1. Hong Kong Journal of Emergency Medicine
Spigelian hernia: a complication of laparoscopic cholecystectomy
SA Mahdi, M Jawad, A Nazir, GY Naroo
Spigelian hernia is a rare abdominal wall hernia. It constitutes about 0.12% of all abdominal wall herniae;
the peak occurrence being between the ages of 40-70 years with a male to female ratio of 1:1.18. Owing to
the rarity of the disease, lack of physician experience and absence of typical hernia-like symptoms, it is a
fairly difficult condition to diagnose. There is a 20% incidence of strangulation reported in the literature.
The elective treatment of a Spigelian hernia is surgical: open or laparoscopic. The latter is preferred due to
reduced mortality, shorter hospital stay, better cosmetic result and perhaps a lower recurrence rate. Reported
here is a case of Spigelian hernia that presented to our institution, a level 1 trauma centre, as a complication
of laparoscopic abdominal surgery. (Hong Kong j.emerg.med. 2010;17:388-391)
0.12% 40-70
1:1.18
20%
Keywords: Abdominal hernia, abdominal pain, abdominal wall, laparoscopic cholecystectomy
Introduction acquired defect in the Spigelian (semilunar) line. 2
Absence of typical hernia-like symptoms and lack of
Spigelian herniae constitute about 0.12% of all clinical experience in dealing with such a hernia can
abdominal herniae,1 the peak occurrence being between make early recognition difficult, thereby increasing the
the ages of 40-70 years, with a male to female ratio of risk of strangulation.3
1:1.18.2 It is defined as a protrusion of pre-peritoneal
fat or peritoneal sac, with or without entrapment of
an intra-abdominal organ, across a congenital or Case report
In March 2007, a 65-year-old woman attended the
Correspondence to: Emergency Department of the Rashid Hospital Trauma
Ghulam Y Naroo, MRCSEd, MRCP(UK), MRCPI Center with a 3-day history of abdominal pain. The
Rashid Hospital Trauma Center, Emergency Department, pain was initially localised to the left lower quadrant
Dubai, United Arab Emirates
and was described as a constant dull ache that later
Email: gynaroo@dha.gov.ae
became generalised and colicky in nature. Her
Shihab A Mahdi, MRCS symptoms were associated with a distended abdomen,
Mohammad Jawad, MS constipation and failure to pass flatus. There had been
Aysha Nazir, MBBS no episode of vomiting. She had past medical

2. Mahdi et al./Spigelian hernia 389
history of diabetes, hypertension, and laparoscopic Discussion
cholecystectomy five years ago. She was afebrile, non-
icteric, and the vital signs were stable. The abdomen Adriaan van den Spiegel was an anatomist who first
was slightly distended. There was a palpable tender described the semilunar line (linea Spigeli) in 1645.4
mass in the left lower quadrant, firm in consistency In 1764, Josef Klinkosch described the hernia as a
and non-reducible. A 15-mm scar mark was noticed clinical entity and labelled it as Spigelian hernia defined
on the medial side of the swelling secondary to as a defect in the semilunar line. 2 Nearly 1000 cases
laparoscopic trocar incision. Bowel sounds were have been reported in the medical literature. Spigelian
audible. Total white cell count was normal but there
was an increase in the neutrophil count. The blood
glucose was 11.4 mmol/L. Urea and electrolytes were
normal. The plain abdominal film revealed a mildly
dilated small bowel loop (Figure 1). Abdominal
ultrasound revealed confluent bowel loops surrounded
by a thin rim of fluid in the left iliac fossa (Figure 2).
Abdominal computed tomography revealed a localised
left abdominal wall hernia containing twisted fluid
filled dilated small bowel loops (Figure 3). The patient
underwent an intra-abdominal laparoscopic hernial
repair, and recovered without sequelae.
Figure 2. Abdominal ultrasound scan showing a confluent
bowel loop surrounded by a thin rim of fluid in the left iliac
fossa.
Figure 1. Plain abdominal film showing a mildly dilated small Figure 3. Abdominal computed tomography revealing a
bowel loop in the left lower quadrant and surgical clips in the localised left abdominal wall hernia containing twisted fluid
right upper quadrant. filled dilated small bowel loops.

