A Moreno-Egea

A Onal

Alice Martin

Eduardo Villatoro

IS Montes

JA Carr

Jane E Patterson

Kelly Finlay

KM Jain

PN Skandalakis

RJ Nauta

Sarah C Thomasset

Sarah Wood

English

PubMed

Springer - Publisher Connector

CASE REPORT Open Access
An unusual Spigelian hernia involving the
appendix: a case report
Sarah C Thomasset*, Eduardo Villatoro, Sarah Wood, Alice Martin, Kelly Finlay, Jane E Patterson
Abstract
Introduction: Spigelian herniae are uncommon and frequently pose a diagnostic challenge.
Case presentation: We report the case of a 71-year-old man in whom an ischaemic appendix was found within
the sac of a Spigelian hernia during emergency repair.
Conclusions: There are very few reported cases in which an appendix has been found within a Spigelian hernia, in
the absence of inflammatory bowel disease. An awareness of the range of viscera which may be encountered in
Spigelian herniae is important for safe repair.
Introduction
Spigelian herniae occur through slit-like defects in the
anterior abdominal wall adjacent to the semilunar line.
They are uncommon and frequently pose a diagnostic
challenge. We report a case in which an appendix was
discovered within the sac of a Spigelian hernia during
repair. The range of viscera which have been found
within Spigelian herniae is discussed. Awareness of pos-
sible contents of these herniae is crucial for safe repair.
Case Presentation
A 71-year old man presented with a 24-hour history of
nausea, vomiting and a painful abdominal swelling
located in the right lower quadrant. There was no his-
tory of a change in bowel habit and he was passing
flatus. Past medical history consisted of open repair of
an abdominal aortic aneurysm, cerebrovascular disease,
diabetes, a myocardial infarct and atrial fibrillation. He
was a non-smoker and consumed only a small amount
of alcohol.
On examination the patient was comfortable and not
tachycardiac or febrile. Abdominal examination revealed
the presence of a tender, irreducible mass located
between the umbilicus and right anterior superior iliac
spine. It was approximately 8 × 8 cm in diameter and
had a positive cough impulse. A clinical diagnosis of an
incarcerated right Spigelian hernia was made. Abdom-
inal x-rays revealed dilated loops of small bowel.
The patient underwent emergency repair of the Spige-
lian hernia. A transverse skin incision was made over
the hernia and the external oblique aponeurosis was
divided to reveal the hernial sac which was opened. It
contained an ischaemic appendix and a knuckle of small
bowel (Figure 1). The appendix was resected and the
small bowel, which was viable, was reduced. The small
muscular defect was approximated without tension in
two layers using polydioxanone (PDS). Postoperative
recovery was unremarkable. Histological examination of
the appendix revealed features characteristic of ischae-
mia but no evidence of inflammation or neoplasia.
Discussion
Spigelian herniae were initially described by Josef Kin-
kosh in 1764 and named after a Belgian anatomist,
Adrian van der Spieghel, who had previously described
the semilunar line. They account for 1-2% of all hernias
and occur through slit-like defects in the anterior
abdominal wall adjacent to the semilunar line. Approxi-
mately 90% are located in a 6 cm zone limited super-
iorly by the transumbilical plane and inferiorly by the
interspinal plane. A particularly weak area is the inter-
section between the semilunar line and the arcuate line
of Douglas. The majority of Spigelian herniae are intra-
mural and remain deep to the external oblique apo-
neurosis. Usual contents are omentum or small bowel,
however large bowel, stomach, gallbladder, ovary, testis,
* Correspondence: sarahthomasset@hotmail.com
Department of General Surgery, King’s Mill Hospital, Mansfield Road,
Nottinghamshire, NG17 4JL, UK
Thomasset et al. Cases Journal 2010, 3:22
http://www.casesjournal.com/content/3/1/22
© 2010 Thomasset et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
bladder, a Meckel’s diverticulum and leiomyoma of the
uterus although rare, have been described [1]. There are
few reported cases in which an appendix has been
found within a Spigelian hernia [2,3] some occurring in
