What is the recommended treatment for a spigelian hernia in a patient with a Body Mass Index (BMI) of 35?

Treatment of Spigelian Hernia in a Patient with BMI 35

Laparoscopic repair is the recommended treatment for spigelian hernia in a patient with BMI 35, with transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) approaches being preferred surgical techniques. 1, 2

Understanding Spigelian Hernias

• Spigelian hernias are rare abdominal wall hernias (0.12-2% of all hernias) occurring through a defect in the spigelian fascia lateral to the semilunar lines 2, 3
• Most commonly found in the "spigelian hernia belt," a 6-cm-wide zone above the interspinal plane 3
• These hernias can be difficult to diagnose due to their location and varied presentations 1
• They carry a significant risk of incarceration and strangulation, making surgical management necessary 4

Surgical Management Options

Laparoscopic Approach (Recommended)

• Laparoscopic repair has become the preferred approach for spigelian hernias, especially in patients with obesity 1, 2
• Two main laparoscopic techniques:
  • Transabdominal preperitoneal (TAPP) repair: Involves placing mesh in the extraperitoneal space after raising a peritoneal flap 2, 5
  • Totally extraperitoneal (TEP) repair: Completely extraperitoneal approach without entering the peritoneal cavity 2
• Benefits of laparoscopic approach:
  • Better visualization of the defect 1
  • Reduced post-operative pain 2
  • Shorter hospital stay 2
  • Lower recurrence rates (studies show no recurrences at follow-up periods of 3+ years) 1, 2

Open Surgical Approach (Alternative)

• Traditional open herniorraphy with mesh reinforcement is an alternative when laparoscopic approach is not feasible 3, 5
• Can be performed using:
  • Primary fascial closure with onlay mesh reinforcement 5
  • Anatomical repair by suturing the defect followed by mesh placement 4

Considerations for Patients with BMI 35

• For patients with BMI 35, the American College of Rheumatology and American Association of Hip and Knee Surgeons conditionally recommend proceeding with surgical intervention without delaying for weight reduction 6
• While higher BMI is associated with increased surgical risks, postponing necessary surgery for weight reduction may not improve outcomes 6
• Patients should be informed of the potential increased risks associated with surgery at their current weight 6
• The use of rigid BMI thresholds for surgical eligibility is discouraged, as not all patients have the necessary resources to effectively lose weight 6

Pre-operative Considerations

• Comprehensive evaluation to identify and optimize any obesity-related comorbidities 7
• If the patient has poorly controlled diabetes mellitus, consider delaying surgery to improve glycemic control 6
• If the patient has nicotine dependence, consider delaying surgery for nicotine cessation 6
• Patients should be counseled on the potential benefits of weight reduction prior to surgery, even if surgery is not delayed 6

Post-operative Management

• Regular follow-up to monitor for recurrence or mesh-related complications 1
• Typical follow-up schedule: 1 week, 6 months, 1 year, and 2 years after surgery 1
• Encourage continued weight management efforts post-operatively 7

Potential Complications

• Surgical complications may include:
  • Mesh-related issues 1
  • Infection 6
  • Recurrence (though rare with proper technique) 1, 2
• Care must be taken not to create iatrogenic spigelian hernias when using laparoscopy trocars 3

In conclusion, while the patient's BMI of 35 is a consideration in surgical planning, it should not delay necessary surgical repair of the spigelian hernia. Laparoscopic repair, particularly using TAPP or TEP approaches, offers excellent outcomes with low recurrence rates and should be the preferred treatment option.