Advertisement

World Journal of Surgery

, Volume 13, Issue 5, pp 573–580 | Cite as

Spigelian hernia

  • Leif Spangen
Article

Abstract

The diagnosis of spigelian hernia presents greater difficulties than its treatment. The clinical presentation varies, depending on the contents of the hernial sac and the degree and type of herniation. The pain, which is the most common symptom, varies and there is no typical pain of spigelian hernia. Findings to facilitate diagnosis are palpable hernia and a palpable hernial orifice. Large, easily palpable spigelian hernias are not a diagnostic problem. It is small hernias and hernial orifices that are overlooked because they are masked by the subcutaneous fat and an intact external aponeurosis. In the absence of a palpable orifice or sac, persistent point tenderness in the spigelian aponeurosis with a tensed abdominal wall most strongly suggests the diagnosis. Spigelian hernia can be ruled out in patients without palpable tenderness. Ultrasonic scanning can be recommended for verification of the diagnosis in both palpable and nonpalpable spigelian hernia. The hernial orifice and sac can also be demonstrated by computed tomography, which gives more detailed information on the contents of the sac than does ultrasonic scanning.

The treatment of spigelian hernia is surgical, and the risk of recurrence is small. A gridiron incision is excellent for operations for palpable hernias. If the hernia cannot be palpated preoperatively, preperitoneal dissection through a vertical incision is recommended. This gives good exposure, facilitates hernioplasty, and permits preperitoneal exploration and treatment of other abdominal wall hernias. The incision is also suitable for exploratory laparotomy, which should be performed on patients with abnormal ultrasonographic or computed tomographic findings in whom no palpable hernia can be detected preoperatively.

Keywords

Cual Abdominal Wall Hernia Spigelian Hernia Permite Hernial Orifice 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Résumé

Le diagnostic d'une hernie de Spiegel est plus difficile que son traitement. Les signes de découverte varient, dépendant du contenu du sac herniaire, d l'importance, et du type de la hernie. La douleur, symptôme le plus fréquent, n'est pas typique. Les signes qui aident au diagnostic sont la palpation de la hernie et de l'orifice herniaire. Lorsque l'orifice est large et palpable, le diagnostic de hernie de Spiegel ne pose pas de problème. Ce sont les hernies de petite taille, à orifice réduit, qui sont souvent masquées par la graisse sous-cutanée et l'aponévrose oblique externe. En l'absence d'orifice ou de hernie palpable, la persistance de la douleur à la palpation au niveau de l'aponévrose, alors que la paroi abdominale est sous tension, est significative. En l'absence de cette douleur provoquée, on peut pratiquement éliminer ce diagnostic. On conseille de vérifier le diagnostic par une échographie, que cette douleur existe ou pas. L'orifice et le sac herniaire se voient bien également par la tomodensitométrie plus performante que l'échographie en ce qui concerne le contenu herniaire.

Le traitement de la hernie est chirurgical; le risque de récidive est réduit. Une incision centrée sur la hernie, sans section musculaire, est excellente. Si la hernie ne peut être palpée, on conseille une incision verticale avec un abord extrapéritonéal. L'exposition est excellente, la cure est aisée et l'exploration prépéritonéale ainsi facilitée, permet en outre la cure d'autres hernies pariétales associées. La même incision convient également pour une laparotomie exploratrice, au cas où l'échographie ou la tomodensitométrie ne montrent rien de spécifique et où il n'existe pas de hernie détectée préopérativement.

Resumen

El diagnóstico de la hernia spigeliana presenta mayores dificultades que su tratamiento. La presentación clínica varía según el contenido del saco herniario y el grado y tipo de herniación. El dolor, que es el síntoma más común, es variable y no existe un dolor que sea típico de la hernia spigeliana. Los signos físicos que facilitan el diagnóstico son la hernia palpable y un orificio herniano palpable. Las hernias spigelianas grandes y fácilmente palpables no constituyen un problema diagnóstico. Son más bien las hernias pequeñas y los orificios mínimos los que pueden pasar desapercibidos al ser enmascarados por la grasa subcutánea y por una aponeurosis intacta. En ausencia de un orificio o de un saco palpable, el dolor a la presión sobre la aponeurosis spigeliana, manteniendo tensa la pared abdominal, sugiere fuertemente este diagnóstico; la hernia spigeliana puede ser excluída como posibilidad diagnóstica en pacientes que no exhiban tal dolor a la palpación. La ultrasonografía puede ser recomendada para verificación del diagnóstico, tanto en las hernias spigelianas palpables como en las no palpables. El orificio y el saco herniarios también pueden ser demostrados mediante tomografía computadorizada, estudio que provee información más detallada que la ultrasonografía sobre el contenido del saco.

