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Table of Contents
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 59-62

A Spigelian hernia: Single-center experience in an uncommon hernia

Department of General Surgery, Taher Sfar Hospital, Mahdia, Tunisia

Date of Submission18-Mar-2019
Date of Acceptance08-Apr-2019
Date of Web Publication10-May-2019

Correspondence Address:
Dr. Mohamed Ali Chaouch
28 Rue Hadj Hedi Chaouch, Ksar Hellal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_9_19

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BACKGROUND: A Spigelian hernia is rare. Diagnosis and treatment remain controversial, mainly because of its unusual presentation. The aim of this study was to report the outcomes of open treatment of eight rare cases and to evaluate our experiences in managing this condition.
PATIENTS AND METHODS: We performed a retrospective and descriptive study about operated patients for Spigelian hernia in our department of surgery between 2002 and 2016.
RESULTS: Eight patients were enrolled. The mean age was 52.25 years. There was a female predominance. All cases presented hernia risk factors. A painful abdominal mass presented the reason for consultation in four cases. Two of our patients had an associated inguinal hernia and one other had an umbilical hernia. In three cases, the hernia was strangulated. The diagnosis was confirmed by clinical examination in two cases and using radiological examinations in six cases. The content was a small bowel in four cases, epiploic in three cases, and colic in one case. A sublay mesh repair was performed in five cases and a primary suture in three cases. No recurrences were detected after 2 years of follow-up.
CONCLUSION: Spigelian hernia is underestimated. Open sublay mesh repair is feasible and safe. It ensure a great short and long term results. The open approach is feasible and safe to treat this condition.

Keywords: Acute abdomen, hernia repair, occult hernia, Spigelian hernia

How to cite this article:
Chaouch MA, Nacef K, Chaouch A, Khalifa MB, Boudokhane M. A Spigelian hernia: Single-center experience in an uncommon hernia. Int J Abdom Wall Hernia Surg 2019;2:59-62

How to cite this URL:
Chaouch MA, Nacef K, Chaouch A, Khalifa MB, Boudokhane M. A Spigelian hernia: Single-center experience in an uncommon hernia. Int J Abdom Wall Hernia Surg [serial online] 2019 [cited 2022 Aug 8];2:59-62. Available from: http://www.herniasurgeryjournal.org/text.asp?2019/2/2/59/257982

  Introduction Top

 Spigelia More Detailsn hernias account about 0.1%–2% of all abdominal wall hernias.[1] They are asymptomatic in 90% of cases.[2] Clinical signs are nonspecific and dominated by a vague abdominal pain associated or not with an abdominal mass. Evolution is frequently marked by severe complications such as incarceration or strangulation. Treatment is a surgical repair. The aim of this study was to report the outcomes of open treatment of eight rare cases and to evaluate our experiences in managing this condition.

  Patients And Methods Top

We performed a retrospective study of all patients diagnosed and treated for Spigelian hernia in our surgery department in Mahdia between 2002 and 2016. We analyzed sociodemographic characteristics, history, clinical presentation, complementary examinations, emergency or elective surgical procedures, postoperative complications, and recurrence.

  Results Top

Between January 2002 and December 2016, 13 patients were admitted with a suspicion of a Spigelian hernia, of which 5 were falsely diagnosed. Then, only eight patients met the inclusion criteria. The mean age was 52.25 years (46–72). There was a female predominance with a sex ratio male: female = 0.33. All cases presented hernia risk factors (6 multiparous, 4 obese, chronic bronchopathy, and median laparotomy) [Table 1]. Clinically, a painful abdominal mass [Figure 1] was the reason for consultation in four cases. The hernia was right sided in seven cases, left side in one case, and no bilateral hernia founded. Two of our patients had an associated inguinal hernia and one other had an umbilical hernia. In three cases, the hernia was complicated by strangulation. The diagnosis was confirmed by clinical examination in two cases, abdominal ultrasound [Figure 2] associated with computed tomography (CT) in two cases, and abdominal CT in four cases [Figure 3]. Surgery was performed under general anesthesia. An elective incision was used in all cases. The hernia sac was opened, explored, and resected in all cases [Figure 4]. The hernia content was a small bowel in four cases, epiploic in three cases, and colic in one case. The hernia orifice was <3 cm in five cases. The median size was 3.6 cm (range, 1–10). A retromuscular sublay mesh (15 cm × 8 cm) repair was performed in five cases. The mesh was fixed using an absorbable suture. A primary suture was made in the three cases complicated by strangulation with suffering small bowel content. We used a nonabsorbable suture. The median operative time was 42 min (range, 35–50), and the median hospital stay was 2.75 days (range, 2–6). All patients were followed up postoperatively and regularly exanimated at the outpatient clinic. No recurrence was detected with a median follow-up of 2 years (range, 1–5).
Table 1: Demography and clinical data

