Laparoscopic Repair of Incidentally Found Spigelian Hernia.

2011·0.41 MB·English

by  Nagarsheth, Khanjan H.

S P
CIENTIFIC APER
Laparoscopic Repair of Incidentally Found
Spigelian Hernia
Khanjan H. Nagarsheth, MD, Todd Nickloes, DO, Greg Mancini, MD, Julio A. Solla, MD
ABSTRACT INTRODUCTION
BackgroundandObjectives:ASpigelianherniaisarare Spigelian hernias are now defined as an anterior wall
typeofherniathatoccursthroughadefectintheanterior defect in the transversus abdominis close to the arcuate
abdominal wall adjacent to the linea semilunaris. Estima- lineofDouglas,lateraltothelateralborderoftheanterior
tion of its incidence has been reported as 0.12% of all rectussheathalongthesemilunarline.1Klinkoshwasthe
abdominal wall hernias. Traditionally, the method of re- firsttoidentifythepresenceofaherniainthisarea,andit
pair has been an open approach. Herein, we discuss a is now referred to as a spigelian hernia after Adrian van
series of laparoscopic repairs. der Spieghel who first reported on the anatomy of the
linea semilunaris in the rectus sheath.2 Spigelian hernias
Methods: Case series and review of the literature.
areararetypeofherniathatoccursthroughadefectinthe
Cases: Three patients are presented. All were evaluated anteriorabdominalwalladjacenttothelineasemilunaris.
and taken to surgery initially for a different disease pro- Estimations of their incidence have been reported as
cess, and all were incidentally found to have a spigelian 0.12% of all abdominal wall hernias.3 Usually these her-
hernia. These patients underwent laparoscopic repair of nias are identified once there is pain or obstruction from
their hernias; 2 were repaired intraperitoneally and one incarceration of the hernia. Therefore, traditionally the
was repaired totally extraperitoneally. Two patients ini- methodofrepairhasbeenanopenapproach.Therehave
tially underwent a mesh repair, while the third had an been several case reports and a few case series that dis-
attempted primary repair. cusstheeffectivenessofusingalaparoscopicapproachto
repair these hernias. Herein, we present 3 patients who
Conclusions: There is evidence that supports the use of
were all incidentally found to have Spigelian hernias that
laparoscopy for both diagnosis and repair of spigelian
were laparoscopically repaired.
hernias. There are also reports of successful repairs both
primarily and with mesh. In our experience with the
CASE ONE
preceding3patients,wefoundthatlaparoscopicrepairof
incidentally discovered spigelian hernias is a viable op- An 87-year-old woman presented to an outside facility
tion, and we also found that implantation of mesh, when withasyncopalepisodeandwasdiagnosedwithaurinary
possible,resultedinsatisfactoryresultsandnorecurrence. tract infection and normocytic anemia. Her hemoglobin
and hematocrit dropped from 10 and 29 to 6.8 and 19.5,
Key Words: Spigelian, Hernia, Laparoscopic, Repair.
respectively.Shewastransferredtoourtertiarycarecenter
after passing a large clot per rectum. On physical exami-
nation after transfer, she was found to have a large, full
thickness, rectal prolapse that was incarcerated and not
reducible, but it was not ischemic or strangulated.
Gastroenterologists were brought in for a consult on this
case due to the full-thickness rectal prolapse. They were
unabletoreducetheprolapsesecondarytoextremepain
felt by the patient on examination. The recommendation
UniversityofTennesseeMedicalCenter,DepartmentofSurgery,Knoxville,Ten- to call in a colorectal surgeon for further evaluation and
nessee(allauthors).
suggestions for therapeutic options was made. On hospi-
Address correspondence to: Khanjan Nagarsheth, MD, 4850 Briar Rock Lane, tal day 4, after cardiology clearance was obtained, the
Knoxville, TN 37920, USA. Telephone: [phone], E-mail: khanjan.
patient was taken to surgery and underwent a perineal
[email protected]
rectosigmoidectomy with levatorplasty to tent her incar-
DOI:10.4293/108680811X13022985131372
ceratedrectalprolapse.Perinealproceduresforrectalpro-
©2011byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby
theSocietyofLaparoendoscopicSurgeons,Inc. lapse have a higher recurrence rate than abdominal pro-
JSLS(2011)15:81–85 81
LaparoscopicRepairofIncidentallyFoundSpigelianHernia,NagarshethKHetal.
Figure1.CTScanimagerevealingrightsidedSpigelianhernia.
