Spigelian hernia: a case report and review of the literature

G Chir V ol. 27 -n. 11/12 -pp. 433-435 N ov embr e-Dicembr e 2006

Spigelian

hernia:

a

case

report

and

review

of

the

literature

A.M. ANGELICI, A.G. NASTI, N. PETRUCCIANI, G. LEONETTI, P . P ALUMBO 433

Introduction

Spigelian hernia, or lateral ventral hernia, is a rar e de -fect of the abdominal wall, occurring thr ough the Spige -lian aponeur osis (1-3); peritoneal sac or organ or pr epe -ritoneal sac can pr otr ude thr ough the hernial orifice (4). It was alr eady kno wn and first described b y D e B legny in 1860, Le D ran in 1742 and Le Clause in 1746. Klinkosh in 1764 gav e to this hernia the defi -nitiv e nosologic and topographic arrangement and named it Spigelian hernia, after a B elgium anatomi -st, A driaan V on Spieghel, who first described the li -nea semilunaris. _Ithas been described in literatur e also with other names: joint tendon hernia, ventral interstitial hernia, semilunar line hernia and lateral ventral hernia (5, 6). Spigelian hernia is infr equently referr ed to in the worldwide literatur e: Spangen ’s revie w in 1993 gathe -red 979 published cases (7); later other authors hav e added ne w cases usually in shor t series (8). Linea semilunaris repr esent the bor der zone betw een muscular and aponeur otic por tion of the transv ersus abdominis muscle; it has medial concavity and str etches fr om VIII-IX costal car tilage to pubic tu -b er cl e (9 ). The por tion of aponeur o si s si tu at ed betw een linea semilunaris and the lateral edge of rec -tus abdominis muscle is called Spigelian fascia. It is a w eek point, in par ticular in the zone cr ossing D ouglas semicir cular line, in which all aponeur osis of large ab -dominal muscles became anterior to the rectus muscle (in his lo w er 1/4 the rectus abdominis muscle is in di -rect contact with transv ersalis fascia) (10, 11). O ther impor tant factors in dev eloping of this hernia ar e: 1) under the umbilicus the fibr es of the transv ersus and internal oblique muscles run parallel giving rise to thin fingerings; 2) Spigelian fascia is cr ossed b y inferior epigastric vessels, cr eating a spa -ce that may lead to the dev elopment of a sliding her -S UMMAR Y : Spigelian her nia: a case repor t and review of the lite -ratur e. A.M. A NGELICI , A.G. N ASTI , N. P ETR UCCIANI , G. L EONET TI , P. P AL UMBO Spigelian her nia is a rar e abdominal her nia that occurs thr ough Spigelian aponeur osis. The A uthors pr esent a case of Spigelian her nia associated with nar -ro wing of sigmoid colon and div er ticular patholog y. They also described historical backgr ound, surgical anatomy and etiopathogenesis of this her nia. By a remar kable revision of liter atur e, they sum up epidemiolog y and clinical featur es of Spigelian her nia. F ur ther mor e, they discuss dia -gnostic and ther apeutic principles. R IASSUNT O : L’er nia di Spigelio: un caso clinico e revisione della letteratura. A.M. A NGELICI , A.G. N ASTI , N. P ETR UCCIANI , G. L EONET TI , P. P AL UMBO L’er nia di Spigelio è una rar a er nia addominale che fuoriesce at -tr av erso l’aponeur esi di Spigelio . G li A utori pr esentano un caso clinico di er nia di Spigelio con im -pegno del colon, associato a patologia div er ticolar e. D escriv ono la storia clinica, l’anatomia chir urgica e l’etiopatogenesi di tale patologia. L’ampia revisione della letter atur a per mette di puntualizzar e l’epi -demiologia e le car atteristiche clinico-chir urgiche del ’er nia. G li A utori discutono inoltr e le pr ocedur e diagnostiche e ter apeutiche. K E Y W ORDS : A bdominal hernia -Spigelian hernia -M esh repair . E rnia addominale -E rnia di Spigelio -E rnioplastica pr otesica. Università degli Studi “La Sapienza” di Roma Dipartimento di Scienze Chirur giche “F . Durante” © Copyright 2006, CIC Edizioni Inter nazionali, Roma

