The symptoms of a spigelian hernia are not specific and may include the following

• Vague lower abdominal pain
• Bulge in the lower abdomen, which may decrease when supine
• Tenderness to touch
• Recurrent pain when stretching or bending
• Nausea, vomiting
• Abdominal distension (indication bowel obstruction)

Spigelian hernias are often difficult to see when very small. Only in a thin person a spigelian hernia can be palpated. Often during the physical exam, it is mistaken for a muscle spasm or localized soft tissue trauma.

• Ascites

  We present the case of an emergency intraperitoneal onlay mesh (IPOM) repair of Spigelian hernia, causing acute small bowel obstruction in a 55-year-old man with liver disease and ascites that was diagnosed using a CT scan. [ncbi.nlm.nih.gov]

  […] frequent in the 5th and 6th decades of life with no gender preference.1, 4 It is usually on the left side.3 Predisposing factors include: obesity, rapid weight loss, multiple pregnancies, chronic obstructive pulmonary disease, chronic constipation, ascites [eurorad.org]

  Excess fluid in the abdomen can also cause weakness in the abdominal walls, called ascites. Spigelian hernias are rare, but they can happen to anyone. Some people, however, have a higher risk. [healthline.com]

  Other common causes include: Long-standing medical conditions that increase abdominal pressure, like chronic coughing, liver cirrhosis with fluid collection (ascites), pregnancy, and obesity Any weakness of the abdominal wall muscles brought on by aging [webmd.com]

  Additional history should seek information related to chronic increases in abdominal pressure–chronic cough secondary to COPD, ascites, obesity, or pregnancy. [statpearls.com]

• Sepsis

  Acute pain at the site of the hernia Features of bowel obstruction (if the hernial content is bowel) Signs of strangulation A tender, irreducible hernia Absent cough impulse Edematous, erythematous, warm overlying skin Toxic appearance, fever, signs of sepsis [amboss.com]

  OBSTRUCTION • Excessive intraluminal gas • Intra-abdominal infection • Trauma • Retroperitoneal irritation (renal colic, neoplasms, infections, hemorrhage) • Vascular insufficiency (thrombosis, embolism) • Mechanical ventilation • Extra-abdominal infection (sepsis [clinicalgate.com]

  Advanced age, obesity, extreme thinness, intense slimming, presence of chronic debilitating disease, muscular atrophy, chronic bronchitis, wound infection and postoperative sepsis are the risk factors associated with occurrence of primary hernia [4] . [arcjournals.org]

  At initial presentation, she had severe sepsis, with metabolic acidosis (pH 7.194, pCO2 10mmHg, HCO3 9.3 mmol/L, base excess -19), elevated lactate (8.7 mmol/L), leukocytosis (14,500/µL), acute kidney injury (creatinine 1.94 mg/dL) and hyperammonemia [facs.org]

  Surgical intervention is required to prevent further complications (eg, perforation and sepsis. In general, patients with uncomplicated inguinal and abdominal wall hernias do well. [emedicine.medscape.com]

• Cough

  Often, a male may be asked to stand and cough or strain, with the examiner searching for bulges in the groin. [losangeleshemorrhoidclinic.com]

  Risk factors for this type of abdominal gap include strain from lifting, constipation or coughing. Pregnancy and gaining weight can also stretch the abdominal muscles. In some cases, the weakness is due to a congenital issue. [drdannyshouhed.com]

  Uncomplicated hernias are asymptomatic, nontender, and completely reducible with an expansile cough impulse. [amboss.com]

  Factors that can contribute towards a Spigelian Hernia include: Obesity Sports activity Coughing Heavy lifting Figure 1. [londonhernia.co.uk]

• Chronic Cough

  Chronic coughing, obesity as well as heavy-lifting as well as other factors cause this type of hernia to develop. [healthool.com]

  Obesity, chronic coughing, multiple pregnancies, surgery, and heavy-lifting are other factors that cause a Spigelian hernia to develop over time. [sharecare.com]

  Risk factors associated with this type of hernia include being overweight, having COPD or similar conditions that result in chronic coughing, experiencing abdominal trauma, pregnancy, and frequent bowel straining. [crownvalleysurgicalcenter.com]

  Those at risk for a hernia include people who are overweight or obese, as well as those who have conditions that cause chronic coughing, such as chronic obstructive pulmonary disease, or COPD. [nyulangone.org]

• Persistent Cough

  They can also be caused by persistent coughing and sneezing, smoking and child birth which weaken the muscles. When the muscles are weak, it provides opportunities for other body organs or fatty tissues to pass through. [healthooze.com]

• Abdominal Pain

  Other times it is not noticeable, only the abdominal pain is felt. Indigestion due to bowel obstruction. Bowel obstruction is caused by hindrance in the intestines making digestion difficult. Recurring pain in the lower abdomen. [healthooze.com]