El tratamiento es quirúrgico y el riesgo de recurrencia es bajo. Una incisíon oblicua o transversa resulta excelente para la operación en hernias palpables; si la hernia no es palpable en el examen preoperatorio, se recomienda realizar disección preperitoneal a través de una incisión vertical. Esto da buena exposición, facilita la hernioplastia, y permite la exploración preperitoneal y el tratamiento de otras hernias de la pared abdominal. La incisión también es adecuada para la laparotomía exploratoria, la cual debe ser realizada en pacientes con hallazgos anormales en la ultrasonografía o en la tomografía computadorizada y en quienes no haya sido posible detectar una hernia palpable preoperatoriamente.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Klinkosch, J.T.: Divisionem Herniarum Novamgue Herniae Ventralis Proponit. Dissertationum Medicorum, 1764, p. 184Google Scholar
  2. 2.
    Spangen, L.: Spigelian hernia. Surg. Clin. North Am.64:351, 1984Google Scholar
  3. 3.
    Stuckej, A.L., Lutjko, G.D., Tivarovskij, V.I.: Hernia of the Spigeli line. Tsitologiia15:10, 1973Google Scholar
  4. 4.
    Houlihan, T.J.: A review of Spigelian hernias. Am. J. Surg.131:734, 1976Google Scholar
  5. 5.
    Persson, P.H., Grennert, L., Jögi, P., Pallin, B.: Diagnos och operativ teknik vid hernia Spigelii. Acta Soc. Med. Suecanae84:213, 1975Google Scholar
  6. 6.
    Ponka, J.L.: Spigelian hernias. In Hernias of the Abdominal Wall, Joseph L. Ponka, Philadelphia, W.B. Saunders Co., 1980, pp. 478–491Google Scholar
  7. 7.
    Gullmo, Å.: Herniography: The diagnosis of hernia in the groin and incompetence of the pouch of Douglas and pelvic floor. Acta Radiol. Scand.361 [Suppl.]:58, 1980Google Scholar
  8. 8.
    Gullmo, Å., Bromeé A., Smedberg, S.: Herniography. Surg. Clin. North Am.64:229, 1984Google Scholar
  9. 9.
    Lindholm, Å., Hulin, E.: Hernia Spigelii—ett vanligt förekommande bråck? Nord. Med. Bd. 82,39:1225, 1969Google Scholar
  10. 10.
    Kienzle, H.F., Staemmler, S.: Die Spieghel-Hernie und ihre Behandlung. Fortschr. Med.96:876, 1978Google Scholar
  11. 11.
    Stirnemann, H.: Die Spigelische Hernie: Verpasst? Selten? Verlegenheitsdiagnose? Der Chirurg.53:314, 1982Google Scholar
  12. 12.
    Holder, L.E., Schneider, H.J.: Spigelian hernias: Anatomy and roentgenographic manifestation. Radiol. Diagn.112:309, 1974Google Scholar
  13. 13.
    Weiss, Y., Lernau, O.Z., Nissan, S.: Spigelian hernia. Ann. Surg.180:836, 1974Google Scholar
  14. 14.
    Lamphier, T.A.: Spigelian hernia. Int. Surg.67:395, 1982Google Scholar
  15. 15.
    Bonini, C.A., Meriggi, F., Cavallero, M., Scotti-Foglieni, C.: Le ernia Ventro-laterali (E.V.I.) dell 'addome. Minerva Chir.42:585, 1987Google Scholar
  16. 16.
    Ferrand, J.A.M.J.: Hernies latérales l'abdomen (Laparocéles). These pour Le doctorat en medicine. Presentée et soutenue le 13 janvier, Paris, 1881Google Scholar
  17. 17.
    Baudoin, R.: Contribution a l'étude des Hernies spontanées de la ligne semi-lunarie de Spiegel. Thése pour Le Doctorat en Medicine, Paris, 1912Google Scholar
  18. 18.
    Pabst, M.: Über die Hernia semilunaris Spigelii. Inaugural Dissertation, Universität Halle Wiltenberg, 1925, Halle Med. Diss., 1925Google Scholar
  19. 19.
    Nachtwey, A.: Über die Hernia Lineae semilunaris Spigelii. Inaugural Dissertation, Universität Köln, 1932, Bd. 83, Inaugural Dissertation, Köln, 1933Google Scholar
  20. 20.
