What is the recommended management for a middle-aged to elderly patient with a history of abdominal surgery or increased intra-abdominal pressure presenting with a Spigelian hernia?

Management of Spigelian Hernia

Immediate Surgical Repair is Indicated

All diagnosed Spigelian hernias should undergo elective surgical repair regardless of symptoms, due to the high risk of incarceration (17%) and strangulation requiring emergency surgery. 1, 2

Why Surgery Cannot Be Delayed

• Spigelian hernias carry a 17% incarceration rate at the time of operation and 10% require emergent surgery, making watchful waiting inappropriate even in asymptomatic patients 2
• The narrow fascial defect predisposes to bowel entrapment and strangulation, which significantly increases morbidity and mortality when emergency repair becomes necessary 1, 3
• Delayed presentation with strangulation leads to bowel necrosis and worse outcomes, emphasizing the need for planned elective repair 4, 2

Surgical Approach Selection

Laparoscopic Repair is Preferred in Stable Patients

Minimally invasive laparoscopic repair should be the first-line approach for elective Spigelian hernia repair, offering lower postoperative complications and shorter hospital stays compared to open surgery. 1

• Laparoscopic totally extraperitoneal (TEP) repair is safe and effective, with mean operative times around 59 minutes, discharge on postoperative day 1, and no recurrences at 36-month follow-up 5
• Transabdominal preperitoneal (TAPP) and intraperitoneal onlay mesh (IPOM) are alternative laparoscopic approaches depending on surgeon experience 5, 6
• The laparoscopic approach allows excellent visualization of the defect and simultaneous repair of other hernias if present 5

Open Repair Remains Valid

• Open surgical repair with mesh reinforcement is appropriate when laparoscopic expertise is unavailable or in emergency settings, with excellent long-term results and very low recurrence rates 1, 6
• Open approach may be necessary for giant Spigelian hernias (>7-8 cm) presenting with bowel obstruction requiring urgent intervention 3

Mesh Reinforcement is Generally Required

Mesh repair should be used in most cases rather than primary suture closure alone, to minimize recurrence risk. 1, 6

• Primary suture closure has been historically used but mesh reinforcement provides more durable repair 2
• For clean-contaminated fields (CDC class II) with bowel resection but no gross spillage, synthetic mesh can be safely used 4
• For contaminated fields with bowel necrosis/spillage, biological mesh is preferred if primary repair is not feasible for defects >3 cm 4

Emergency Presentation Management

Unstable Patients with Strangulation

For patients presenting with signs of strangulation (constant pain, abdominal tenderness, systemic symptoms), immediate surgical exploration is mandatory without delay for imaging. 4, 2

• Open laparotomy is recommended for unstable patients with severe sepsis or septic shock to prevent abdominal compartment syndrome 7
• Intraoperative assessment of bowel viability is critical, with resection of necrotic bowel as needed 3, 2
• Intra-abdominal pressure should be measured intraoperatively in patients with intestinal strangulation and peritonitis (grade 2C recommendation) 7

Spontaneous Reduction Concerns

• If a previously palpable hernia spontaneously reduces but the patient has persistent abdominal pain and tenderness, diagnostic laparoscopy is specifically recommended to assess for ischemic bowel that reduced back into the abdomen 4
• Spontaneous reduction does not exclude bowel ischemia—the bowel may have been compromised during incarceration 4

Critical Pitfalls to Avoid

• Do not delay surgery for extensive imaging workup when clinical suspicion of strangulation exists—imaging should not postpone surgical exploration 4
• Do not assume asymptomatic Spigelian hernias are safe to observe—the high incarceration risk mandates repair 1, 2
• Do not attempt primary closure under tension—this increases recurrence risk and may necessitate mesh reinforcement 7
• In patients with history of abdominal surgery or increased intra-abdominal pressure, maintain high clinical suspicion as these factors increase hernia risk 7

Postoperative Considerations

• Hospital stay is typically 1 day for uncomplicated laparoscopic repair 5
• Seroma formation may occur but typically resolves with conservative management 5
• Overall recurrence rates are very low (approximately 4%) with appropriate surgical technique 2
• Long-term follow-up shows excellent durability with mean follow-up of 8 years demonstrating sustained results 2