Laparoscopic Repair of Spigelian Hernia: A Case Report

Background

A spigelian hernia is a congenital defect in the transverse aponeurosis fascia. Ideally anterior abdominal hernipoplasty is used for the repair. We report a case of spigelian hernia which was repaired laparoscopically in our setup.

A 65yrs. old lady came with complaints of swelling in the (L) lower abdomen since past 10 yrs. which was initially small and gradually progressed to attain present size. Swelling increase in size on coughing and straining but reduced partially on lying down. Lady giveshistory of LSCS 40 yrs.ago. She is a known diabetic on treatment. A 25×30 cm swelling was seen in the anterior abdominal wall in the Left Iliac Fossa extending 1 cm short of midline medially upto left anterior superior iliac spine laterally, inferiorly extending from the groin crease upto the level of umbilicus superiorly. Expansile impulse on cough was noted, skin over the swelling was stretched. Pfannanstiel incision noted healed by primary intention. Hernial orifices are normal. On palpation swelling was soft in consistency, completely reducible and reduces with gurgle. Defect of 5×5 cm noted in the abdominal wall 4 cm below and lateral to umbilicus. This defect was separate from the Previous Pfannensteil Incision.

Method

Patient was operatedin supine position and under general anaesthesia. 3 ports were used for the repair. 11 mm umbilical port 10 mm port (L) palmar point port and 5 mm port was placed in right mid clavicular line. After creating Pneumoperitoneum an initial diagnostic laproscopy was performed. Dense adhesions were noted between the small bowel and anterior abdominal wall in the area of the previous pfannensteilscar. Small bowel was noted herniating through the iliacdefect separately seen from the scar in the Left Fossa. Adhesiolysis was done initially. Small bowel in the hernia sac was reduced. A defect of 6 × 6 cm was noted in the anterior abdominal wall with well-defined margins. A 10 × 15 cm dual mesh (LOTUS) was placed with adequate overlap and the defect was closed. The mesh was tacked to the anterior abdominal wall around the defect. Post-operative period was uneventful, and patient was discharged on POD 2

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Figure 1

Diagrammatic representation of spigelian belt

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Figure 2

Pre op CT showing defect in the anterior abdominal wall with herniation of small bowel

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Figure 3

Intra op image showing adhesions

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Figure 4

Intra op images showing small bowel herniating through the defect

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Figure 5

Intra op image showing size of the defect following reduction of the contents

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Figure 6

Intra op image showing placement of dual mesh

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Figure 7

Post-operative image of the patient

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Discussion

Spigelian hernia is protrusion of sac of the peritoneum or the viscus through the defect in the spigelian fascia. Spigelian fascia is located along the spigelian line through the transverse abdominisaponeurosis close to the level of arcuate line.¹ usually spigelian hernias occur in “spigelian hernia belt” which is a 6cm wide transverse zone which lies above interspinal plane (between anterior superior ilac spine on either side)²

Spigelian hernia represents 2% of the anterior abdominal wall hernias.³ Diagnosis needs to be confirmed on the basis of history examination findings and imaging modality. Predominant symptom with patient presented was lump in the abdominal wall. However patients can present with pain abdomen, or an irreducible lump. Imaging modality helps in detecting the defect. Since they have a high rate of complications like incarceration and strangulation spigelian hernias need surgical repair⁴. Ideally most of the repairs are done on selective basis. Laparoscopic repairs include preperitoneal repair with prolene mesh, dual mesh, onlay mesh repairs using PTFE mesh⁵. We performed a laparoscopic transabdominal underlay repair with dual mesh. No post-operative complications were seen and patient was discharged on post-operative day 2.

Conclusion

Laparoscopic repair of spigelian hernia is a viable alternative in management of SpigelianHernias in centres with adequate laparoscopic surgeons.