    Spangen, L.: Spigelian hernia. Acta Chir. Scand.462[Suppl.]:1, 1976Google Scholar
  21. 21.
    Spieghel, A.: Opera Quae Extore Omnia, Amsterdam, John Bloew, 1645, p. 103Google Scholar
  22. 22.
    Bertelsen, S.: The surgical treatment of Spigelian hernia. Surg. Gynecol. Obstet.122:567, 1966Google Scholar
  23. 23.
    Nora, P.F.: Spigelian hernia. In Operative Surgery, Principles and Techniques, Philadelphia, Lea & Febiger, 1972, pp. 681–709Google Scholar
  24. 24.
    Sheehan, V.: Spigelian hernia. J. Irish Med. Assoc.29:87, 1951Google Scholar
  25. 25.
    Som, P.M., Khilmani, M.T., Wolf, B.S.: Spigelian hernia. Acta Radiol. Diagn.17:305, 1976Google Scholar
  26. 26.
    Naylor, J.: Combination of Spigelian and Richter's hernias: A case report. Am. Surg.44:750, 1978Google Scholar
  27. 27.
    Balthazar, E.J., Subramanyam, B.R., Megibow, A.: Spigelian hernia: CT and ultrasonography diagnosis. Gastrointest. Radiol.9:81, 1984Google Scholar
  28. 28.
    River, L.P.: Spigelian hernia. Ann. Surg.116:405, 1942Google Scholar
  29. 29.
    Read, R.C.: Observations on the etiology of spigelian hernia. Ann. Surg.152:1004, 1960Google Scholar
  30. 30.
    Cooper, A.: Of the ventral hernia. In The Anatomy and Surgical Treatment of Crural and Umbilical Hernia, London, T. Cox. Bensley, 1807, pp. 58–61Google Scholar
  31. 31.
    Stühmer, A.: Über die Hernien der Bauchwand seitlich der Mittellinie unter besonderer Berücksichtigung der Hernien der Linea semilunaris (Spigelii). Bruns. Beitr. Klin. Chir.66:113, 1910Google Scholar
  32. 32.
    Olsson, R.O., Davis, W.C.: Spigelian hernia: Rare or obscure? Am. J. Surg.116:842, 1968Google Scholar
  33. 33.
    Paul, M., Hill, W.C.O.: Spigelian hernia with report on a case. Br. J. Surg.30:385, 1943Google Scholar
  34. 34.
    Beyer, U.: Über die Hernien der Linea semilunaris (Spigelii). Zentralbl. Chir.92:2373, 1967Google Scholar
  35. 35.
    Beluzzi, V.: Observazioni cliniche. Ernia di Spigelio strozzata contenente lo stomaco. Policlinico Sez. Prat.36:1151, 1957Google Scholar
  36. 36.
    Kirchberger, J.: Ein Fall von herzförmiger Leber, mit ihrem rechten Rande eingebetteter Niere, im Vereine mit einer seltenen Art von Hernia epigastrica lateralis. Wien. Klin. Wochenschr., 1867, p. 996Google Scholar
  37. 37.
    Durst, J., Müller, G., Münch, B.: Inkarzeration des Gallenglasenfundus in de linea semilunaris Spigheli. Med. Welt.28:490, 1977Google Scholar
  38. 38.
    Massabuau, M.M., Guibal A. et Cabanac, A. Deux cas de hernies ventrales lateralés spontanées étranglées: Presence du diverticule de Meckel dans une de ces hernies. Arch. Soc. Med. Biol. Montpellier14:340, 1933Google Scholar
  39. 39.
    Chalier, A.: Etranglement de l'appendice dans une hernia de la ligne semi-lunarie de Spigel. Soc. Chir. Lyon43:455, 1948Google Scholar
  40. 40.
    Ferrand, J., Pequello, J., Destaing, F., Debaille, R.: Les Hernies du sillon latéral de l'abdomen. A propos d'etranglement appendiculare dans une hernia de la ligne semi-lunarie de Spiegel. Presse Med.64:2055, 1956Google Scholar
  41. 41.
    Blikra, G.: Hernia spigelii. T. Norske Lägeforen79:1124, 1959Google Scholar
  42. 42.
    Hibbard, L.T., Schumann, W.R.: The spigelian hernia in gynecology. Am. J. Obstet. Gynecol.83:1439, 1962Google Scholar
  43. 43.
    Jain, K.M., Hastings, O.H., Kunz, V.P., Lazaro, F.J.: Spigelian hernia. Am. Surg.43:596, 1977Google Scholar
  44. 44.
    Nauta, R.J., Heres, F.K., Walsh, D.B.: Crohn's appendicitis in an incarcerated Spigelian hernia. Dis. Colon Rectum29:659, 1986Google Scholar