the presence of Crohn’s disease [4,5].
Pain which is exacerbated by contraction of the
abdominal musculature is the most common symptom
associated with Spigelian herniae and is described by
over 60% of patients. The second most common clinical
feature is a palpable abdominal mass which is present in
approximately 35% of cases [2]. Spigelian herniae char-
acteristically possess a narrow neck (0.5-2 cm in dia-
meter) and at presentation approximately 20% of
hernias are incarcerated and 14% are strangulated [6].
Clinical diagnosis is often complicated by the intramural
position of Spigelian herniae and the fact that obesity is
a predisposing factor. Ultrasonography and computer
tomography (CT) may confirm the presence of a hernia
in cases of clinical uncertainty.
Treatment of a Spigelian hernia involves primary fas-
cial closure, with synthetic mesh reinforcement if a large
defect is identified. Recently, laparoscopic Spigelian her-
nia repair, using both intra-abdominal and extraperito-
neal approaches, has been described. A randomised
control trial, albeit involving a small number of patients,
has compared outcomes following Spigelian hernia
repair. There were no differences in recurrence rates
between open and laparoscopic hernia repair, however,
laparoscopic repair conferred benefits in terms of hospi-
tal stay and morbidity. An extraperitoneal approach was
recommended for uncomplicated elective repair and an
intra-abdominal approach if co-existent pathology
requires surgery during the same intervention. In the
case of emergency Spigelian hernia repair an open
approach, as performed here, was advocated [7].
Conclusion
Spigelian herniae are uncommon and frequently pose a
diagnostic challenge. A range of viscera may be found
within a Spigelian hernia; caution is therefore required
when the hernial sac is opened to prevent damage to its
contents.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the journal’s Editor-in-Chief.
Authors’ contributions
All authors approved and equally contributed to this manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 22 December 2009
Accepted: 13 January 2010 Published: 13 January 2010
References
1. Skandalakis PN, Zoras O, Skandalakis JE, et al: Spigelian hernia: surgical
anatomy, embryology, and technique of repair. Am Surg 2006, 72:42-8.
2. Jain KM, Hastings OM, Kunz VP, et al: Spigelian hernia. Am Surg 1977,
43:596-600.
3. Onal A, Sokmen S, Atila K: Spigelian hernia associated with strangulation
of the small bowel and appendix. Hernia 2003, 7:156-7.
4. Carr JA, Karmy-Jones R: Spigelian hernia with Crohn’s appendicitis. Surg
Laparosc Endosc 1998, 8:398-9.
5. Nauta RJ, Heres EK, Walsh DB: Crohn’s appendicitis in an incarcerated
spigelian hernia. Dis Colon Rectum 1986, 29:659-61.
6. Montes IS, Deysine M: Spigelian and other uncommon hernia repairs.
Surg Clin North Am 2003, 83:1235-53.
7. Moreno-Egea A, Carrasco L, Girela E, et al: Open vs laparoscopic repair of
Spigelian hernia: a prospective randomized trial. Arch Surg 2002,
137:1266-8.
doi:10.1186/1757-1626-3-22
Cite this article as: Thomasset et al.: An unusual Spigelian hernia
involving the appendix: a case report. Cases Journal 2010 3:22.
Figure 1 An ischaemic appendix (white arrow) and loop of
terminal ileum within a Spigelian hernia.
Thomasset et al. Cases Journal 2010, 3:22
http://www.casesjournal.com/content/3/1/22
Page 2 of 2


An unusual Spigelian hernia involving the appendix: a case report

Crossref

Atila K: Spigelian hernia associated with strangulation of the small bowel and appendix. Hernia

DB: Crohn’s appendicitis in an incarcerated spigelian hernia. Dis Colon Rectum

et al: Spigelian hernia. Am Surg

Karmy-Jones R: Spigelian hernia with Crohn’s appendicitis. Surg Laparosc Endosc

Open vs laparoscopic repair of Spigelian hernia: a prospective randomized trial. Arch Surg

Spigelian and other uncommon hernia repairs. Surg Clin North Am

Spigelian hernia: surgical anatomy, embryology, and technique of repair. Am Surg

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2820006

An unusual Spigelian hernia involving the appendix: a case report

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