mesh in complicated and recurrent incisional hernias have been studied. METHODS: After preparation and excision of the entire hernia sac, the peritoneum and posterior rectus sheath are closed with a continuous looped polyglyconate suture. The prosthesis used for the midline hernias is positioned on the posterior rectus sheath and extends far beyond the borders of the myoaponeurotic defect. The prosthesis for lumbar and subcostal hernias is placed in a prepared space between the transverse and oblique muscles. Intraperitoneal placement of the mesh must be avoided. Between January 1997 and September 1998 a total of 57 incisional hernia repair (25 primary hernias, 32 recurrent hernias) have been performed using this technique (28 women, 29 men, mean age 56+/-13 years). RESULTS: Local complications occurred in 6 patients (11%). One patient suddenly died on the 3rd postoperative day from severe pulmonary embolism (mortality 1,7%). Thirthy-seven patients with a minimum follow-up of 6 months were reexamined clinically (follow up time 6-33 months). Till now one recurrent hernia has been observed. There were only minor complaints like a feeling of tension in the abdominal wall (n = 3) and slight pain under physical stress (n = 9). CONCLUSIONS: The aforementioned technique of underlay prosthetic repair allows an anatomical and consolidated reconstruction of the damaged abdominal wall with excellent results and low complication rates especially in high risk patients and complicated hernias.     

Incisional herniation induces decreased abdominal wall compliance via oblique muscle atrophy and fibrosis

OBJECTIVE: The purpose of this study is to measure abdominal wall myopathic histologic and mechanical changes during incisional herniation and its effect on incisional hernia repairs. SUMMARY BACKGROUND DATA: Unloaded skeletal muscles undergo characteristic atrophic changes, including change in fiber type composition, decreased cross-sectional area, and pathologic fibrosis. We hypothesize that these atrophic changes decrease muscle elastic properties and may contribute to the high laparotomy wound failure rate observed following incisional hernia repair. METHODS: A rat model of chronic incisional hernia formation was used. Failing midline laparotomy incisions developed into incisional hernias. Controls were uninjured and sham laparotomy (healed) groups. Internal oblique muscles were harvested for fiber typing, measurement of cross-sectional area, collagen deposition, and mechanical analysis. Mesh hernia repairs were performed on a second group of rats with chronic incisional hernias or acute anterior abdominal wall myofascial defects. RESULTS: The hernia group developed lateral abdominal wall shortening and oblique muscle atrophy. This was associated with a change in the distribution of oblique muscle fiber types, decreased cross-sectional area, and pathologic fibrosis consistent with myopathic disuse atrophy. These muscles exhibited significant decreased extensibility and increased stiffness. The healed (sham) laparotomy group expressed an intermediate phenotype between the uninjured and hernia groups. Recurrent hernia formation was most frequent in the chronic hernia model, and hernia repairs mechanically disrupted at a lower force compared with nonherniated abdominal walls. CONCLUSIONS: The internal oblique muscles of the abdominal wall express a pattern of changes consistent with those seen in chronically unloaded skeletal muscles. The internal oblique muscles become fibrotic during herniation, reducing abdominal wall compliance and increasing the transfer of load forces to the midline wound at the time of hernia repair.     

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     

Modified Lichtenstein Procedure for Repair of Direct or Indirect Inguinal Hernia by Triangulation of the Inguinal Canal

A modified Lichtenstein hernioplasty procedure was performed, by triangulating the inguinal canal, for indirect or direct inguinal hernia. A series of 276 patients is reported, who underwent a modified Lichtenstein procedure for surgical repair of the indirect or direct inguinal hernia, 32 of which were recurrent hernias. Because of the presence of bilateral hernia in 28 of the cases, the total number of modified Lichtenstein procedures performed was 304. The Lichtenstein hernioplasty procedure was modified by placement of the polypropylene mesh between the Poupart's ligament and the intersection line of the aponeuroses of the external oblique and internal oblique abdominal muscles. The main aim of this modification is to provide stabilization of the inguinal canal. Postoperative pain, and hematoma or seroma formation were very rare in the postoperative period. No recurrence was observed. Based on these results, a modified Lichtenstein hernioplasty procedure with inguinal canal triangulation should be considered for surgical stabilization of the inguinal canal, especially in the case of recurrent hernia.     

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.     

Posterior components separation during retromuscular hernia repair

BACKGROUND: Retromuscular ventral hernia repair with mesh is a durable technique. In this paper, we describe a novel technique which allows for significant mesh overlap via the retromuscular space in cases of massive ventral hernia. METHODS: The retromuscular space is developed laterally, to the edge of the rectus sheath. The posterior rectus sheath is incised, dividing the posterior aponeurosis of the internal oblique. The dissection is carried out laterally between the internal oblique and the transversus abdominis muscle, creating space for a large mesh underlay. RESULTS: We have performed this technique successfully in 20 patients with a mean defect area of 223 cm(2) and a mean mesh area of 698 cm(2). Three patients developed wound complications and none complained of long-term pain or abdominal wall deformity. There has been one recurrence due to technical error after a mean 12-month follow-up. CONCLUSION: This technique of dissection between the internal oblique and transversus abdominis muscles allows for the closure of large hernia defects. The mechanism is two-fold: (1) mobility for closure of the posterior rectus sheath, dorsal to the prosthetic; and (2) increased mobility of the rectus, internal, and external obliques, allowing reconstruction of the linea alba.     

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.     

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 lateral incisional hernia: anatomical considerations for a standardized retromuscular sublay repair

Background  The management of incisional hernias outside the midline remains a challenging procedure. Evidence-based data and even any kind of guidelines for dealing with this problem are still lacking. The aim of the study was to elucidate this field of hernia surgery and give some guidelines for retromuscular sublay mesh repair outside the midline. Materials and methods  Fresh-frozen corpses were used to perform anatomical studies. During all the investigations the main target was to find the layer which can maintain the maximum overlap of healthy tissue with the implanted mesh material. Afterwards the findings were evaluated during clinical situations, using photo-documentation and drawings. Results  The layer between the external oblique muscle and the internal oblique muscle is the ideal place to position the mesh with adequate overlap. Even for subcostal hernias, this layer offers adequate mesh overlap behind the ribs. For lumbar hernias the same plane of dissection is usually useful. Only if the defect is situated close to the bone might preperitoneal dissection and mesh placement be necessary. Conclusion  The repair of lateral hernias must follow the same principles as median sublay repair. With sufficient knowledge of the anatomical layers of the abdominal wall, adequate mesh overlap can be achieved for any kind of lateral hernia. Therefore the retromuscular sublay repair can be regarded as the standard procedure for all types of hernia outside the midline.