  45. 45.
    Nadjafl, A., Maurer, W.: Die Spiegelische Hernia. Schweiz. Med. Wochenschr.97:1070, 1967Google Scholar
  46. 46.
    Biaggi, J., Küpfer, K., Stirnemann, H.: Die Spiegelische Hernie. Schweiz. Med. Wochenschr.107:119, 1977Google Scholar
  47. 47.
    Benjamin, R.B., Webber, R.J.: Spigelian hernia. Bull. St. Louis Park. Med. Ctr.10:31, 1966Google Scholar
  48. 48.
    Cullen, T.S.: An extra-abdominal multilocular ovarian cyst. J.A.M.A.57:1251, 1911Google Scholar
  49. 49.
    Mathews, F.S.: Hernia through the conjoined tendon. Ann. Surg.78:300, 1923Google Scholar
  50. 50.
    Lamb, W.K.: Discussion of Hibbard, I.F., Schumann, W.R.: The Spigelian hernia in gynecology. Am. J. Obstet. Gynecol.83:1445, 1962Google Scholar
  51. 51.
    Louw, P., Lauritzen, J.B.: Hernia Spigelii fremkaldt af uterusfibrom. Ugeskr. Laeger143:1222, 1981Google Scholar
  52. 52.
    Schoofs: Un cas de hernie ventrale du testicule. Arch. Med. Belges4:229, 1895Google Scholar
  53. 53.
    Gravier, L., Bernstein, D., RuBane, C.F.: Lateral ventral (Spigelian) hernias in infants and children. Surgery83:228, 1978Google Scholar
  54. 54.
    Svahn, T., Spangen, L.: Peritoneography in Spigelian hernias. Acta Radiol. Diagn.17:97, 1976Google Scholar
  55. 55.
    Spangen, L.: Ultrasound as a diagnostic aid in ventral abdominal hernia. J. Clin. Ultrasound3:211, 1975Google Scholar
  56. 56.
    Nelson, R.L., Renigers, S.A., Nyhus, L.M., Sigel, B., Spigos, D.G.: Ultrasonography of the abdominal wall in the diagnosis of Spigelian hernia. Am. Surg.46:373, 1980Google Scholar
  57. 57.
    Balthazar, E.J., Subramanyam, B.R.: Radiographic diagnoses of Spigelian hernia. Am. J. Gastroenterol.78:525, 1983Google Scholar
  58. 58.
    Le Joliff, L., Letoquart, J.P., Focard, Langella, B., Mambrini, A.: Les hernies ventrales latérales ou de la ligne de Spiegel. J. Chir. (Paris)122:409, 1985Google Scholar
  59. 59.
    Vas, W.V., Nguyen, K.T., Cockshott, W.P.: Computed tomography diagnosis of Spigelian hernia: Case report. Diagn. Imaging49:326, 1980Google Scholar
  60. 60.
    Pyatt, R.S., Alona, B.R., Daye, S.: Case report: Spigelian hernia. J. Comput. Assist. Tomogr.6:643, 1982Google Scholar
  61. 61.
    Papierniak, K.J., Wittenstein, B., Bartizal, J.F.: Diagnosis of Spigelian hernia by computed tomography. Arch. Surg.118:109, 1983Google Scholar
  62. 62.
    Luedke, M., Scholz, F.J., Larsen, C.R.: Computed tomographic evaluation of Spigelian hernia. Comput. Med. Imaging Graph.12:123, 1988Google Scholar
  63. 63.
    Goldberg, B.B.: Ultrasonic evaluation of superficial masses. J. Clin. Ultrasound3:91, 1975Google Scholar
  64. 64.
    Fried, A.M., Meeker, W.R.: Incarcerated Spigelian hernia: Ultrasonic differential diagnosis. Am. J. Roentgenol.133:107, 1979Google Scholar
  65. 65.
    Spangen, L., Andersson, R., Ohlsson, L.: Non-palpable inguinal hernia in the female. Am. Surg.54:574, 1988Google Scholar
  66. 66.
    Spampinato, C.: Dati e problem etio-patogenetici sullernia spontanea della cosidetta linea dello Spigelio. Sicilia Sanit.3:3, 1950Google Scholar
  67. 67.
    Mills, J.L., Selinkoff, P.M.: Spigelian hernia: Uncommon or unrecognized? South. Med. J.78:411, 1985Google Scholar

Copyright information

© Société Internationale de Chirurgie 1989

Authors and Affiliations

  • Leif Spangen
    • 1
  1. 1.Department of SurgeryCentral HospitalKarlstadSweden

Personalised recommendations