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Figure 1: Clinical presentation of a right-sided Spigelian hernia

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Figure 2: Abdominal ultrasound showing parietal defect, collar, and hernia sac

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Figure 3: Abdominal computed tomography scan showing a right-sided Spigelian hernia

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Figure 4: Intraoperative picture for strangulated Spigelian hernia showing the incarcerated bowel and the hernia orifice

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  Discussion Top

The hernia of Spieghel does not fail due to its reputation of a rare hernia by the existence of only eight cases in our service during a study spread over 15 years. However, in the literature, some authors report a larger number of patients. Larson in the United States during 21 years has collected 81 cases,[3] and Moles estimated the number of cases in the Spanish literature until 2003–162 cases.[4] This type of hernia was described for the first time by Adriaan van den Spieghel, surgeon and anatomist (1578–1625). It is located at the junction between the rectus muscle fascia and the lateral muscles of the abdomen. Spigelian herina is the protrusion of preperitoneal fat, peritoneal sac, or organ(s) through a congenital or acquired defect in the spigelian aponeurosis.[5] Our results are similar to many others in the world literature where this pathology is described as occurring from the fifth decade.[6],[7] Moreno-Egea found an average age of 60 years.[8] Many cases have been described in children with a congenital defect in the Spieghel line. Risk factors were the weakness of the abdominal wall or the increase of intra-abdominal pressure, all associated with an anatomical predisposition of the Spieghel line. These include obesity, chronic obstructive pulmonary disease, previous surgery, or abdominal trauma. According to Moles, the retraction of a scar behind an area of weakness increases the risk of hernia. He found these factors in 100 patients of 162 patients. There was a surgical history for 39%, obesity 21%, and multiparity 14%.[4] All patients of Moreno–Egea present these factors, six cases with surgical history, six cases of abdominal trauma, six cases of obesity, and the remainder were Chronic Obstructive Pulmonay Disease (COPD).[8] In the literature, these risk factors were reported with various degrees. This hernia can occur at any point of the Spieghel line,[5] below which all the aponeurotic layers are reflected in front of the rectus muscle. They are located infraumbilically in 90% of cases.[9] Clinical manifestations are not specific. They depend on hernia contents. According to Mathonnet, 90% would be asymptomatic.[9] The most frequent symptomatology is an abdominal mass that can be painful.[4] The pain can be explained by the narrowness of the hernia orifice. Strangulation rate is estimated as 40% according to Moles.[4] The diagnosis is usually made by abdominal examination. However, if the Spieghel hernia is small and covered by the aponeurosis of the external oblique muscle or if the patient is obese the diagnosis becomes difficult. In addition, a lower localization could be misdiagnosed as an inguinal hernia. It is recommended to perform an ultrasound or better a CT to diagnose this disease [Figure 2] and [Figure 3].[4],[10],[11] Sometimes, laparoscopy is a promising diagnostic and therapeutic alternative. The surgical treatment can be suture closure, muscle plasty, or mesh repair with good results.[12],[13],[14] The open approach ensures good results in terms of morbidity and recurrence but usually requires longer hospitalization and wide dissection.[4],[14],[15] In 1992, Carter published the first laparoscopic repair of a Spigelian hernia.[16] This alternative reduces significantly the hospital delay (5.2 days in open approach vs. 1 day in TEP approach vs. 1.4 days in intraperitoneal laparoscopic repair).[13] However, it has a specific complication such as bowel perforation and trocar site complications. On the other side, the completely extraperitoneal laparoscopic approach could avoid these disadvantages and allow repair of the defect at its origin in the abdominal wall.[14],[17]

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Conflicts of interest

There are no conflicts of interest.

