What is the recommended treatment for a Spigelian hernia?

Treatment of Spigelian Hernia

Prosthetic repair is the treatment of choice for Spigelian hernias, with laparoscopic approach preferred in stable patients without signs of strangulation or need for bowel resection. 1

Surgical Approach Options

Elective Setting

• Laparoscopic repair is recommended as the first-line approach for uncomplicated Spigelian hernias due to lower wound infection rates and comparable recurrence rates compared to open repair 2, 3
• Three main laparoscopic techniques can be employed:
  • Transabdominal preperitoneal (TAPP) repair - allows for proper mesh placement with good visualization 2, 4
  • Total extraperitoneal (TEP) repair - avoids entering the peritoneal cavity 4
  • Intraperitoneal onlay mesh (IPOM) repair - suitable for selected cases 4

Emergency Setting

• Immediate surgical intervention is required when intestinal strangulation is suspected 1
• For incarcerated/strangulated Spigelian hernias:
  • In clean surgical fields (CDC wound class I), prosthetic repair with synthetic mesh is recommended 1
  • In clean-contaminated fields (CDC wound class II), emergent prosthetic repair with synthetic mesh can still be performed 1
  • In contaminated or dirty fields (CDC wound classes III and IV), primary tissue repair is recommended for small defects (<3 cm) 1
  • When direct suture is not feasible in contaminated fields, biological mesh may be used 1

Mesh Selection and Placement

• For defects that cannot be closed with direct suture, mesh reinforcement is recommended 1
• Mesh selection should be based on the surgical field classification:
  • Clean fields: Synthetic mesh provides lower recurrence rates without increased infection risk 1
  • Contaminated fields: Biological or polyglactin mesh should be considered 1
• Proper mesh fixation and adequate overlap (at least 5 cm) are critical for successful outcomes 2, 4

Special Considerations

• Diagnostic laparoscopy may be useful to assess bowel viability after reduction of incarcerated Spigelian hernias 1
• Spigelian hernias carry a significant risk of incarceration (reported as high as 17%) and strangulation, making surgical repair indicated upon diagnosis even in asymptomatic patients 5, 6
• Antimicrobial prophylaxis recommendations:
  • Short-term prophylaxis for intestinal incarceration without ischemia 1
  • 48-hour antimicrobial prophylaxis for intestinal strangulation and/or concurrent bowel resection 1
  • Full antimicrobial therapy for patients with peritonitis 1

Outcomes

• Both open and laparoscopic approaches show comparable results for 90-day readmission, reoperation, and long-term recurrence rates 3
• Emergency repair (approximately 16% of cases) shows similar outcomes to elective repair when appropriate surgical techniques are employed 3
• Long-term follow-up is recommended to monitor for recurrence, though recurrence rates are generally low with proper mesh repair 2, 5

Pitfalls and Caveats

• Spigelian hernias can be difficult to diagnose clinically due to their location and varied presentations 2, 4
• CT scan is the preferred diagnostic modality when clinical diagnosis is uncertain 6
• The hernia sac is often interparietal, passing through the transversus and internal oblique aponeuroses before spreading beneath the intact external oblique aponeurosis 4
• Failure to use adequate mesh overlap (minimum 5 cm) may lead to recurrence 2
• In emergency settings with bowel compromise, careful assessment of tissue viability is essential before deciding on mesh placement 1