J Nippon Med Sch 1998; 65(1) (55)55

Reports on Experiments and Clinical Cases

Spigelian hernia: Case report

Kiichiro Uchiyama, Tetsuo Shibuya, Yoshimasa Watanabe

Koei Chin and Shigeo Tanaka

Department of Surgery (II), Nippon Medical School

Abstract

A spigelian hernia is an uncommon hernia of the anterior abdominal wall. We herein

report a case of spigelian hernia, pre-operatively diagnosed as an incisional hernia. A

61-year-old woman had undergone an abdominal hysterectomy 14years prior to her admis

sion to our hospital complaining of a left lower abdominal mass with recurring pain. At the

time of the operation the hernial orifice appeared not to be related to her previous surgical

scar, but was located at the spigelian fascia below the level of the umbilicus. The hernial sac

was dissected and the defect of the abdominal wall was closed. The diagnosis of a spigelian

hernia can be difficult because of its nonspecific clinical findings and insidious nature.

Diagnostic procedures and differential diagnosis are herein discussed with a review of the

literature. (J Nippon Med Sch 1998; 65: 55-57)

Key words: spigelian hernia, ventral hernia, abdominal wall hernia

Introduction

The spigelian hernia occurs through a defect in

the spigelian fascia of the transversus aponeurosis

lying between the semilunar line and the lateral

edge of the rectus muscle. Adrian van der Spieghel,

a Flemish anatomist, first described the linea

semilunaris (Spigelii), which extends downward

from the costal margin to the pubic tubercle. In

1764, Klinkosh described a hernia located in the

spigelian fascia and coined the term spigelian her-

nia. Most spigelian hernias previously reported have

been found in patients between 40 and 70years of

age. Here we report a case of a spigelian hernia

pre-operatively diagnosed as an incisional hernia.

Case Report

A 61-year-old woman was admitted to our hospi-

tal complaining of an intermittently reducible left

lower quadrant mass associated with recurring

pain. At the age of 47 she had undergone an abdomi-

nal hysterectomy through a transverse skin incision.

One year later, she had noticed a mass near the

operative scar in the left lower abdominal quadrant.

She visited a doctor and was diagnosed as having an

incisional hernia. Fourteen years later, she decided

to undergo an operation and visited our hospital. On

examination in the upright position, there was a

palpable soft mass, 5cm in diameter, 6cm below the

left edge of the previous transverse skin incision.

The mass disappeared when the patient reclined.

The hernial orifice could not be palpated. Routine

physical examination was unremarkable. A plain

film of the abdomen demonstrated a nonspecific gas

pattern. The patient was diagnosed as having an

incisional hernia because the mass was located near

the previous operative scar. Contrast studies of the

gastrointestinal tract, ultrasonography and comput-

ed tomography were not performed.

At the time of the operation, a lower median

incision was made. It appeared that the mass did not

protrude from the defect of the previous operative

scar. The external oblique aponeurosis was incised

over the mass and the hernia containing the

Correspondence to Kiichiro Uchiyama, Institute of Gastroenterology, The Second Hospital, Nippon Medical School, 1-396 Kosugi-cho, Nakahara-ku, Kawasaki, 211-8533 Japan

56(56)

omentum was identified. The hernial orifice was

located at the junction of the arcuate line of Doug-

las and the semilunar line, below the umbilicus (Fig.

1a,b). The sac was dissected and the defect in the

transversus and internal oblique muscles was ap-

proximated with 2-0 absorbable suture in layers.

The external oblique aponeurosis was also sutured.

The patient's recovery was uneventful and she is

now symptom free.

Discussion

The spigelian hernia is a protrusion from the

spigelian fascia and it represents less than 2% of all

anterior abdominal wall hernias. Spigelian fascia is

a portion of the aponeurosis between the lateral

edge of the rectus sheath and the semilunar line.

The posterior rectus sheath is deficient below the

linea semicircularis (the arcuate line of Douglas).

This potential weakness allows most spigelian her-

nias to occur below the umbilicus along the linea

Fig.1 a:Operative view of spigelian hernia. The

external oblique aponeurosis was divided

and the hernial sac was exposed, penetrat-

ing through the internal oblique muscle.

b:Schematic cross-section of the operative

site. The spigelian hernia protrudes through

a defect in the anterior abdominal wall.

semilunaris. The hernia protrudes through a defect

in the transversalis fascia, transversus abdominis

and internal oblique muscles, and mushrooms out

beneath the intact external oblique aponeurosis.

Hernia is usually proceeded by a mass of preper-

itoneal fat. The risk of incarceration and strangula-

tion is high (21.4%) because of the small orifice of

the hernia.

A diagnosis of spigelian hernia is difficult to

make because of its noncharacteristic symptoms

and insidious nature. Frequent complaints are of an

intermittent pain and a reducible mass in the lower

abdomen. These symptoms sometimes are elicited

by standing, straining or coughing but are relieved

by lying down to rest. Ultrasonography (US) and

computed tomography (CT) are valuable modalities

to evaluate abdominal wall hernias. They usually

demonstrate precise information in detecting the

hernial orifice, hernial sac, and contents of the sacs.