Figure2.LaparoscopicviewofSpigelianherniadefect.
cedures but have a lower morbidity rate. Perineal
CASE TWO
procedure or Altermeier’s4 procedures are often per-
formed in elderly and high-risk populations. A 79-year-old female was admitted to our facility with a
diagnosis of acute cholecystitis. She had recently had a
Postoperatively,thepatientwassenttotheintensivecare
cardiacpacemakerplacedandwasquiteconcernedabout
unit for close monitoring and management. In the ICU,
undergoing surgery and potentially getting an infection
this patient became more distended and began to have
that would compromise her pacemaker. She was started
tenderness in her abdomen. She was obstipated after
on antibiotic coverage until the cardiology department
surgeryandhadnothadabowelmovementsinceherday
wasabletoclearherforsurgery.Radiographicandsono-
oftransfer.Itwasfeltthatthepatienthadapostoperative
graphicstudiesrevealedgallbladderwallthickening,cho-
ileus but with her worsening distention and then nausea
lelithiasis, and pericholecystic fluid. Once the cardiology
and vomiting, a CT scan of the abdomen was obtained
departmentclearedthepatientforsurgery,shewastaken
that revealed an enlarged Spigelian hernia with a portion
to the operating room for laparoscopic cholecystectomy.
of ileum that appeared kinked (Figure 1). On examina-
Once the abdomen was entered with the laparoscope, a
tion, she had an extremely tender right-sided ventral her-
surveyrevealedaSpigelianherniaintheusuallocationat
nia with inflammatory changes to the overlying skin. The
thelineasemilunarisintherightlowerquadrant,andthis
hernia was not reducible at bedside, so it was decided to
defect contained herniated omental fat. The hernia was
take the patient emergently to the operating room for a
takendownlaparoscopically,andthedecisionwasmade
laparoscopic Spigelian hernia repair with mesh.
totryandclosethedefectprimarilyandnotimplantmesh,
Intraoperatively, we were able to reduce the hernia and because the defect was only 2.5cm x 2cm, and there was
the hernia sac (Figure 2). The portion of ileum in the an acutely infected gallbladder present. The hernia was
hernia appeared viable, and peristalsis was visualized in closed primarily by way of transabdominally placed 2-0
thissegmentonceitwasreduced.A12-cmx12-cmround Prolene sutures. The repair appeared to be good and
Parietex mesh was implanted against the hernia defect attention was turned to the gallbladder, which was noted
that was 4cm x 4cm in size. At the end of the procedure, to be very edematous and tense. Bile was aspirated with
the hernia defect was widely covered by the mesh. only a little amount spilled and then suctioned. The gall-
bladderwasremovedinthestandardfashionandaspec-
Postoperatively, the patient began having flatus and a
imen was sent for analysis.
bowelmovementonpostoperativeday2,andhernausea
andvomitinghadresolved.Shewastransferredoutofthe Postoperatively, the patient was sent to the floor where
ICU and to the floor and eventually was discharged to a she began returning to normal function quickly and was
skillednursingfacilityforrehabilitationandphysicalther- discharged on postoperative day number 2 with minimal
apy. tenderness and tolerating a regular diet. She did suffer
82 JSLS(2011)15:81–85
Figure 3. Laparoscopic view depicting Spigelian hernia and Figure4.Laparoscopicviewshowingcontusedbutviablesmall
reducedbowel. bowel,reducedfromSpigelianhernia.
fromsomeurinaryretentionandwasthereforereferredto staff, and she was found fit for discharge a few days after
theurologydepartmentfortreatment.Shewasseeninthe surgery. She is currently doing well without any further
office approximately one week after discharge and was issues from her hernia or the repair.
noted to be doing well.
CASE THREE
However, this patient returned to the emergency depart-
ment approximately 1 month after her office visit with A 67-year-old man arrived at ambulatory surgery to un-
complaints of nausea, vomiting, and crampy abdominal dergolaparoscopicrepairofbilateralinguinalhernias.He
pain in the right lower quadrant. Physical examination hadbeensufferingfromtheright-sidedherniaformonths.
revealed tenderness in this area, and as per the patient, When he was evaluated in the surgeon’s office, he was
she had not been able to have a bowel movement in noted to have a left-sided hernia also. The patient was
several days. A CT scan revealed a recurrence of the prepped for bilateral repair to be done laparoscopically.
