A rare case of Spigelian hernia combined with direct and indirect inguinal hernias

Abstract

Spigelian hernia is a rare type of ventral hernias with nonspecific symptoms and signs. Therefore, its diagnosis is often difficult and requires more clinical attention. Although intermittent abdominal swelling and pain are the main symptoms, Spigelian hernias can be sometimes asymptomatic and are discovered incidentally at the operation. In some cases, these hernias can be associated with other abdominal wall hernias, therefore a detailed physical examination of the patients is necessary to avoid mistakes in diagnosis. Herein, we report an interesting and educational case of Spigelian hernia with accompanying ipsilateral both direct and indirect inguinal hernias in a male patient treated by open surgical repair with use of polypropylene mesh. Keywords:Abdominal wall hernia, inguinal hernia, Spigelian hernia, ventral hernia INTRODUCTIONInguinal hernia is one of the most common surgical disorders in general surgery practice. Indirect form of inguinal hernia is characterized by the presence of a protruding peritoneal sac through the deep inguinal ring. However, Spigelian hernia (SH) is an uncommon type of hernia with an incidence of 0.1-2% of all abdominal wall hernias (1). SH, also known as hernia of semilunar line, is the protrusion of preperitoneal fat, peritoneal sac or intraabdominal organs through a congenital or acquired defect in the Spigelian zone. This zone is formed by the fusion of transverse abdominis and internal oblique aponeurosis, and is bounded medially by the lateral margin of the rectus muscle and laterally by the linea semilunaris. Although the Spigelian aponeurosis extends from the pubic tubercle to the costal cartilage of the eighth rib, most of SHs are located in a 6 cm wide region inferior to the umbilicus and superior to the interspinous line, which is called as the Spigelian hernia belt (Figure 1). However, low SH is rare and may mimic inguinal hernias. Additionally, coexistence of Spigelian and inguinal hernia is an extremely rare clinical entity. To our knowledge, there is a small number of cases of SH combined with inguinal hernia in the literature. Herein, we report a case of low SH with incidentally found coexisting ipsilateral inguinal hernia in a 62 years-old male patient. CASE PRESENTATIONA 62-years-old-man presented with a painful abdominal swelling at the right lower quadrant of abdomen for approximately 3 years. He was retired with a medical past of umbilical hernia repair and laparoscopic cholecystectomy before 10 and 6 years, respectively, and diabetes mellitus under treatment. Abdominal examination revealed the presence of a painful, reducible bulge located between the umbilicus and right anterior superior iliac spine (Figure 2). The mass was more prominent while the patient was standing and coughing. Ultrasound (US) revealed a fascial defect, 18 mm in diameter, at the lateral border of the rectus muscle in the right lower quadrant with herniation of bowel loops. The hernia sac was revealed by transverse skin incision, and it was seen that there was not any sign of incarcer...

Hernia de Spiegel como causa de obstrucción intestinal de íleon en una paciente anticoagulada por fibrilación auricular, abordaje laparoscópico. Reporte de caso.

“…Otro factor importante es la cirugía previa: varias publicaciones describieron la relación de aparición de HS con intervenciones quirúrgicas anteriores, mayoritariamente por vía laparoscópica 3,7 . En este trabajo, en el que describen una serie de 201 pacientes intervenidos por vía laparoscópica, encontraron un 2 % de HS, mientras que en este caso clínico los autores sugirieron que hasta en el 50 % de los casos de hernia de Spiegel existen antecedentes de cirugía abdominal previa 8,9 . La explicación puede ser doble: en primer lugar, el traumatismo directo de la inserción del trocar de laparoscopia o de la incisión quirúrgica si se realiza vía abierta, puede condicionar la formación de una eventración a ese nivel, sobre todo si se realiza en una zona débil como la línea semilunar.…”

Laparoscopic herniorrhaphy of bilateral inguinal herniae and an incidental Spigelian hernia with intra corporeal suturing of the Spigelian hernia neck: A case report

“…Although open herniorrhaphy with polypropylene mesh still is the most frequent surgical technique, laparoscopic techniques have been increasing in recent years [ 1 ]. Originally sutures were used to close the defect in the Spigelian fascia, but recently mesh is being placed intra- or extraperitoneally through the creation of a peritoneal flap [ 2 ].…”

“…Their incidence ranges from 0.1 to 2.0% of all abdominal wall hernias and a common synonym is the hernia of the semilunar line. A Spigelian hernia occurs when there is protrusion of preperitoneal fat, peritoneal sac, or intra abdominal organs through the Spigelian zone in an area of congenital or acquired defect [ 1 ]. The hernia sac is often interparietal passing through the aponeuroses of the transversus abdominis and internal oblique and located under the intact external oblique aponeurosis [ 2 ].…”

“…Most Spigelian herniae occur in the Spigelian hernia belt, a six centimeter wide region superior to the interspinous line and inferior to umbilicus. The Spigelian aponeurosis extends from the costal cartilage of the eighth rib to the pubic tubercle [ 1 ]. The presence of concomitant Spigelian and inguinal herniae is an extremely rare clinical occurrence and to our knowledge has rarely been reported in the English literature based on a Pubmed and Medline search.…”