nia (12-14). H igher Spigelian hernias occur abo ve the inferior epigastric vessels, while the lo w er ones ar e loca -ted caudally to this vessels (8). R elating to muscular-apo -neur otic planes, Spigelian hernia can be intraparietal (75-85%), pr eperitoneal or super ficial (13). M ost hernial orifices (75-90%) occur in the Spigelian hernia belt of Spangen, which is a transv erse strip at 0 to 6 cm ov er the interspinal line, included among interspi -nal line, semilunar line, spinal-umbilical line and the ex -ternal edge of rectus muscle, wher e Spiegel ’s aponeur osis is wider . H ernial sac usually contains gr eater omentum or omentum fat, small bo w el, colon, but ar e described also other intra-saccular organs: gallbladder , stomach, M ec ke l’s div er ticulm, appendix, epiploic appendix, ov ar y, uterine leiomy oma, testis and a primar y car cino -ma of the peritoneum (15-17). The hernial orifice is almost always small less than 2 cm -57 % of cases gather ed by a recent Spanish revie w (8) -ov al or rounded and it has stiff and w ell-defined margins. A ccor ding to the literatur e, Spigelian hernia affects 1-2,4% of the population with hernia defects, with a sli -ghtly higher incidence in women (female:male ratio 1,5-2:1). It arises usually during the fifth and sixth decades of life, although also cases of congenital Spigelian hernia in infants and childr en ar e described it is most fr equen -tly localiz ed on the right side (18-20). P redisposing factors ar e: obesity , multiple pr egnancy , rapid w eight loss, chr onic obstr uctiv e pulmonar y disea -se, traumas, ascites, pr evious surger y and chr onic consti -pation (21, 22). A ccor ding to some A uthors complications ar e pr esent at the onset in 21-33% of cases: the most common ar e in -testinal obstr uction (23%), intestinal sub-obstr uction (8%), strangulation (20%), incar ceration (14-24,1%) (23-25). The high fr equency of complications is due to the mentioned conformation of hernial orifice that is small (0,5-2 cm) and has rigid margins in the most of ca -ses. In other cases the onset is insidious; most fr equent symptoms ar e not specific: pain in 31-86% of cases and abdominal sw elling in 1/3 of cases (26). O ther symptoms that may occur ar e nausea, vomiting and dyspepsia.

Case

report

A 73 years-old ov er w eight man was admitted to our D epar tment with a histor y of a left-sided abdominal mass, constipation and lo w abdominal pain, the onset of which dated back to about 6 months prior the admission. H e had noted a lo w er left quadrant abdominal mass localiz ed in left flank, that enlarged during V alsalv a manoeuvr e, without tenderness or cutaneous alterations. P ast histor y of intestinal sub-obstr uction. The patient hadn ’t had surgical inter vention on ab -domen. H e was affected by div er ticular disease diagnosed 8 years befor e by a colonoscopy . O n admission, the patient was in good clinical conditions, without fev er .The abdominal examination rev ealed an ov al palpable soft sw elling in left flank, co ver ed by normotr ophic skin. The mass had a maximum diameter of 6 cm and was reducible; it transmitted cough impulses and was not aching neither tenderness. Bo w el sounds w er e normal and peristalsis was pr esent. Ther e w er e no signs of peri -tonitis. Laborator y wor k-up sho w ed no pathological findings. A colonoscopy sho w ed the div er ticular pathology (without mu -cosal inflammation) and stiffness of sigma. A contrast-enhanced computed tomography display ed a voluminous left abdominal hernia with diastases of oblique muscles, with engagement of a por tion of the sigmoid colon; sigma was slightly narr ow ed in the point of enga -gement in hernial orifice and the adipose tissue was hyper-dense as for inflammation. M ultiple div er ticuli w er e found in left colon. The patient under w ent to surger y. A median lapar otomy was per formed to check the vitality of the sigma engaged in the hernial orifice and to ev aluate the perivisceral inflammation sho wn by CT findings and the extent of div er ticular pathology; this appr oach was indicated to hav e the possibility to make a bo w el resection if neces -sar y. Intraoperativ e findings confirmed the diagnosis of Spigelian her -nia. The peritoneal cavity and the bo w el w er e explor ed: ther e w er e no lesions of sigma, so no resection was per formed and colon was cor -rectly replaced. H ernia was repair ed using an extraperitoneal mesh te -chnique. The postoperativ e course was unr emar kable with an unev entful reco ver y of the patient. The patient was discharged on the 8 thposto -perativ e day .