  Signs this may have happened include unbearable abdominal pain, blood in stool, pain combined with nausea and vomiting, and failure to have a bowel movement for several days coupled with severe stomach pain. [losangeleshemorrhoidclinic.com]

  For years, the patient had been able to relieve her abdominal pain by applying pressure over the right lower quadrant. The abdominal examination was normal, except for tenderness in the right lower quadrant. [nejm.org]

  The abdominal pain varies from 31% to 86% of cases [6]. [hindawi.com]

  Most people with a spigelian hernia experience abdominal pain or vague discomfort, especially when straining the abdominal muscles, such as when lifting or straining to have a bowel movement. [medicalnewstoday.com]

• Abdominal Mass

  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. [ncbi.nlm.nih.gov]

  A 61-year-old woman had undergone an abdominal hysterectomy 14 years prior to her admission to our hospital complaining of a left lower abdominal mass with recurring pain. [jstage.jst.go.jp]

• Abdominal Colic

  The patient presents with symptoms and signs of intestinal obstruction (abdominal colic, vomiting, constipation, abdominal distension) (see Small bowel obstruction ), together with a tender irreducible hernia. [surgwiki.com]

• Biliary Colic

  Differential diagnosis Depending on its location, a Spigelian hernia may mimic intra-abdominal pathologies which can present with pain such as acute appendicitis, twisted ovarian cyst, tubo-ovarian pathologies, mesenteric lymphadenitis, biliary colic, [intechopen.com]

• Muscle Weakness

  Melanonychia 318 Menieres Disease 319 Meningitis Chronic 320 Menopause 321 Metabolic Syndrome 322 Metatarsalgia 323 Microcytosis 324 Mild Cognitive Impairment 325 Mitral Regurgitation 326 Monoarthritis Acute 327 Mononucleosis 328 Mucormycosis 329 Mumps 330 Muscle [books.google.ro]

  And the more children that a woman has, the more damaged and weak that the abdominal muscles usually become. Of course, with exercise, this muscle weakness can often be reversed, which decreases their risk of a spigelian hernia developing. [thehealthyapron.com]

  People with polio or paralysis affecting lower limb are prone to develop Hernia due to weakness of muscles. Weakness of the muscle due to old age. [herniahelpclinic.com]

  Abdominal wall muscle weakness due to age. In case of abdominal wall muscle relaxation, which limits the anulus internus turur slack. In case of intra-abdominal pressure was not high and the inguinal canal runs more vertically. [herryyudha.blogspot.com]

  Blunt force trauma may cause muscle or fascial weakness with resultant herniation. [ahcmedia.com]

• Muscle Strain

  They kept telling me for so long it was a "deep muscle strain" and would heal within 6-8 weeks. Now that we are almost 3 months out and it is still painful and persistent - I am worried. [ehealthforum.com]

  Acquired hernias are caused by the wear and tear of living, such as childbirth, weight gain, and other muscle strain. Congenital hernias are present from birth and happen at points of weakness in the abdominal wall. [herniaclinic.co.nz]

• Salpingitis

  […] pneumonia, empyema, pulmonary infarction • Vascular: ruptured aortic aneurysm • Cutaneous: herpes zoster • Trauma • Intestinal: high fecal impaction, perforated colon, diverticulitis • Irritable bowel syndrome • Urinary tract infection, pyelonephritis, salpingitis [clinicalgate.com]

  Acute salpingitis Almost impossible to distinguish the inflamed hernia with a suffered strangulation 3. Some Special Types Hernia A. [herryyudha.blogspot.com]

There is no blood work that is specific for diagnosis of a spigelian hernia. However since all spigelian hernias do require surgery, routine workup should include:

• Complete blood count
• Coagulation profile
• Electrolytes
• Urine analysis
• ECG
• Chest X-ray
• Abdominal X-ray is done if there is suspicion of bowel obstruction

Ultrasound is now widely used as the first imaging test of choice. The test can scan the abdominal wall and reveal the discontinuity in the Spigelian fascia caused by the hernia orifice at the point of tenderness. However, because the test is very operator dependent, small hernias may be missed. CT scan or MRI is the definitive test to make a diagnosis of a spigelian hernia.

All spigelian hernias need to be repaired. In asymptomatic patients the surgery can be done on an elective basis. In symptomatic patients, the surgery should be done as soon as the diagnosis is made. If there is bowel incarceration or strangulation immediate surgery is required [8] [9] [10].

The surgery may be done under general or regional anesthesia. The types of surgical procedures for spigelian hernia include the open approach and laparoscopy. The open technique requires general anesthesia. The laparoscopic procedure results in faster recovery, less need for analgesia and faster discharge from hospital.

The surgical treatment is the same as for any hernia. The hernia sac is identified and excised, the bowel contents are reduced and a mesh is used to repair the defect. Whatever procedure is done most surgeons now use a mesh to prevent tension along the suture lines and prevention of recurrence.