Spigelian hernia now with a loop of small bowel stuck
Duringsurgery,aperiumbilicalincisionwasmadeandthe
within it and a small bowel obstruction. The patient was
preperitoneal area was entered. Space was created using
taken to the operating room emergently for risk of isch-
a balloon dissector. Two more 5-mm trocars were placed
emia to this segment of bowel.
in the midline, and dissection commenced to reduce the
The patient underwent a laparoscopic reduction and re- bilateral inguinal hernias. On visualization of the left lat-
pairofherrecurrentSpigelianhernia.Itappearedthatthe eralwall,therewasanabnormalitynotedthatappearedto
priorprimaryclosureofherherniahadbrokendown,and beanotherherniaatthelineasemilunaris.Onpalpationof
nowthedefectcontainedtheterminalileum.Thisloopof the abdominal wall, it was noted that there was a small,
bowel was gently reduced, and although the bowel barelyvisibleherniaontheleftside.ThisSpigelianhernia
lookedbruised,itdidnotlookfranklyischemicorhavea was delineated in the preperitoneal space, and the sack
perforation (Figures 3, 4). At this point, the defect was was reduced into the abdomen. The defect was noted to
noted to be about 3cm in diameter, and a closure was be 3cm x 3cm.
performed with a 15-cm Parietex mesh and the aid of
At this point, our Parietex mesh was placed bilaterally to
transfascial sutures and absorbable tacks.
cover our direct hernia defects, and the left side was
Again the patient tolerated this procedure well and was positioned such that the Spigelian hernia defect was also
sentbacktothefloorinstablecondition.Shecontinuedto covered. Tacks were placed at the pubic tubercle and on
do well and again recovered quickly. Her cardiac issues Cooper’s ligament as well as out laterally on the muscle
were being controlled by the internal medicine house wall.
JSLS(2011)15:81–85 83
LaparoscopicRepairofIncidentallyFoundSpigelianHernia,NagarshethKHetal.
Thepatienttoleratedtheprocedurewellandwasreleased theaddedmorbidityandcostofforeignmaterials,namely
home that same day. On follow-up he was doing well, mesh implantation.
with no recurrence of his inguinal hernias and no pain at
the Spigelian hernia site. This patient did very well with All the patients in this series were seen or admitted for
his laparoscopic repairs and tolerated repair of his inci- another surgical pathology, and either during their ini-
dentally found Spigelian hernia. tialsurgeryorduringtheirsubsequenthospitalcoursea
Spigelian hernia was identified and repaired. Two of
our 3 patients had no further recurrences or problems
DISCUSSION
withtheirlaparoscopicSpigelianherniarepairs,andwe
attributethistotheuseofmeshfortheirrepair.Theone
As mentioned previously, the incidence of Spigelian her-
patient that did have some difficulty after repair had a
nias is quite low, and part of that is likely the anomalous
primary laparoscopic repair without mesh, and did
constellationofsymptomsthatcanaccompanyit,suchas
have a recurrence with subsequent incarceration and
a vague abdominal pain, nausea, and an area of swelling
neededameshrepair.Wefeelthatplacingmeshduring
that may or may not be present.5 A reason that the swell-
theinitialsurgerycouldhavepotentiallybeenproblem-
ing or mass of a Spigelian hernia is not always readily
atic given the nature of the planned operation and risk
evident is because it protrudes through the transversus
ofcontaminationandinfectionofaprostheticmeshifit
abdominis and is still covered by the external oblique
had been used. As stated before, very little information
aponeurosis.This additional layer masks the hernia and
isavailableontheserarehernias,andnothinghasbeen
may prevent it from being palpable thus making the
said about repairing them when operating on a patient
diagnosisdifficult.Infact,itisreportedthatonly50%of
for other pathology.
all Spigelian hernias are diagnosed in the preoperative
period.6 This makes it all the more important to deter-
mine whether repair of incidentally identified Spigelian CONCLUSION
hernias is justifiable and under what circumstances one
should proceed with repair. It has additionally been Givenourexperiencewiththeselimitedsituations,wedo
notedthatthefascialdefectforSpigelianherniasisvery advocate laparoscopic repair of incidentally identified
often quite narrow. There are reports of incarceration Spigelian hernias, but the caveat we add to this is that
and strangulation in as many as 24% of these hernias.7,8 mesh should be utilized in the repair when possible,
especiallyifthedefectisnotedtobeover2cmindiameter
Moreno-Egea et al9 tackled the question of open versus and there is no risk of contamination of the mesh with
laparoscopic repair in 2002 when they attempted a pro- entericorbiliarycontents.Wealsocitetheneedforlarger
spectiverandomizedtrialtoanalyzeelectivesurgicaltreat- series’ to help identify the true benefit of repair of inci-
ment of Spigelian hernias. In their analysis of 22 patients dentally found Spigelian hernias.
(11 open repairs, 11 laparoscopic repairs), they found
significantly less morbidity and shorter hospital length of
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