Acute management of a unilateral incarcerated spigelian hernia in a patient with bilateral spigelian hernias

Abstract

Spigelian hernias were first described by Joseph Klinkosch in the 18th century, and have since posed a diagnostic and surgical problem owing to their non-specific presentation and rarity. While the management of unilateral hernias is fairly well described in today's literature, bilateral Spigelian hernias are very rare. We describe the emergency management of a patient with bilateral Spigelian hernias, diagnosed on computed tomography. case historyA 52-year-old woman was admitted to the surgical assessment unit after having developed right iliac fossa pain over the previous 12 hours. The onset was gradual and the pain had worsened with time. She had noticed a swelling over the right side. She had opened her bowels normally that day and, despite being nauseated, she had not vomited. She had no urinary or gynaecological symptoms. The patient was otherwise fit and well, and had not undergone any previous surgery. She was on no regular medication. She smoked 15 cigarettes a day and drank alcohol rarely. On arrival, the patient's vital observations were entirely normal. Examination revealed a very tender right iliac fossa with voluntary guarding. There was a distinct 10cm x 10cm smooth mass palpable, which appeared to be intra-abdominal rather than in the abdominal wall. This was particularly tender and did not have a cough impulse. The remainder of the abdomen was soft. Rectal examination revealed an empty rectum. Her routine blood results on admission were within the normal limits and an arterial blood gas showed a normal lactate level of 0.9mmol/l.In view of the rapid onset of symptoms and despite the lack of inflammatory features, the main differential diagnosis at this stage was an appendicular mass and computed tomography (CT) was organised. This revealed bilateral Spigelian hernias (Figs 1 and 2). The left contained small bowel loops and the descending colon. The right contained the caecum and ileum with surrounding fat stranding, suggesting the presence of reactive inflammatory changes.A laparoscopy was performed and reduction of the rightsided hernia (Fig 3) was attempted. The left side had reduced prior to surgery. The plan was to repair both hernias simultaneously at laparoscopy. Unfortunately, this was not possible as it was impossible to reduce the incarcerated caecum safely. A midline laparotomy incision was made and the hernia reduced manually via an intra-abdominal approach. The caecum, appendix and terminal ileum were extracted and deemed viable. The right-sided peritoneal defect was plicated using 3/0 Vicryl ® (Ethicon, Somerville, NJ, US) interrupted sutures. The midline incision was then closed in a standard fashion. A transverse incision was made over the right hernial orifice and the defect repaired with size 0 Prolene ® (Ethicon) continuous sutures. The left hernia was not fixed on this occasion. discussion Spigelian hernias were first described by Joseph Klinkosch in the 18th century.

Terminal ileum within a Spigelian hernia: a rare presentation of small bowel obstruction

“…Establishing a clinical diagnosis can be difficult, in part due to the fact that Spigelian hernias often lie beneath an intact EO aponeurosis and may therefore be impalpable in large patients. Computed tomography has close to 100% sensitivity and positive predictive value and once diagnosed, urgent surgical repair is advisable due to high rates of strangulation . Following repair, recurrence is low at 0–8% with no single technique or approach demonstrating superiority over others…”

“…Computed tomography has close to 100% sensitivity and positive predictive value 7 and once diagnosed, urgent surgical repair is advisable due to high rates of strangulation. 9 Following repair, recurrence is low at 0-8% with no single technique or approach demonstrating superiority over others. 10…”