What is the management of a spigelian hernia?

Management of Spigelian Hernia

Surgical repair is strongly recommended for all Spigelian hernias due to their high risk of incarceration and strangulation (10-17%), regardless of symptoms. 1, 2

Diagnosis

• Clinical presentation:

  • Most common symptoms: palpable mass, abdominal pain, or both
  • May present with bowel obstruction in emergency cases
  • Often difficult to diagnose due to vague symptoms

• Imaging:

  • CT scan with contrast is the gold standard for confirming diagnosis
  • Ultrasonography can identify the defect and reducible contents

Surgical Management

Approach Selection

1. For stable, non-complicated hernias:

   • Laparoscopic approach is preferred 3
     • Options include:
       • Laparoscopic intraperitoneal repair
       • Laparoscopic transabdominal preperitoneal (TAPP)
       • Laparoscopic totally extraperitoneal (TEP) repair

2. For unstable patients or suspected strangulation:

   • Open surgical approach via laparotomy 3
   • Immediate surgical intervention is necessary when intestinal strangulation is suspected

Repair Technique

• Small defects (<3 cm):

  • Primary suture repair with non-absorbable sutures 3

• Larger defects (>3 cm):

  • Mesh reinforcement is recommended to prevent excessive tension 3
  • Mesh should overlap the defect edge by 1.5-2.5 cm

• Contaminated field (Class III/IV wounds):

  • Consider biological or biosynthetic mesh 3
  • In dirty/infected cases, primary repair may be preferable with delayed mesh placement

Special Considerations

• Incarcerated hernias:

  • Assess bowel viability after reduction
  • Diagnostic laparoscopy may be useful to assess bowel viability after spontaneous reduction 3
  • Resect non-viable bowel if necessary

• Bilateral Spigelian hernias:

  • Rare but should be considered during surgical planning 4
  • Careful examination of contralateral side during operation

Outcomes and Follow-up

• Recurrence rates are low (approximately 4%) with proper surgical technique 1
• Mesh repair has shown decreased complication and recurrence rates compared to primary repair alone 5
• Follow-up imaging (chest X-ray) at 3-6 months to assess for recurrence

Pitfalls to Avoid

1. Delayed diagnosis due to vague symptoms - maintain high index of suspicion
2. Failure to recognize bilateral hernias - examine both sides during surgery
3. Inadequate mesh overlap - ensure 1.5-2.5 cm overlap to prevent recurrence
4. Delayed intervention in suspected strangulation - immediate surgery is warranted

The World Society of Emergency Surgery guidelines emphasize that the choice of repair technique should be based on the contamination of the surgical field, the size of the hernia, and the surgeon's experience 3.