, Volume 21, Issue 3, pp 355–361 | Cite as

Contemporary thoughts on the management of Spigelian hernia

  • V. Webber
  • C. Low
  • R. J. E. Skipworth
  • S. Kumar
  • A. C. de Beaux
  • B. Tulloh
Original Article



Spigelian hernias are said to be a rare condition of the elderly population, usually arising below the arcuate line. Local experience has led us to challenge these commonly held beliefs.


Operations for Spigelian hernia from 2006–2016 were identified from the Edinburgh Lothian Surgical Audit computerised database and case notes were reviewed.


One hundred and one patients underwent surgery for 107 Spigelian hernias in the 10-year period. The female-to-male ratio was 2:1. Ages ranged from 32 to 88 with a median of 64 years. Sixty-five operations were done open and 42 were laparoscopic. Twelve of the 27 for which the precise anatomic location was recorded were situated above the arcuate line. Twenty-nine hernias had small defects and comprised interstitial fat only with no peritoneal sac. Ages in this group ranged from 32 to 80 (median = 48 years). All presented with intermittent local pain and/or swelling, although in three patients the hernias were impalpable. Those three also underwent ultrasound, CT and/or laparoscopy, but the hernias were only identified after open surgical exploration. The remaining 78 cases had peritoneal sacs of varying size with defects up to 9 cm across, and all were identified on imaging and/or laparoscopy. Ages ranged from 38 to 88 (median = 67 years; p < 0.01). Eighteen patients presented as emergencies and all were in this group.


Spigelian hernias may be more common than we think and are probably under-diagnosed. They commonly arise above the arcuate line. We describe three clinical stages: Stage 1 hernias are those without peritoneal sacs and tend to arise in younger patients, can be difficult to diagnose and may not seen at laparoscopy. Stages 2 and 3 hernias arise in older patients, do have peritoneal sacs, are visible at laparoscopy and are more likely to present as emergencies. Stage three hernias are too large for laparoscopic repair. The differences between stages likely reflect the natural history of the condition, which begins as extraperitoneal fat protrusion and progresses over many years to develop a peritoneal sac.


Aetiology Anatomy Classification system Hernia repair Spigelian hernia 


Compliance with ethical standards

Conflict of interest

BT declares conflict of interest not directly related to the submitted work. All the remaining authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by the authors.


  1. 1.
    Spangen L (1989) Spigelian Hernia. World J Surg 13:573–580CrossRefPubMedGoogle Scholar
  2. 2.
    Bittner JG IV, Edwards MA, Shah MB, MacFadyen Jr BV, Mellinger JD (2008) Mesh-free laparoscopic Spigelian hernia repair. Am Surg 74:713–720PubMedGoogle Scholar
  3. 3.
    Moreno-Egea A, Campillo-Soto A, Norales-Cuenca G (2015) Which should be the gold standard laparoscopic technique for handling Spigelian hernias? Surg Endosc 29:856–862CrossRefPubMedGoogle Scholar
  4. 4.
    Jones BC, Hutson JM (2015) The syndrome of Spigelian hernia and cryptorchidism: a review of the paediatric literature. J Paediatr Surg 50:325–330CrossRefGoogle Scholar
  5. 5.
    Sharma A, Dey A, Khullar R, Soni V, Baijal M, Chowbey PK (2011) Laparoscopic repair of suprapubic hernias: transabdominal partial extraperitoneal (TAPE) technique. Surg Endosc 25:2147–2152CrossRefPubMedGoogle Scholar
  6. 6.
    Brady RR, Ventham NT, de Beaux AC, Tulloh B (2014) Laparoscopic partially extraperitoneal (PEP) mesh repair for laterally placed ventral and incisional hernias. Surg laparosc Endosc Percutan Tech 24:99–100CrossRefGoogle Scholar
  7. 7.
    Skandalakis PN, Zoras O, Skandalakis JE, Mirilas P (2006) Spigelian Hernia: surgical anatomy, embryology, and technique of repair. Amm Surg 72:42–48Google Scholar
  8. 8.
    Read RC (1960) Observations on the etiology of Spigelian hernia. Ann Surg 152:1004–1009CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Mittal T, Kumar V, Khullar R, Sharma A, Soni V, Baijal M, Chowbey PK (2008) Diagnosis and management of Spigelian hernia: A review of literature and our experience. J Min Access Surg 4:95–98CrossRefGoogle Scholar
  10. 10.
    Polistina FA, Garbo G, Trevisan P, Frego M (2015) Twelve years of experience treating Spigelian hernia. Surgeryu 157:547–550CrossRefGoogle Scholar
  11. 11.
    River LP (1942) Spigelian Hernia. Ann Surg 116:405CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Zimmerman LM, Anson BJ, Morgan EH, McVay CB (1944) Ventral Hernia due to normal banding of the abdominal muscles. Surg Gynaec Obst 78:535Google Scholar
  13. 13.
    Larson DW, Farley DR (2002) Spigelian hernias: repair and outcome for 81 patients. World J Surg 26:1277–1281CrossRefPubMedGoogle Scholar
  14. 14.
    Dulucq JL, Wintringer P, Mahajna A (2011) Occult hernias detected by laparoscopic totally extraperitoneal inguinal hernia repair: a prospective study. Hernia 15:399–402CrossRefPubMedGoogle Scholar
  15. 15.
    Tulloh B, de Beaux AC (2016) Defects and donuts: the importance of the mesh:defect area ratio. Hernia 20:893–895CrossRefPubMedGoogle Scholar
  16. 16.
    Malik A, Macdonald ADH, de Beaux AC, Tulloh BR (2014) The peritoneal flap hernioplasty for repair of large ventral and incisional hernias. Hernia 18:39–45CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag France 2017

Authors and Affiliations

  1. 1.Department of Upper GI SurgeryRoyal Infirmary of EdinburghEdinburghUK

Personalised recommendations