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Indian Journal of Surgery
Medknow Publications on behalf of Association of Surgeons of India
ISSN: 0972-2068
Vol. 64, Num. 6, 2002, pp. 527-528

Indian Journal of Surgery, Vol. 64, No. 6, Nov - Dec. 2002, pp. 527-528

Case Report

Spigelian Hernia

Shyam S. Jaiswal

Military Hospital, Establishment No.22, C/O 56 APO
Address for correspondence: Lt. Col. S. S. Jaiswal, Classified Specialist (Surgery), Military Hospital Alwar (Raj) 301 001

Paper received: February 2001
Paper accepted: December 2001

Code Number: is02012

Abstract

A case of Spigelian hernia in a 75-year-old male patient was diagnosed clinically and treated by surgical repair. The patient had an uneventful postoperative recovery. It is being reported and the relevant anatomical and clinical details and current management are being reviewed.

Key words: Spigelian hernia, Interstitial Hernia, Spigelian Fascia

INTRODUCTION

Spigelian hernias are ventral hernias occurring along the subumbilical portion of Spiegel's semilunar line and through Spiegel's fascia. They are uncommon and only about 1000 cases have been reported in the literature.1 This case is being reported because of its rarity.

CASE REPORT

A 75-year-old male presented with a small, painful lump in the right lower abdomen of approximately one year duration. The lump had gradually increased in size and become more prominent on standing up and straining. There was no history of local trauma or indicative of intestinal obstruction. Physical examination revealed an elderly patient in satisfactory general health with no associated major systemic illness. The anterior abdominal wall showed a swelling in its infra-umbilical portion along the lateral border of the right rectus abdominis muscle. It measured 4 cm x 3 cm and was more prominent in the upright position. Local tenderness and cough impulse were present and it was partially reducible.

A diagnosis of Spigelian hernia was made and the patient was taken up for surgery under general anaesthesia. A transverse incision was made over the swelling. The external oblique aponeurosis was split and the hernial sac was found lying beneath it (Fig. 1). The sac was dissected out and opened - it was found to be empty (Fig. 2). The sac was excised and the defect in the Spigelian fascia and the internal oblique muscle was repaired using 2/0 polypropylene. The patient had an uneventful postoperative recovery and has remains free of recurrence at the end of four years of follow up.

DISCUSSION

Adriaan Van Den Spieghel (1578 - 1625), Professor of Surgery and Anatomy at Padua first described the semilunar line which marks the transition from muscle to aponeurosis in the transverse abdominis muscle and stretches from the costal arch to the pubic tubercle. The part of the aponeurosis that lies between the semilunar line and the lateral edge of the rectus muscle is called the Spigelian fascia.2 Most Spigelian hernias occur in the area between the level of the umbilicus and the arcuate line or fold of Douglas, particularly at the point where the semilunar and arcuate lines meet. There is no posterior rectus sheath below this point and the rearrangement of the fibres at this point is believed to cause an area of functional weakness through which herniation can occur.1 Sometimes the hernia occurs below the level of the arcuate line and is then called "low" Spigelian hernia. Other hernias such as umbilical, epigastric and inguinal may sometime coexist.1 Usually the sac lies in the loose areolar tissue between the internal oblique and the external oblique muscles and enlarges laterally. The rectus sheath inhibits medial enlargement. Sometimes the sac may lie below the internal oblique muscle and rarely subcutaneously, above the external oblique.1

The commonest age of presentation is between the 40 and 70 years.2 However cases have been reported in infants and children. The usual complaints are pain or lump or both at the site of herniation. Features of intestinal obstruction may be present. A localized perforation in to the sac may present as an abdominal wall abscess fistula.1

The diagnosis is made clinically and may be confirmed by ultrasonography or a CT scan. Ultrasonography is easier to perform, is cheaper and does not involve exposure to radiation and represents the gold standard in the diagnosis of Spigelian hernia.3 The latter is preferred only when more information regarding contents of the hernial sac is desired. Radiographic examination using plain film and contrast media is generally unsatisfactory.2 The use of intra operative ultrasonography for the localization of the hernial sac in obese patients has also been reported.

The treatment of a Spigelian hernia is by operative repair. For palpable hernias a grid incision is recommended and for non-palpable cases a preperitoneal approach via a vertical incision is advocated.2 Laparoscopic repair of Spigelian Hernia has also been reported4 and is likely to be more widely used in the future. Recently a new technique which utilizes a preshaped polypropylene umbrella type plug for a tension free occlusion of the hernia ring has also been described.5

In conclusion the possibility of a Spigelian Hernia must be considered in any patient presenting with persistent localized pain or a vague lump in the lower abdomen just lateral to the outer border of the rectus muscle. This helps in reaching an early diagnosis and proper management in these patients.

REFERENCES

  1. Abrahamson J. Hernias in Zinner MJ, Schwartz SI, Ellis H. Ed. Maingot's Abdominal Operations, 10th ed. Connecticut: Appleton and Lange 1997; 544-546.
  2. Spangen L. Spigelian Hernia. In Nyhus LM and Condon RF. Ed. Hernia, 4th ed. Philadelphia: J. B. Lippincott Company, 1995; 381-392.
  3. Torzilli G, Carmana G, Lumachi V, et al. The Usefulness of ultrasonography in diagnosis of the Spigelian hernia. Int Surg 1995; 80: 280-2.
  4. Kasirajan K, Lopez J, Lopez R. Laparoscopic technique in the management of Spigelian hernia. J Laparoendosc Adv Surg Tech 1997; 7: 385- 8.
  5. Sanchez-Montes I, Deysine M. Spigelian hernias: a new repair technique using preshaped polypropylene umbrella plugs. Arch Surg 1998;133: 670-2.

Copyright 2002 - Indian Journal of Surgery. Also available online at http://www.indianjsurg.com


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[is02012f1.jpg] [is02012f2.jpg]
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