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.     

Spigelian hernias: a prospective analysis of baseline parameters and surgical outcome of 34 consecutive patients

Most of the papers published on spigelian hernia are either case reports or small retrospective series. In this prospective multicenter study, we aimed to outline the specific features of spigelian hernias and patients’ characteristics more clearly. Surgeons enrolled patients to be entered into the database as they diagnosed and treated the hernias at will. The baseline and surgical outcome parameters were noted in each patient. A painful mass was the main presenting complaint in half of 34 patients. Accurate preoperative diagnosis was possible in 31 patients. Open intraperitoneal mesh repair was the preferred technique. The mean hospital stay and time until return to normal daily activities were 4.1 and 15.6 days. Although a rare condition, diagnosis of a spigelian hernia is not difficult once remembered. Its surgical repair seems to cause few complications and is very well tolerated by the patient.     

Facilitation of open spigelian hernia repair by laparoscopic location of the hernial defect

A spigelian hernia is an uncommon entity. The diagnosis and location of this disorder often is difficult. We present a case in which the hernia could not be located at the time of operation, despite exploration. Laparoscopy performed subsequently enabled location and repair of the hernia under direct visualization, with good results. Laparoscopy is advocated as an adjunct to the diagnosis and treatment of spigelian hernia.     

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.     

Endometriosis in a Spigelian Hernia Sac: An Unexpected Finding

Describes the existence of endometrioma in a spigelian hernia sac. Spigelian Hernia is a rare ventral hernia, presenting difficulties in diagnosis and carrying a high incarceration and obstruction risk. Endometriomas occur due to implantation of endometrial cells into a surgical wound, most often after a cesarean delivery. A 37-year-old woman presented to our department with persistent abdominal pain, exacerbating during menses, and vomiting for 2 days. Physical examination revealed a mass-like lesion in the border between the left-upper and left-lower quadrant. Ultrasound examination was inconclusive and a computed tomography scan of the abdomen revealed an abdominal wall mass. During surgery, a spigelian hernia was found 5 to 7 cm above a previous cesarean incision. Tissue like “chocolate cysts” was present at the hernia sac. Hernia was repaired while tissue was excised and sent for histological examination that confirmed the diagnosis. Spigelian hernia is a hernia presenting difficulties in diagnosis and treatment. Endometrioma in a spigelian hernia sac is a rare diagnosis, confirmed only histologically. Clinical suspicion can be posed only through symptoms and thorough investigation.Key words: Spigelian hernia, Endometriosis, Cesarean sectionSpigelian hernia (SH) is a rare ventral hernia occurring through semiluminar line and carrying a high incarceration risk. Endometrioma is implantation of endometrial tissue. Authors present a rare case of symptomatic endometriomas discovered within a spigelian hernia sac.     

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.     

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.     

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.

Recurrent spigelian hernia: a case report

Only seven cases of spigelian hernia recurrence have been previously reported. We report the case of a 75-year-old male patient who presented with extremely large hernia after four unsuccessful suture repairs over 12 years. The abdominal wall defect was repaired with Marlex mesh. The advantage of using prosthetic mesh in both primary and recurrent spigelian hernia is supported by recent clinical research data indicating a generalized collagen metabolism disorder in patients with primary and recurrent hernia. Mesh repair allows for tension-free anatomic restoration of distorted tissues associated with repair failures.     

Simultaneous laparoscopic totally extraperitoneal repair for concurrent ipsilateral spigelian and indirect inguinal hernia

Simultaneous unilateral spigelian and inguinal hernia is uncommon. Majority of the approaches to repair of spigelian hernia is open surgery. We report our technique of a simultaneous repair of both spigelian and inguinal hernia using the totally extraperitoneal laparoscopic mesh repair.     

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.     

Lateral ventral (spigelian) hernias in infants and children.

Lateral ventral hernias are found in the spigelian fascia lateral to the junction of the arcuate and semilunar lines and below the level of the umbilicus. Three cases are reported in infants and children. Diagnosis depends on finding an unusual mass on the anterior abdominal wall and palpation of the rim of the hernia defect upon reduction of the mass. A spigelian hernia may be misdiagnosed easily if the examiner is unaware that it can occur in childhood. The edge of the defect must be outlined while the child is straining, prior to induction of anesthesia, as the rim may be difficult to find when the patient is asleep.     

Open vs laparoscopic repair of spigelian hernia: a prospective randomized trial

HYPOTHESIS: The elective treatment of a spigelian hernia is still under discussion, fundamentally owing to its rarity. The purpose of the study is to analyze the elective surgical treatment of spigelian hernia. DESIGN: A prospective, randomized controlled trial. SETTING: University teaching hospital. PATIENTS AND INTERVENTIONS: Two surgeons performed 11 conventional and 11 laparoscopic repairs for a spigelian hernia, alternating roles as primary surgeon and assistant. Each time the type of technique was randomly chosen using a computerized program. MAIN OUTCOME MEASURES: Epidemiological, clinical, and surgical factors are analyzed according to treatment, ie, the open or laparoscopic approach. RESULTS: The statistical study shows no significant differences for epidemiological or diagnostic factors, but it does show significant advantages for laparoscopy in terms of morbidity (P<.05) and hospital stay (P<.001). CONCLUSION: The approach using extraperitoneal laparoscopy is the technique that offers best results in the elective treatment of spigelian hernia.     

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.     

Ultrasonography of the abdominal wall in the diagnosis of spigelian hernia

Gray scale ultrasonography of the abdominal wall was used in the evaluation of patients suspected to have spigelian hernia. This diagnostic technique was found to be accurate in displaying defects in the spigelian fascia. Application of this technique to patients with mild abdominal tenderness may result in the detection of more cases of spigelian hernia and also prevent unnecessary exploration in patients in whom the sonogram is normal.     

A man with recurrent lower abdominal pain: Spigelian hernia

Recurrent abdominal pain due to spigelian hernia (SH) is rare and notoriously difficult to diagnose. This is particularly true when patient present with pain only without visible or palpable mass. Ultrasonic scanning and computed tomography is valuable in diagnosing this rare condition. However, for a small hernia with its content reduced spontaneously during examination, even computed tomography will miss the diagnosis. In the era of laparoscopic surgery, the role of laparoscopy in the management of recurrent abdominal pain of unknown origin has become more and more important. It is especially true in the management of SH as it is both diagnostic and therapeutic. We report a case of SH presented as recurrent lower abdominal pain of unknown origin and its successful diagnosis and treatment by laparoscopic approach.     

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.     

Abdominal wall ectopic testis mimicking spigelian hernia

We encountered a patient with a swelling in the left lateral infraumbilical region and a left undescended testis. The appearance of the swelling was suggestive of a spigelian hernia. At operation, the swelling was actually an abdominal ectopic testis with associated inguinal hernia. This unusual finding led us to report this occurrence and present a brief review of the relevant literature.     

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

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.