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Spigelian Hernia

Hernia Linea Semilunaris

Spigelian hernia is a very rare hernia of the abdominal wall. It occurs along the lateral edge of the rectus muscle and aponeurosis of the transverse abdominus muscle. Because of its small size, it has a high risk of incarceration.


Presentation

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

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.

Abdominal Pain
  • Abstract A spigelian hernia is a rare cause of acute abdominal pain and its diagnosis is often difficult to make.[ncbi.nlm.nih.gov]
  • We report a 31 years old patient from the Sultan Qaboos University Hospital who presented with colicky lower abdominal pain associated with a tender swelling above and lateral to the inguinal canal.[ncbi.nlm.nih.gov]
  • CASE REPORT: The patient presented with a six-hour history of nausea, constant abdominal pain, and a palpable mass in the left lower quadrant.[ncbi.nlm.nih.gov]
  • Abstract An 87 yr man was referred for abdominal pain over a pre-existing hernia in the right iliac fossa. Physical examination revealed a red painful palpable mass in the right lower abdominal quadrant.[ncbi.nlm.nih.gov]
  • 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.[ncbi.nlm.nih.gov]
Lower Abdominal Pain
  • We report a 31 years old patient from the Sultan Qaboos University Hospital who presented with colicky lower abdominal pain associated with a tender swelling above and lateral to the inguinal canal.[ncbi.nlm.nih.gov]
  • We present a patient with a history of lower abdominal pain since 10 weeks with a large intra-abdominal mass in the right iliac fossa.[ncbi.nlm.nih.gov]
  • 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[symptoma.com]
  • Marcos Duarte Siosaki, Márcia Maria Hagge Coelho Costa, Higino Felipe Figueiredo, Messias Froes da Silva Junior and Rubem Alves da Silva Junior , A differential diagnosis in chronic lower abdominal pain , International Journal of Surgery Case Reports[doi.org]
  • Diagnosis and Reasoning This middle aged lady has presented with chronic lower abdominal pain - a clinical entity with a differential diagnosis encompassing the urinary, gastrointestinal and reproductive systems, as well as the abdominal wall.[prognosisapp.com]
Abdominal Tenderness
  • Physical examination of the patient revealed abdominal tenderness and a round-shaped tumefaction of 3 cm in size, located in the left lower abdominal quadrant.[ncbi.nlm.nih.gov]
Cryptorchidism
  • Al-Salem AH (2000) Congenital Spigelian hernia and cryptorchidism: cause or coincidence? Pediatr Surg Int 16:433–436 CrossRef PubMed Google Scholar 4.[doi.org]
  • Nearly 28% of pediatric Spigelian hernias reported in the literature are associated with ipsilateral cryptorchidism. However, the pathogenetic relationship between the two has not been satisfactorily explained in the past.[ncbi.nlm.nih.gov]
  • However we report the case of a four-month-old, with an associated hypospadias and cryptorchidism, where the testis was lying in a spigelian hernia. AIMS: To highlight this unusual presentation of cryptorchidism.[ncbi.nlm.nih.gov]
  • A recent association has been made between paediatric spigelian hernias and cryptorchidism. We report this phenomenon in a 60-year-old adult male.[ncbi.nlm.nih.gov]
  • A few case reports describing SH in the paediatric population have been published and an association with cryptorchidism has been very rarely reported. OBJECTIVE: To report three examples of SH.[ncbi.nlm.nih.gov]

Workup

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.

Treatment

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.

Prognosis

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.

Etiology

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: 

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

Epidemiology

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.

Sex distribution
Age distribution

Pathophysiology

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].

Prevention

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.

Summary

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].

Patient Information

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.

References

Article

  1. Noomene R, Bouhafa A, Maamer AB, Haoues N, Oueslati A, Cherif A. Spigelian hernias. Presse Med. 2014 Mar;43(3):247-51
  2. Kelly KB, Ponsky TA. Pediatric abdominal wall defects. Surg Clin North Am. 2013 Oct;93(5):1255-67
  3. Cinar H, Polat AK, Caglayan K, Ozbalci GS, Topgül HK, Polat C. Spigelian hernia: our experience and review of the literature. Ann Ital Chir. 2013 Nov-Dec;84(6):649-53.
  4. Cabry RJ Jr, Thorell E, Heck K, Hong E, Berkson D. Understanding noninguinal abdominal hernias in the athlete. Curr Sports Med Rep. 2014 Mar-Apr;13(2):86-93.
  5. Vega Y, Zequeira J, Delgado A, Lugo-Vicente H. Spigelian hernia in children: case report and literature review. Bol Asoc Med P R. 2010 Oct-Dec;102(4):62-4
  6. Foster D, Nagarajan S, Panait L. Richter-type Spigelian hernia: A case report and review of the literature. Int J Surg Case Rep. 2015;6C:160-2
  7. Spinelli C, Strambi S, Pucci V, Liserre J, Spinelli G, Palombo C. Spigelian hernia in a 14-year-old girl: a case report and review of the literature. European J Pediatr Surg Rep. 2014 Jun;2(1):58-62
  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.
  10. Skouras C, Purkayastha S, Jiao L, Tekkis P, Darzi A, Zacharakis E Laparoscopic management of spigelian hernias. Surg Laparosc Endosc Percutan Tech. 2011 Apr;21(2):76-81

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Last updated: 2018-06-22 08:36