Large Spigelian Hernia: Case Report and Review of Literature

Case Report

Large Spigelian Hernia: Case Report and Review of Literature

Bashir MU¹, Sbeih MA¹, Weerasinghe D¹ and Chua A³
¹Department of Surgery, Columbia University, USA
²Department of Surgery, Woodhull Medical Center, NYU Langone Medical Center, USA

^*Corresponding author: Mohammad U. Bashir, Department of Surgery, Harlem Hospital Center, Columbia University, 506 Lenox ave, New York, NY 10037, USA

Published: 19 Sep, 2016
Cite this article as: Bashir MU, Sbeih MA, Weerasinghe D, Chua A. Large Spigelian Hernia: Case Report and Review of Literature. Clin Surg. 2016; 1: 1124.

Abstract

A Spigelian hernia is a lateral ventral abdominal hernia that occurs with protrusion of a viscus or preperitoneal fat through a defect in the aponeurotic layer between the lateral edges of the rectus abdominis medially and the semilunar line laterally. Spigelian hernias are relatively uncommon, and represent only 2% of all abdominal hernias. Due to their overall rarity and evasive presentation, Spigelian hernias and their associated complications are not well described in literature. We report here a rare presentation of a Spigelian hernia with large and small bowel strangulated portion in hernia sac, necessitating emergent laparotomy with bowel resection and repair of the hernia defect.
Keywords: Spigelian hernia; Cecum; Laparotomy; Abdomen

Introduction

A spigelian hernia is the result of an anterior abdominal wall defect. A spigelian hernia results from protrusion of a viscus or preperitoneal fat through a defect in the transversus abdominis muscle, it occurs laterally to the lateral border of the anterior rectus sheath along the semilunar line, where a transition from muscle to aponeurosis occurs. Spigelian hernia management is a challenge to general surgeons. Elective repair of uncomplicated Spigelian hernias can be performed both laparoscopically and by an open technique, with the former reported to be associated with a lower morbidity and shorter hospital stay [1-2]. However, an open approach is more feasible in emergent presentations associated with viscus incarceration, as this prevents undue delays and rapid reduction with possible revival of ischemic tissues, as well as reduction of the rate of iatrogenic bowel injury during trocars insertion for the laparoscopic approach. This case report will present an open repair performed in an emergent situation for incarcerated large spigelian hernia.

Case Presentation

A 49 year-old Hispanic female presented to the emergency department with a 12 hours history of progressively worsening right lower quadrant pain with multiple episodes of nausea and vomiting and associated abdominal distention. The pain was reported to be severe and persistent with no radiation. Further pertinent history included four pregnancies and a surgical history of a caesarean section about 20 years ago.
On examination, she had a weight of 73 kg with a BMI of 31 kg/m2. Physical examination revealed a well-developed female in acute distress due to abdominal pain. Her blood pressure was 102/59 but other vital signs were within normal limits. Abdominal exam revealed a distended abdomen with severe tenderness in the right lower quadrant; a non-reducible firm and tender mass measuring 10 cm x 10 cm was also palpated in the right lower quadrant, and bowel sounds were found to be hypoactive. A CT scan of the abdomen revealed a spigelian hernia in the right lower quadrant containing a dilated cecum (up to 7.1 cm) with collapse of proximal bowel loops, suggesting mechanical small bowel obstruction (Figure 1,2). Based on the above history and corresponding radiographic findings, a diagnosis of incarcerated Spigelian hernia was established.
After resuscitation, patient was taken to the operating room for exploratory laparotomy and hernia repair. Intraoperatively, the hernia sac was first approached through a gridiron incision and dissection was continued until the hernia sac containing the strangulated cecum was visualized. The cecum and adjoining portion of the ascending colon as well as the terminal ileum were found to have wall necrosis. Thereafter, a right hemicolectomy was performed via a separate midline incision including the distal necrotic portion of the ileum in the resected specimen; a primary ileocolic anastomosis was performed. The Spigelian hernia defect was then repaired by primary suture closure using non absorbable sutures with imbrication of both the internal oblique and external oblique fibers.
Postoperatively, the patient recovered well and her remaining hospital stay was uneventful. She was discharged on the fifth postoperative day after tolerating diet and having regular bowel movements, she continued to follow in surgery clinic with no recurrence. Surgical pathology was consistent with transmural necrosis with marked mucosal and submucosal hemorrhage involving the cecum, ileocecal valve and proximal ascending colon.

