Overview
Definition:
A Spigelian hernia is a protrusion of abdominal contents through the linea spicularis, specifically through a defect in the aponeurosis of the rectus abdominis muscle, typically located lateral to the rectus muscle and medial to the semilunar line
Laparo-endoscopic repair refers to the surgical correction of this hernia using minimally invasive laparoscopic or endoscopic techniques.
Epidemiology:
Spigelian hernias account for approximately 0.5% to 2% of all abdominal wall hernias
They are more common in middle-aged individuals, with a slight predilection for males
They can occur at any age but are less common in children.
Clinical Significance:
Spigelian hernias pose a significant clinical challenge due to their often subtle presentation, leading to delayed diagnosis and an increased risk of complications, particularly incarceration and strangulation
Laparo-endoscopic techniques offer potential advantages in terms of reduced pain, faster recovery, and cosmesis compared to open repairs, making them an important consideration for surgical residents preparing for examinations.
Clinical Presentation
Symptoms:
Intermittent or constant abdominal pain, often localized to the lower quadrants
A palpable or visible bulge, which may disappear when supine
Nausea and vomiting, especially if incarcerated
Symptoms of bowel obstruction if strangulation occurs.
Signs:
A localized tender mass or bulge in the abdominal wall, usually inferolateral to the umbilicus
Cough impulse may be present
Incarceration may present as a tense, irreducible mass
Signs of peritonitis if perforation occurs.
Diagnostic Criteria:
Diagnosis is primarily clinical, supported by imaging
There are no specific formal diagnostic criteria for Spigelian hernia beyond the presence of a defect and extruded abdominal contents, confirmed by imaging or intraoperatively.
Diagnostic Approach
History Taking:
Detailed history of pain onset, character, and exacerbating/relieving factors
Ask about prior abdominal surgeries and history of trauma
Inquire about any palpable masses or changes in bowel habits
Red flags include acute severe pain, fever, or signs of obstruction.
Physical Examination:
Careful palpation of the abdominal wall in both supine and erect positions, as well as during Valsalva maneuver
Assess for any tenderness, masses, or reducibility
Auscultate for bowel sounds
Perform a digital rectal examination to rule out other causes of abdominal pain.
Investigations:
Ultrasound is often the initial imaging modality of choice, demonstrating the defect and herniated contents
CT scan of the abdomen and pelvis provides a more detailed anatomical assessment, confirming the diagnosis and evaluating for complications
MRI can be used in select cases
Laboratory tests are typically normal unless complications like strangulation or perforation are present.
Differential Diagnosis:
Other abdominal wall hernias (inguinal, femoral, umbilical)
Desmoid tumors
Lipomas
Rectus sheath hematoma
Musculoskeletal pain
Abscesses.
Surgical Management
Indications:
Symptomatic hernias
Asymptomatic hernias with a defect greater than 1.5-2 cm
All incarcerated or strangulated hernias
Hernias in patients with occupation or lifestyle demanding heavy lifting.
Laparo Endoscopic Technique:
The laparoscopic approach involves creating pneumoperitoneum and identifying the Spigelian hernia defect
A prosthetic mesh is then placed anterior or posterior to the transversalis fascia to cover the defect
For endoscopic repair, small incisions are made, and instruments are used with a direct visualization system.
Mesh Placement:
The mesh is typically fixed using tacks or sutures, ensuring adequate overlap beyond the defect margins
The type of mesh (e.g., polypropylene, composite) is chosen based on the surgical situation and surgeon preference.
Advantages Of Laparoscopy:
Improved visualization of the defect and surrounding anatomy
Reduced postoperative pain
Shorter hospital stay and faster return to normal activities
Lower risk of wound infection and hernia recurrence compared to some open techniques.
Complications
Early Complications:
Bleeding
Seroma formation
Wound infection
Mesh infection
Bowel injury
Urinary retention.
Late Complications:
Chronic pain
Nerve entrapment
Mesh migration or erosion
Recurrence of the hernia
Adhesions.
Prevention Strategies:
Meticulous surgical technique
Appropriate mesh selection and fixation
Prophylactic antibiotics
Careful handling of tissues
Postoperative mobilization and pain management.
Prognosis
Factors Affecting Prognosis:
Timeliness of diagnosis and intervention
Presence and severity of complications like incarceration or strangulation
Surgeon's experience
Patient's overall health status.
Outcomes:
Successful laparo-endoscopic repair generally results in a good prognosis with low recurrence rates and rapid recovery
Incarceration and strangulation significantly worsen outcomes.
Follow Up:
Routine follow-up is recommended at 2 weeks, 1 month, and 3-6 months postoperatively to monitor for complications and recurrence
Patients should be advised to avoid strenuous activities for 4-6 weeks.
Key Points
Exam Focus:
High-yield: Spigelian hernia location (lateral to rectus, medial to semilunar line)
Increased risk of incarceration/strangulation
Laparoscopic repair indications and advantages
Differential diagnoses.
Clinical Pearls:
Palpate the abdominal wall systematically, especially in patients with unexplained abdominal pain
Consider Spigelian hernia in patients with atypical groin or flank pain
Laparoscopy offers excellent visualization of the transversalis fascia defect.
Common Mistakes:
Missed diagnosis due to subtle presentation
Inadequate mesh coverage of the defect
Insufficient fixation of the mesh
Overlooking incarcerated bowel during surgery
Incomplete preoperative assessment.