What is the recommended treatment for a 40-70 year old adult patient, possibly with a history of obesity, multiparity, or previous abdominal surgery, presenting with a Spigelian hernia?

Spigelian Hernia: Recommended Treatment

Primary Recommendation

All diagnosed Spigelian hernias should undergo elective surgical repair with mesh, regardless of symptoms, due to the high risk of incarceration (up to 30%) and strangulation. 1, 2, 3

Rationale for Surgical Intervention

• Spigelian hernias carry a significant incarceration risk reaching 30%, mandating operative repair even in asymptomatic patients to prevent emergency surgery with bowel resection. 1, 2, 3
• The hernia's anatomical location beneath the intact external oblique aponeurosis makes clinical diagnosis difficult and increases the risk of delayed presentation with complications. 1, 4
• Emergency repair of incarcerated hernias is associated with higher morbidity, mortality, and need for bowel resection compared to elective repair. 5

Surgical Approach Selection

Laparoscopic Repair (Preferred)

Laparoscopic repair is the preferred approach for Spigelian hernias, offering lower postoperative complications and shorter hospital stays compared to open repair. 1

• Totally extraperitoneal (TEP) technique is safe and effective, with mean operative time of 59 minutes, discharge on postoperative day 1, and no recurrences at 36-month follow-up. 6
• Transabdominal preperitoneal (TAPP) and intraperitoneal onlay mesh (IPOM) are alternative laparoscopic approaches. 6
• Laparoscopic approach allows simultaneous identification and repair of concomitant hernias (inguinal, contralateral). 6

Open Repair (Alternative)

• Open surgical correction remains the most common approach with excellent results, particularly when urgent repair is needed or laparoscopic expertise is unavailable. 4
• Open approach is appropriate in centers without laparoscopic experience, given the rarity of the condition and long learning curve for laparoscopic repair. 4

Mesh Utilization

Synthetic mesh repair is mandatory for Spigelian hernias, as direct closure carries a considerable recurrence rate. 2

• Non-absorbable mesh achieves 8% recurrence rate versus 57% with absorbable mesh at 18-month follow-up. 7
• Mesh repair is generally advised in most cases regardless of surgical approach. 1

Emergency Presentation Management

If Incarceration/Strangulation Suspected:

• Obtain CT scan with contrast immediately—reduced bowel wall enhancement has 56% sensitivity and 94% specificity for bowel strangulation. 8
• Check laboratory studies: CBC, arterial lactate, CPK, D-dimer, fibrinogen, and assess for SIRS criteria as predictors of strangulation. 8
• Diagnostic laparoscopy is useful to assess bowel viability after reduction of complicated hernias. 5
• Laparoscopic repair can be performed when no bowel resection is needed; if bowel resection/anastomosis is required, mini-open approach (small laparotomy) is preferred. 5
• In contaminated surgical fields requiring bowel resection, suture repair without mesh is preferred due to infection risk. 5

Special Considerations for This Population

• Patients with obesity, multiparity, or previous abdominal surgery are at higher risk for incisional hernias and should have optimized preoperative planning. 5
• For patients with ascites, control ascites before elective herniorrhaphy, as uncontrolled ascites increases recurrence and complication rates. 8
• Age >70 years requires careful consideration but is not an absolute contraindication to repair. 5

Postoperative Management

• Encourage acetaminophen and NSAIDs as primary pain control; limit opioid prescribing. 8
• Monitor for wound infection, chronic pain, recurrence, and seroma formation (managed conservatively). 8, 6
• Overall recurrence rate for Spigelian hernias is very low with appropriate mesh repair. 1