3. 390 Hong Kong j. emerg. med. Vol. 17(4) Oct 2010
hernia usually occurs between the ages of 40-70 years. Around 20% of Spigelian herniae present with
The aetiology can either be congenital or acquired. strangulation; the treatment of choice being surgical
Obesity is generally considered the principal repair preferably under general anesthesia. 13 An
aetiological factor. The age of occurrence varies from alternative option is laparoscopic technique. In 1992,
6 months to 94 years. 5,6 It is known to be more Carter published the first intraabdominal laparoscopic
common in females, more on the right and mostly correction.14 Although the intra-peritoneal approach
below the level of the umbilicus. Only 28 cases have is simple, it converts an abdominal wall surgery into
been reported above this level.7 an intra-peritoneal surgery with possible risks of
visceral injury and postoperative adhesions. In 1999,
The hernial sac in most cases is located between the Moreno-Egea et al described the first total extra-peritoneal
abdominal wall and the overlying external oblique laparoscopic approach for Spigelian herniae. 15
fascia which is almost always intact. The hernial sacs Laparoscopic repair offers an advantage over open mesh
were situated subcutaneously in only 15 cases. 1 repair owing to reduced morbidity, shorter hospital
However, it has been reported that these herniae had stay, favourable cosmetic result and perhaps lower
an incidence of incarceration ranging from 14-21%. recurrence rate.
The organs usually found to be strangulated are loops
of small bowel, colon or omentum,1 but rare cases with
incarcerated stomach, gall bladder, appendix and ovary Conclusion
have been reported.8 These patients usually complain
of pain or a lump at the site of herniation.1 The pain is Herniation through a secondary laparoscopic trocar site
sharp, constant or intermittent; though in some cases is rare, but care must be taken to avoid creating an
a dragging discomfort has been repor ted. 6 If iatrogenic Spigelian hernia. This may result from using a
strangulation of herniated contents occurs, pain may laparoscopy trocar in the Spigelian aponeurotic layer
be severe and constant, associated with partial or between the rectus muscle medially and semilunar line
complete intestinal obstruction leading to gangrene or laterally, especially at or below the arcuate line. Spigelian
peritonitis.9 Ultrasound scan is reported to be the best, hernia is a rare entity; further studies are required to
earliest and most reliable bedside diagnostic tool highlight the clinical implications of similar aetiology.
available.10 Testa et al9 showed that an ultrasound scan Interestingly, there has been no previous report of such
diagnosis was accurate in 86% of cases. If the hernia is complication resulting from laparoscopic cholecystectomy
reduced and no mass is palpable, the scan will show a in the medical literature. Computed tomography is a
break in the echogenic shadow of the semilunar line useful tool in making an accurate preoperative diagnosis
corresponding to the fascial defect. 10 However, of Spigelian hernia.
ultrasound scanning is operator-dependent and studies
have shown computed tomography to be superior in
terms of diagnosis, especially when these herniae References
become strangulated. In some cases, the definitive
1. Spangen L. Spigelian hernia. World J Surg 1989:13(5):
diagnosis may still be in doubt until exploration.11,12 573-80.
In our case, abdominal computed tomography enabled 2. Houlihan TJ. A review of Spigelian hernias. Am J Surg
us to make a definitive diagnosis of Spigelian hernia 1976;131(6):734-5.
3. Larson DW, Farley DR. Spigelian hernias: repair and
associated with acute incarcerated small bowel. This outcome for 81 patients. World J Surg 2002;26(10):
was later confirmed when the patient underwent intra- 1277-81.
abdominal laparoscopic hernial repair. 4. Schwartz SI, Ellis H, editors. Maingot's abdominal

4. Mahdi et al./Spigelian hernia 391
operations, 9th ed. Norwalk: Appleton & Lange; 1990: LF, Al-Jurf AS. Spigelian hernia: diagnosis by high-
vol. 1; ch. 11: p. 269. resolution real-time sonography. J Ultrasound Med
5. Azuma T, Nakamura S, Hatakeyama G, Nagahara N, 1997;16(3):183-7.
Nakamura T, Yonekura T, et al. A spigelian hernia in 11. Rogers FB, Camp PC. A strangulated Spigelian hernia
an infant. Osaka City Med J 1992;38(2):155-60. mimicking diverticulitis. Hernia 2001;5(1):51-2.
6. Ondo N'Dong F, Lorofi R, Comes G, Bellamy J, Diane 12. Losanof JE, Jones JW, Richman BW. Recurrent
C. [Spigelian hernia. Apropos of a series of 31 cases]. Spigelian hernia: a rare cause of colonic obstruction.
[French] J Chir (Paris) 1992;129(4):210-2. Hernia 2001;5(2):101-4.
7. Spangen L. Spigelian hernia. Surg Clin North Am 1984: 13. A r t i o u k h DY, Wa l k e r S J . Sp i g e l i a n h e r n i a e :
64(2):351-66. presentation, diagnosis and treatment. J R Coll Surg
8. Onal A, Sokemen S, Atila K. Spigelian hernia associated Edinb 1996;41(4):241-3.
with strangulation of the small bowel and appendix. 14. Carter JE, Mizes C. Laparoscopic diagnosis and repair
Hernia 2003;7(3):156-7. of spigelian hernia: report of a case and technique. Am
9. Testa T, Falco E, Celoria G, Beatini M, Rollandi R, J Obstet Gynecol 1992;167(1):77-8.
Nardini A, et al. Spigelian hernia: its echotomographic 15. Moreno-Egea A, Carrasco L, Girela E, Martine JG,
diagnosis and surgical treatment. [Italian] G Chir 1992; Aguayo JL, Canteras M. Open vs. laparoscopic repair
13(1-2):29-31. of spigelian hernia: a prospective trial. Arch Surg 2002;
10. Mufid MM, Abu-Yousef MM, Kakish ME, Urdaneta 137(11):1266-8.