Figure 1

Figure 1
CT Abdomen reveals the spigelian hernia with dilated cecum and entrapped mesentery and omentum- Coronal view.

Figure 2

Figure 2
CT Abdomen reveals the spigelian hernia with dilated cecum- Cross sectional view.

Discussionn

A spigelian hernia is most likely an acquired abdominal wall defect, although a congenital predisposition secondary to weakening of the spigelian fascia from perforating vessels may also contribute [3,4]. Acquired factors that predispose to a spigelian hernia include obesity, multiple previous pregnancies, Chronic Obstructive Pulmonary Disease (COPD) and previous surgeries [3]. These hernias occur equally in males and females, and present mostly in the fifth to sixth decade of life [4]. Most spigelian hernias (almost 90%) occur through the spigelian aponeurosis in a 6 cm wide area extending from the umbilicus superiorly to the interspinal plane inferiorly (the line connecting the anterior superior iliac spines); the spigelian aponeurosis is located lateral to the rectus muscle and is made up of the transversus abdominis aponeurosis and the posterior leaf of the internal oblique aponeurosis [5].
Spigelian hernias present mostly with abdominal pain and a palpable mass in the area of the hernia [3,5]. Incarceration with spigelian hernias has been reported in 10-24% of patients with symptomatic spigelian hernia, with the hernia sac usually containing a portion of the omentum [3,6]; other viscera that have been reported to be involved include the colon, appendix, ovaries, testes and the small intestine [6,8]. A pertinent clinical exam and an abdominal US may both assist in the work up of a Spigelian hernia, however a CT scan is the most definitive test in establishing a diagnosis of a spigelian hernia [6,7]. Further, a CT scan also assists in defining the anatomy of the hernia sac and any associated complications such as mechanical obstruction.
The management of Spigelian hernias is almost always surgical, with a low recurrence rate after surgical repair [3,5]. Elective repair of uncomplicated Spigelian hernias can be performed both laparoscopically or by an open technique, with the former reported to be associated with a lower morbidity and shorter hospital stay [9]. However, an open approach is more feasible in emergent presentations associated with viscus incarceration, as this prevents undue delays and rapid reduction with possible revival of ischemic tissues, as well as reduction of the rate of iatrogenic bowel injury during trocars insertion for the laparoscopic approach. In our patient, an open approach to the hernia allowed optimal exposure in a timely fashion, although the involved portion of the bowel was beyond salvage. Nevertheless, reduction of the hernia contents expeditiously prevented further necrosis and a primary anastomosis with healthy viable margins was achieved.

Conclusion

Spigelian hernias are rare disorder that results from acquired or congenital factors results in defect in the transversus abdominis muscle in anterior abdominal wall and subsequent protrusion of visceral content through the hernia defect. Spigelian hernias carry a significant risk of incarceration and strangulation of sac content. Clinical presentation is often vague, leading to delayed diagnosis. A thorough physical examination along with high clinical suspicion remains crucial in the diagnosis of the Spigelian hernia; additionally, CT scan is the most definitive radiologic test in establishing a diagnosis of a spigelian hernia [6,7]. The management of spigelian hernias is almost always surgical, with a low recurrence rate after surgical repair [3,5]. Spigelian hernias can be repaired in a traditional open fashion or laparoscopically. Multiple intra-abdominal organs have reportedly been found in spigelian hernias, but the presence of a cecum is very rare. Early prompt surgical intervention prevents catastrophic complications of incarcerated spigelian hernias.

Case Report