Discussion

As abo ve mentioned, Spigelian hernia is a rar e abdo -minal hernia that occurs mainly in women, in the right side, it is often small and it is not palpable in almost 2/3 of cases; the engagement of sigmoid colon is not com -mon and is scantly described in worldwide literatur e. This pr ompted us to describe our “not conv entional ” in -ter esting case: our patient was a male, his Spigelian her -nia was localiz ed in the left side and he pr esented a big tumefaction. E ngagement and narr owing of sigmoid co -lon associated to chr onic sev er e constipation cr eated a vi -cious cir cle: the rising of abdominal pr essur e due to ch -ronic constipation pr oduced the enlargement of hernia and a consequent worsening of constipation. F ur ther -mor e the patient was also affected by div er ticular disea -se. Clinical diagnosis of Spigelian hernia can be difficult for the follo wing reasons: 1) it is a rar e pathology; 2) symptoms ar e often not specific, intermittent and va -gue; 3) a palpable tumefaction is not pr esent in the mo -st of cases; 4) hernia ar e fr equently intramural; 5) plain abdominal radiograph is not diagnostic. A ccor ding to Stirnemann et al., physical examination fails to establish the diagnosis in up to 50% of cases (27). D iffer ential diagnosis includes: lipoma and other neoplasms of abdominal wall, desmoid tumours, hae -matoma and my ositis of rectus muscle. U ltrasound scan is consider ed the first examination to be per formed, because of its lo w price and non inv a-sivity , but it can be not useful in ov er w eight patients. 434 A.M. A ngelici e Coll.

P reoperativ e CT scan is recommended b y many authors: it pr ovides detailed information about hernial sac, herniated contents and localization. It should be used in pr esence of other abdominal pathology like in our case. _Spigelian hernia should be always tr eated surgically to av oid serious complications that hav e high fr equency . T o av oid recurr ences is advisable the positioning of a synthetic mesh, as w e did; this tr eatment guarantees bet -ter results and major str ength and resistance compar ed to simple repair . In literatur e ar e described various surgical techniques: midline lapar otomy is the mor e indicated appr oach in case of strangulation or if ther e is another concomitant pathology or when pr eoperativ e diagnosis is uncer tain. This appr oach route allo ws an optimum exploration of the abdominal cavity and permits an ev entual bo w el re -section. Lateral paramedian and local appr oaches ar e al -so recommended by many authors. Lapar oscopic repair was first repor ted in 1992 (28) and it seems associated with decr eased patient morbidity and a shor tened hospital stay . 435 Spigelian her nia: a case repor t and review of the liter atur e 1. Spangen L. Spigelian hernia. A cta Chir Scan Suppl 1976; 462: 1-47. 2. Spangen L. Spigelian hernia. Surg Clin N or th Am 1984; 64: 351-366. 3. Spangen L. Spigelian hernia. W orld J Surg 1989; 13: 573-580. 4. Skandalakis LJ, G adacz TR, M ansberger AR, M itchell WE, Colborn JL, Skandalakis JE. Spigelian (lateral ventral) hernia. In Carnfor th, M odern hernia repair . The embr yological and anatomical basis of surger y. P ar thenon P ublishing G roup , 1996: 71-74. 5. N ov ell F, B adia JM, Sunol J. H ernia de Spiegel. R ev Q uir Esp 1987; 14: 205-208. 6. W eiss Y , Lernau OZ, N issan S. Spigelian H ernia. Ann Surg 1974; 180: 836-839. 7. Spangen L. Spigelian hernia. In N yhus LM, Condon RE, H er -nia, 4 th edition. Lippincott ed., P hiladelphia 1995: 381-392. 8. 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References