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Image of the Month—Diagnosis
Arch Surg. 2007;142(3):306.
Answer: Spigelian Hernia
Spigelian hernias constitute 0.1% to 0.2% of all abdominal wall hernias. Twenty percent are complicated by strangulation.1 Spigelian hernias account for 2% of cases undergoing emergency surgery for abdominal wall hernia. However, it is rarely considered in the differential diagnosis for abdominal pain. We report a case of a giant spigelian hernia with bowel strangulation requiring bowel resection and abdominal wall repair with Surgisis mesh (Cook Medical, Inc, Bloomington, Ind).
Spigelian hernias can occur anywhere along the semilunar line, which runs parallel with the lateral edges of the rectus sheath. However, spigelian hernias most commonly occur at the level of the arcuate line. The arcuate line defines the point at which the posterior lamina of the internal oblique muscle and the aponeurosis of the transverse abdominal muscle become part of the anterior rectus sheath, leaving only the relatively thin transversalis fascia to cover the rectus abdominis posteriorly.2 Spigelian hernias are described both in children and adults. Most cases are reported in adults between the ages of 40 and 70 years. They tend to be more common in women than men. Obesity, ascites, trauma, previous surgery, and increased intra-abdominal pressure are factors that contribute to the development of hernia.
Most of the spigelian hernias are intramural. The hernia usually enters the transverse and internal oblique muscles and is covered by the external oblique aponeurosis. Most patients present with nonspecific abdominal symptoms because the external oblique aponeurosis covers their hernias. They usually reveal a painful palpable mass on examination. Specific symptoms and findings may vary depending on the hernia contents. Omentum, gallbladder, stomach, small intestine, colon, Meckel diverticulum, appendix, ovaries, and testes have all been known to herniate.3
In addition to physical examination, ultrasonography and computed tomography are used for the identification of spigelian hernias. In fact, only 20% of all cases are correctly diagnosed preoperatively. Treatment is surgical. Repair has historically been performed via an open approach with primary approximation of tissues. Larger-sized hernias have used mesh. In 1992, Carter and Mizes4 performed the first documented intra-abdominal laparoscopic spigelian hernia repair. Currently, the extraperitoneal laparoscopic approach is recommended for elective repair of noncomplicated spigelian hernias.5 In our case, the presence of a large-sized spigelian hernia of 5 x 5 cm with bowel strangulation and perforation necessitated an open repair with Surgisis mesh as seen in Figure 2.
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The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archsurg.com). Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery (http://archsurg.ama-assn.org/misc/ifora.dtl). No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.
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AUTHOR INFORMATION
Correspondence: Subhashini Ayloo, Department of Surgery, University of Illinois at Chicago, 840 S Wood St, M/C 958, Chicago, IL 60612 (ayloosub{at}uic.edu).
Accepted for Publication: January 28, 2006.
Author Contributions: Study concept and design: Prieto. Acquisition of data: Prieto. Analysis and interpretation of data: Ayloo. Drafting of the manuscript: Prieto and Ayloo. Administrative, technical, and material support: Prieto. Study supervision: Ayloo.
Financial Disclosure: None reported.
REFERENCES
1. Benito MP, Valderrama JE, Gonzalez FJ, Muniain JM. Intestinal occlusion and spigelian hernia. J Clin Gastroenterol. 1999;29:213-214.
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2. Moore KL. Clinically Oriented Anatomy. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999.3. Ribeiro EA, Cruz Junior RJ, Moreira SM. Intestinal obstruction induced by a giant incarcerated Spigelian hernia: case report and review of the literature. Sao Paulo Med J. 2005;123:148-150.
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4. Carter JE, Mizes C. Laparoscopic diagnosis and repair of spigelian hernia: report of a case and technique. Am J Obstet Gynecol. 1992;167:77-78.
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5. Moreno-Egea A, Carrasco L, Girela E, Martin JG, Aguayo JL, Canteras M. Open vs laparoscopic repair of spigelian hernia: a prospective randomized trial. Arch Surg. 2002;137:1266-1268.
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SECTION EDITOR: GRACE S. ROZYCKI, MD
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