Spigelian Hernia: Surgical Anatomy, Embryology, and Technique of Repair

Abstract

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.

Adriaan van den Spiegel (1578–1625): Anatomist, physician, and botanist

“…Spiegel's line or linea semilunaris extends between the 9th costal cartilage and the pubic tubercle (Hilger and Baglaj, ). Subsequently, the aponeurosis of the transverse abdominal muscle, limited by the linea semilunaris laterally and the lateral margin of the rectus abdominis muscle medially, was named the Spigelian aponeurosis (Skandalakis et al, ). Spigelian hernia, also known as lateral ventral hernia, constitutes 1–2% of all hernias and is a protrusion of preperitoneal fat, a peritoneal sac or organs through a congenital or acquired defect in the Spigelian aponeurosis (Skandalakis et al, ).…”

Sonographic diagnosis of incarcerated Spigelian hernia during pregnancy

“…A Spigelian hernia is the protrusion of preperitoneal fat or a peritoneal sac, with or without an intra‐abdominal organ, across a congenital or acquired defect at the linea semilunaris (Spigelius line). They are rare and constitute only 1%–2% of all hernias [1]. Anatomically, nearly 90% of these hernias lie in a paramedian region, up to 6 cm cranial to the interspinal line.…”

“…Anatomically, nearly 90% of these hernias lie in a paramedian region, up to 6 cm cranial to the interspinal line. The defect most commonly lies in a weak triangular area limited by the semilunar line laterally, semicircular line superiorly, and the deep inferior epigastric vessels inferiorly [1].…”

Laparoscopic Rare Abdominal Hernia Treatment

“…Transverse abdominis aponeurosis in the area between the semilunar line and the lateral sheath of the rectus is called Spiegel's fascia, and from this point preperitoneal fat tissue or intraabdominal organs protruding are defined as Spiegel hernia (SH) [2]. Ninety percent of hernias occur on the transverse line approximately 6 cm above the interspinous line [3]. It has an increasing frequency with age, peaks in the fifth decade, and is more common in women and left side of the abdominal wall [4].…”