Spigelian Hernia: A Rare Case Report

Case Report

Spigelian Hernia: A Rare Case Report

Wael Zaki and Awad Ali M Alawad^*
Department of Surgery, Prince Sultan Armed Forces Hospital, Saudi Arabia

^*Corresponding author: Awad Ali M. Alawad, Department of Surgery, Prince Sultan Armed Forces Hospital, Medina, Saudi Arabia

Published: 06 Mar, 2017
Cite this article as: Zaki W, Alawad AAM. Spigelian Hernia: A Rare Case Report. Ann Clin Case Rep. 2017; 2: 1288.

Abstract

Spigelian hernias are rare abdominal wall defects that occur at the semilunar line lateral to the rectus abdominis muscle. They are located between the muscular layers of the abdominal wall and can be easily overlooked because of abdominal obesity. Generally, they are difficult to diagnose because of their location and vague symptoms. The diagnosis has been considerably aided by the introduction of ultrasonography and Computed Tomography. Once the diagnosis is made operative management is indicated due to risk of incarceration. We report a 32 years old female patient from who presented with right upper abdominal pain associated with a swelling below the right subcostal margin. A diagnosis of Spigelian hernia and gallbladder stones was made. The patient underwent laparoscopic mesh repair and cholecystectomy. Her recovery was uneventful.

Keywords: Spigelian hernia; Lateral ventral hernias; Laparoscopic mesh repair

Introduction

Spigelian hernia is named after Adrian Van der Spighel who described semilunar like (lineaspigeli) in 1645. The hernia was first described Klinkosch in 1764 [1]. Spigelian hernia is a rare abdominal hernia, occurring through the spigelianaponeurosis, it carries a significant risk of incarceration and strangulation. Most spigelian hernias occur below the level of the umbilicus close to the level of the arcuate line (inferior margin of posterior leaflet of rectus sheath within the abdomen), though they have being reported to occur above the level of the umbilicus [2].
Diagnosis of Spigelian hernia requires a high degree of suspicion, with the most common finding on clinical examination being a lump at the semilunar line. Radiological tests are useful in confirming the diagnosis. Once diagnosed, Spigelian hernias require operative repair. 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 [3]. We present a case of spigelian hernia in a female patient and its management and discuss about the various investigations and the treatment modalities available for its repair, with literature review.

Case Presentation

A 32 years old female patient presented to the outpatient department with history of intermittent right upper quadrant pain for 8 years. She underwent laparoscopic sleeve gastrectomy 2 years ago. On examination, she had a weight of 89 kg with a BMI of 33 kg/m². Physical examination revealed a firm lump of about 6 x 5 cm was found on the right upper abdomen at the margin of the right semilunar line. The lump would increase on coughing and decrease in lying position.
On investigation, haemogram, liver function tests, blood urea and creatinine were normal. Ultrasonography showed multiple gall stones and right hypochondrium anterior abdominal wall defect (Figure 1). CT scan showed the defect of a Spigelian hernia about 3 cm in diameter, containing omentum (Figure 2).
After adequate preparation she was planned for laparoscopic cholecystectomy and hernia repair. Intraoperatively, right sided SH was detected. There was also hemangioma on the lower part of the right lobe. Laparoscopic cholecystectomy was done and the hernia was managed laparoscopically. Omentum adherent to the defect was reduced. The defect was seen as a large opening in the peritoneum, along the lateral margin of rectus abdomens muscle on the right side (Figure 3). After dissection of the adhesions with the help of Harmonic scalpel, a prosthetic composite mesh (10 x 10 cm) was introduced into the peritoneal cavity and was fixed with the help of tacks to cover the defect (Figure 4). A full laparoscopic exploration of the abdomen was completed without finding other defects. Postoperative recovery was uneventful and the patient was discharged on postoperative day 2.

Figure 1

Figure 1
Right hypochondrium anterior abdominal wall defect averaging 2.6 cm with omental content.

Figure 2

Figure 2
CT scan showing the defect of a Spigelian hernia about 3 cm in diameter, containing omentum.

Figure 3

Figure 3
Laparoscopic image showing the defect of a Spigelian hernia and the previous port.

Figure 4

Figure 4
Laparoscopic image showing the defect of a Spigelian hernia and the previous port.

Discussion

Since ages, deposited or impacted foreign bodies have been a less amusement to the clinicians as well as to the population. Sometimes it may turn out uneventfully, otherwise it endangers the life of the patient depending on the type, size and location of the foreign body [2,5]. Deposition or impaction of foreign bodies is a very scary situation for the patient as well as their close ones. They are usually secondary to a gunshot or stab wound [6,7]. There have been reports of impacted chopsticks [8], pen [6] and wooden piece [2]. However, retention of a surgical blade (No.11) is less reported. The diagnosis of penetrating neck trauma with an associated foreign body in situ is generally quite obvious from history or clinical examination. However identifying a foreign body can be very challenging at times, especially in cases where the impacted body is very thin or radiologically not very clear [6,9]. Precise localization of the foreign object is essential for complication free removal [6]. The current mortality rate for penetrating neck injury is 3-6%. The usual complications of penetrating neck injuries is less than 10% to as high as 20% and a mortality rate of as high as 20% is also reported [2,5,10].
The present case is interesting because of the mode of entry of the surgical blade in the neck, which the patient has been unaware off. It is also interesting in the way it travels under the subcutaneous tissue of the neck without creating any complications. It was detected with an orthopantamogram. It traveled sub platysmally and was stuck 5 mm below the base of the mandible on the left side of the neck. To prevent any complications intra-operatively or post- operatively, the wound should be explored by horizontal incision in the skin crease with proper wound debridement.
Thorough knowledge of the anatomy of the neck, physical examination and current recommendations for diagnostics and therapeutic interventions are necessary for the appropriate removal of the foreign bodies in the neck region [2].

Conclusion

Foreign bodies in the neck are an uncommon but potentially life threatening and crisis condition. Pre-operative imaging is very important in deciding upon the surgical approach for the retrieval of impacted foreign bodies. A thorough knowledge of the anatomy, and various management protocols with a changing technique compel the surgeon to perform a close evaluation of the patient. Each maneuver should be directed to reduce the rate of morbidity and mortality by means of timely intervention. In cases of surgical blade as foreign bodies, early exploration and surgical removal reduces the chances of fibrosis, infection and damage to vital structures, resulting in a favorable outcome.

Case Report