Most patients are discharged home the same day or after an overnight stay in the hospital. The recovery is slow for the first week. Ambulation is encouraged but sports and heavy lifting should be avoided for 6 weeks.

The prognosis for most patients with a spigelian hernia is excellent. Elderly patients with multiple comorbidities may not do well, especially if there is bowel incarceration or strangulation. All spigelian hernias need surgical treatment. If the diagnosis is missed or surgery is delayed, there is a high risk of incarceration. The surgery to repair a spigelian hernia has few complications and most people do not have recurrences.

Spigelian hernia has the same causes as other hernias and that include the following:

• Chronic coughing
• Obesity
• Sporting activities that involve excessive turning or twisting motions [4] [5]
• Straining during defecation or urination
• Lifting heavy objects
• Injury to the abdomen
• Multiple pregnancies
• Spigelian hernias have also been described in patients who have had abdominal peritoneal dialysis catheter.

Disorders that are often mistaken for a spigelian hernia include: 

• Rectus sheath hematoma
• Abdominal wall abscess
• Muscle spasm

Less than 50% of spigelian hernias are diagnosed on a physical exam. In many cases, surgeons have frequently discovered spigelian hernia only during surgery.

There are no large data banks on spigelian hernia. It appears that these hernias are not very common and only isolated reports exist. Spigelian hernias can occur in both genders and in all races. Overall spigelian hernias are very are and only account for about 1 out of every 1,000 abdominal wall hernias. Spigelian hernias tend to occur most commonly in individuals between the fourth and seventh decade of life, are related to stretching actions of the abdomen and can be caused by multiple pregnancies, obesity, prior abdominal surgery or scars.

The spigelian hernia frequently occurs at the level of the semicircular line (also known as the arcuate line of Douglas). Just underneath this line of Douglas, the spigelian aponeurosis is a single layer and resistant to herniation. However, at the level of the semicircular line, the fascias of transverse abdominus and the fascia of the oblique muscles divide to form two separate layers. It is at this point that the aponeurosis is the weakest and prone to hernia. Sometimes perforating vessels may also cause weakening of the Spigelian fascia, which allows fat to enter the defect.

Some defects occur below the level of the arcuate line of Douglas and pass through the internal oblique muscles and conjoined tendon of transverse abdominus. These low spigelian hernias are often mistaken for inguinal hernia. Sometimes an umbilical, incision or epigastric hernia may be associated with a spigelian hernia.

In most cases, the hernia sac only contains the greater omentum; however cases have been described which report presence of other organs such as small bowel, stomach, colon, gallbladder, appendix, ovaries, testes and even meckel diverticulum trapped in the hernia [6] [7].

Spigelian hernias like all other hernias occur because of increased abdominal pressure or trauma. Thus, the individual should refrain from lifting heavy weights, discontinue sports that require intense abdominal exertion, have benign prostate hypertrophy treated and eat a high fiber diet to prevent constipation. Any action that increases intraabdominal pressure can cause a hernia, so it is essential to prevent unnecessary increases in abdominal pressure.

Spigelian hernia was first described in the mid 1600s. By the late 1700s, the anatomical defect in a spigelian hernia had been shown in autopsy studies. Over the years, it was observed that spigelian hernias, even though small, had a high probability of entrapping bowel. Spigelian hernias may be congenital or acquired. The primary defect occurs in the spigelian fascia, which is the anatomical area along the lateral edge of the rectus muscle and aponeurosis of the transversus abdominus muscle. It is at this point where there is transition of the transversus abdominus muscle to its aponeurotic tendon.

Spigelian hernias generally tend to be very small (< 2-3 cm) and hence bowel obstruction is likely, compared to large umbilical hernias. While most patients only present with abdominal pain, at least 1/5th of patients present with bowel obstruction [1] [2] [3].

A spigelian hernia is a hernia that occurs just about the pubis. The hernia usually occurs because of weakness in the supporting tissues and presents with vague abdominal pain and sometimes a small mass. The hernia often feels and hurts like a bruise. A spigelian hernia is not common and it is often not easy to diagnose just by looking. Doctors usually order an ultrasound or CT scan to make the diagnosis. The treatment of all spigelian hernias, whether symptomatic or not, is surgery. The surgery today is done via a scope and most patients can be discharged home the same day. Recovery is fast. There is a very small chance of recurrence if the patient continues to lift heavy weights.

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8. Barker R, Gill RS, Brar AS, Birch DW, Karmali S. Emergent laparoscopic repair of a spigelian hernia: case report and review of the literature. Case Rep Med. 2013;2013:197561.
9. Nagarsheth KH, Nickloes T, Mancini G, Solla JA. Laparoscopic repair of incidentally found Spigelian hernia. JSLS. 2011 Jan-Mar;15(1):81-5.
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