Plain abdominal films and contrast studies are

usually of limited value in establishing the diagno-

sis. A hernia can occur anywhere along the

semilunar line, and sometimes the point where the

mass is present is apart from the real hernial ori-

fice. When an anterior abdominal mass is palpable

several causes must be considered (Table1). Appen-

dicitis, direct inguinal hernia and incisional hernia

are especially important for differential diagnosis.

In the case of an incisional hernia, it can be present

at any point depending on the location of the previ-

ous operative scar. The low spigelian hernia which

is found caudal and medial to the inferior epigastric

Table1 Causes of palpable mass of the anterior

abdominal wall

(57)57

artery, i.e., within the Hasselbach triangle, should

be differentiated from appendicitis and direct in-

guinal hernia. Although it is said in many reports

that the diagnosis of a spigelian hernia is difficult to

make because of its asymptomatic and deceptive

nature, careful history and repeated abdominal

examinations with US and CT can lead to an accu-

rate diagnosis. In the review by Weiss the correct

preoperative diagnosis was made in only 92 of 178

(51.5%) cases. However, according to the recent

reports using US and CT the diagnostic accuracy

has been improving. In the review of 32 reports

covering the years between 1972 and 1996, a correct

diagnosis was made in 54 of 69 cases (78.3%). Three

cases were mistaken for an appendicitis, a direct

inguinal hernia' and a right adnexal mass. In

another three cases, spigelian hernias were found

incidentally during laparoscopic operation for other

diseases In nine cases, no certain diagnosis was

made before the operation. In 69 cases, the shortest

period from the beginning of the symptoms until the

diagnosis was 10hours, while the longest history

was 21years. Our patient also had a long history

of 14years. A prompt and definite diagnosis of

spigelian hernias is important because they are

associated with a high rate of bowel obstruction and

strangulation. In order to make a definite diagnosis,

collecting a careful history and repeating examina-

tions for the abdominal mass which protrudes while

standing should be emphasized. Diagnosis of

spigelian hernia is not difficult if physicians are

aware of the existence of this type of hernia, and

confirm it with US and CT.

In the surgical repair of a spigelian hernia, a

gridiron incision over the mass is recommended.

The external oblique aponeurosis is incised in the

direction of its fibers, exposing the hernial sac. The

sac is divided and sutured after its contents are

returned. The internal oblique muscle and external

oblique aponeurosis are reapproximated in layers.

Recently, laparoscopic approaches for the diag-

nosis and repair of spigelian hernia have been repor-

ted. The exact location of the hernial defect could

be identified, the hernia sac reduced and the defect

patched with non-absorbable mesh. Laparoscopy

may afford a safe and minimally invasive surgery

without prolonged recovery.

References

1. Spieghel A: Opera Quae Extore Omnia. 1645; p 103

John Bloew, Amsterdam.2. Klinkosh JT, cited by Holloway JK: Spontaneous

lateral ventral hernia. Ann Surg 1992; 75: 677-685.

3. Holder LE, Schneider HJ: Spigelian hernias: Anat

omy and roentgenographic manifestations. Radiol

ogy 1974; 112: 309-313.

4. Spangen L: Spigelian hernia. World J Surg 1989; 13:

573-580.

5. Luedke M, Scholz FJ, Larsen CR: Computed tomo

graphic evaluation of spigelian hernia. Comp Med Imag and Graphics 1988; 12: 123-129.

6. Weiss Y, Lernau OZ, Nissan S: Spigelian hernia.

Ann Surg 1974; 180: 836.

7. Nauta RH, Heres EK, Walsh DB: Crohn's appendicitis in an incarcerated spigelian hernia. Dis Col Rect

1986; 29: 659-661.

8. Kelly KM, Dwyer WA, Lawn F: Spigelian hernia: Problem in diagnosis and management. N J Med

1987; 84: 581-583.

9. Timmes JJ, Rocko J, Harper PL, Zolli AJ: The "Unrecognized" spigelian hernia . Am Fam Physi

cian 1976; 13: 141-144.

10. DeMatteo RP, Morris JB, Broderick G: Incidental

laparoscopic repair of a spigelian hernia. Surgery

1994; 115: 521-522.

11. Artioukh DY, Walder SJ: Spigelian herniae: Presen

tation, diagnosis and treatment. J R Coil Surg Edinb

1996; 41: 241-243.

12. Hiller N, Alberton Y, Shapira Y, Hadas-Halpern I:

Richiter's hernia strangulated in a spigelian hernia:

Ultrasonic diagnosis. J Clin Ultrasound 1994; 22:

503-505.

13. 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.

(Received, August 11, 1997)

(Accepted for publication, September 25, 1997)