  References Top

Houlihan TJ. A review of Spigelian hernias. Ann Surg 1976;131:734-5.  Back to cited text no. 1
Spangen L. Spigelian hernia. In: Nyhus LM, Condon's RE, editors. Hernia. 14th ed. Philadelphia: J.B. Lippincott; 1995. p. 381-92.  Back to cited text no. 2
Larson DW, Farley DR. Spigelian hernias: Repair and outcome for 81 patients. World J Surg 2002;26:1277-81.  Back to cited text no. 3
Moles Morenilla L, Docobo Durántez F, Mena Robles J, de Quinta Frutos R. Spigelian hernia in Spain. An analysis of 162 cases. Rev Esp Enferm Dig 2005;97:338-47.  Back to cited text no. 4
Skandalakis PN, Zoras O, Skandalakis JE, Mirilas P. Spigelian hernia: Surgical anatomy, embryology, and technique of repair. Am Surg 2006;72:42-8.  Back to cited text no. 5
de la Hermosa AR, Prats IA, Liendo PM, Noboa FN, Calero AM. Spigelian hernia. Personal experience and review of the literature. Rev Esp Enferm Dig 2010;102:583-6.  Back to cited text no. 6
Perrakis A, Velimezis G, Kapogiannatos G, Koronakis D, Perrakis EJH. Spigel herina: A single center experience in a rare herina entity. Herina 2012;16:439-44.  Back to cited text no. 7
Moreno-Egea A, Flores B, Girela E, Martín JG, Aguayo JL, Canteras M. Spigelian hernia: bibliographical study and presentation of a series of 28 patients. Hernia 2002;6:167-70.  Back to cited text no. 8
Mathonnet M, Mehinto D. Anterolateral hernias of the abdomen. J Chir (Paris) 2007;144:5S19-22.  Back to cited text no. 9
Vos DI, Scheltinga MR. Incidence and outcome of surgical repair of spigelian hernia. Br J Surg 2004;91:640-4.  Back to cited text no. 10
Shenouda NF, Hyams BB, Rosenbloom MB. Evaluation of spigelian hernia by CT. J Comput Assist Tomogr 1990;14:777-8.  Back to cited text no. 11
Fried AM, Meeker WR. Incarcerated Spigelian hernia: ultrasonic differential diagnosis. AJR Am J Roentgenol 1979;133:107-10.  Back to cited text no. 12
Moreno-Egea A, Carrasco L, Girela E, Martín JG, Aguayo JL, Canteras M, et al. Open vs. laparoscopic repair of spigelian hernia: A prospective randomized trial. Arch Surg 2002;137:1266-8.  Back to cited text no. 13
Bittner R, Bingener-Casey J, Dietz U, Fabian M, Ferzli GS, Fortelny RH, et al. Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International endohernia society (IEHS)-part 1. Surg Endosc 2014;28:2-9.  Back to cited text no. 14
Coda A, Mattio R, Bona A, Filippa C, Ramellini G, Ferri F, et al. Spigelian hernia: An up-to-date. Minerva Chir 2000;55:437-41.  Back to cited text no. 15
Carter JE, Mizes C. Laparoscopic diagnosis and repair of spigelian hernia: Report of a case and technique. Am J Obstet Gynecol 1992;167:77-8.  Back to cited text no. 16
Moreno-Egea A, Torralba J, Aguayo J. Totally extraperitoneal laparoscopic repair of spigelian hernia. Eur J Coeliosurg 1999;32:83-4.  Back to cited text no. 17


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]

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