Inguinal hernia usually developed and descended into scrotum. The clinical presentation is inguinal or
inguino-scrotal swelling. Abdominal wall weakness as it is frequently seen in African tropical zones
produces often rare clinical case. We report a case of inguinal hernia presented as an abdominal wall swelling clinically suggestive of a
Spigelian hernia and discuss the mechanism

A Mohta

A. Sy

AN Kingsnorth

B. Diop

BJ Anson

D. Fall

DL Sanders

I. Konate

S. Ka

S. M. Sarre

T Mittal

Y. Wone

English

PubMed

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Indirect inguinal hernia masquerading as a Spigelian hernia

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Hernia

CASE REPORT
Indirect inguinal hernia masquerading as a Spigelian hernia
B. Diop • I. Konate • S. Ka • D. Fall •
A. Sy • Y. Wone • S. M. Sarre
Received: 29 December 2009 / Accepted: 12 June 2010 / Published online: 9 July 2010
 The Author(s) 2010. This article is published with open access at Springerlink.com
Abstract Inguinal hernia usually developed and des-
cended into scrotum. The clinical presentation is inguinal
oringuino-scrotal swelling. Abdominal wall weakness as it
is frequently seen in African tropical zonesproduces often
rare clinical case. We report a case of inguinal hernia
presented as an abdominal wall swelling clinically sug-
gestive of aSpigelian hernia and discuss the mechanism.
Keywords Inguinal hernia  Spigel hernia 
Abdominal wall  Prothesis
Introduction
Adult hernia pathology viewed from African tropical zones
features specific anatomy characteristics [1]. The absence
of a balanced diet and hard chores create conducive con-
ditions to the development of hernia caused by parietal
weakness in most of the rural and manual worker popula-
tions. Furthermore, late medical consultation gives rise to
hernia and original clinical pattern owing to the width of
the ring, the size of the sac, the weight of the intra-sacculus
viscera and the frequency of complications [1]. Inguinal
hernia classically develops in the direction of the bursa to
become inguinal, funicular or inguino-scrotal.
We report a case of a hernia located in the lateral
inguinal fossa with ascending development towards the
iliac fossa and the flank and discuss the mechanism
involved.
Observation
A 69-year-old man was admitted in May 2009 to the
Ouakam Military Hospital in Se´ne´gal for swelling in the
right lower quadrant. He was an active farmer with a
medical past of left side inguinal surgery 23 years ago and
hypertension under treatment. Symptoms started about
10 years ago, marked by an intermittent swelling at the
right lower quadrant. It was painless, reducible, bulging on
coughs and increasing regularly in volume. Subsequently,
it became permanent with the presence of peristaltic
undulations. He did not report any signs of urinary or
digestive disorder.
At admission, the medical examination showed a pain-
less, gurgling and partially reducible tumor of 15 cm on the
long axis in the right lower quadrant (Fig. 1).
The diagnosis was evidently a Spiegel hernia, except
that the collar of the hernia was located very low in the
inguinal area.
The abdomen was resilient, painless and did not contain
any palpable mass. The testes looked normal in the scrotum
and the prostate had a normal size and tenderness. The
abdominopelvic ultrasonography revealed a hernia through
a parietal defect located in the right lower quadrant and
containing digestive loops. No organomegaly were detec-
ted in the abdominal cavity and the prostate had a normal
sonographic structure and volume. The indication of a
surgical treatment was opted out and performed through
the oblique pararectal approach stretched to the right side
of the inguinal region. Exploration highlighted a subcuta-
neous hernia bag in the right iliac fossa. The collar was
B. Diop (&)  S. Ka  D. Fall  A. Sy  Y. Wone  S. M. Sarre
Department of Surgery, Military Hospital of Ouakam,
Dakar, Senegal
e-mail: dballa33@yahoo.fr
I. Konate
Department of General Surgery, University Hospital Aristide Le
Dantec, Dakar, Senegal
123
Hernia (2011) 15:579–581
DOI 10.1007/s10029-010-0698-4
about 5 cm wide and located outside the epigastric vessels
and inside the right seminal region (Fig. 2). It contained
small intestinal loops with some adherence to the bag. The
middle inguinal fossa was the location of a direct hernia
that contained the vesicular horn. A reintegration of the
small loops, followed by a resection and reclosing of the
bag was performed. Treatment was achieved through fitting
a polypropylene prosthesis attached on the inguinal arch
and the inguinal falx according to the Lichtenstein proce-
dure (Fig. 3).
Drainage through suction followed by elastic contention
was performed. Post-operative care was simple and the
patient was discharged from the hospital 4 days after the
surgical operation. He was re-examined 6 months later and
the clinical examination was unremarkable.
Discussion
Hernia of the anterolateral abdominal wall develop through
architecturally and structurally weak zones which include
the inguinal canal, umbilicus, linea alba or laterally on the
Spiegel linea. The clinical manifestations are often typical
and enable easy diagnosis in most cases.
Inguinal hernia, the most frequent, develop in a canal,
enlarged or not, and generally grow towards the bursa to
become inguinal, funicular and, subsequently, become
inguino-scrotal.
Spiegel hernia, or lateral ventral hernia, develop through
a tight aponeurotic band called the ‘‘Spiegel’s semi-lunar’’
line laterally limited by the transverse muscles outside and
by the musculus rectus abdominis inside [2]. The hernia
collar can be located in all areas of the semi-lunar line, the
preferred location being at the level of the Douglas line
(mid-third of the spino-umbilical line). It remains always
separated from the inguinal canal by the transverse muscles
and the inferior oblique muscle. However, the collapse of
the inguinal wall, as frequently observed in African tropical
zones, produces uncommon clinical presentations.
In the reported case, the clinical presentation suggests
a priori a lateral ventral hernia or Spiegel’s hernia. But the
seminal line and the hernia sac were located in the same
lateral inguinal fossa. We observed an extreme widening of
the lateral and medial inguinal fossa. A similar clinical
feature has been described by Mohta and Gupta [3] in
patients aged 8 years. They described an inguinal sac
which reaches the superficial inguinal ring and then
ascends in a subcutaneous plane toward the iliac fossa
instead of passing into the testicular bag [3].
The exact mechanism of such a clinical presentation
cannot be stated. In the reported case, collapse of the
posterior wall of the inguinal canal has given rise to a large
gaping annulus, exposing the passage to an important
Fig. 1 Right abdominal wall swelling clinically reducible
Fig. 2 Right inguinal hernia through a large inguinal defect.
a Indirect hernia with bowel content, b spermatic cord, c direct hernia
Fig. 3 Hernia repair by Lichtenstein hernioplasty
580 Hernia (2011) 15:579–581
123
intestinal mass. The anatomic and dynamic factors seem to
be determinant in the genesis of the collapse of the inguinal
wall.
In regard to anatomy, the architectural weakness of the
inguinal canal can be accentuated by variations of the low
attachment of the internal oblique muscle in the weak
inguinal zones which have non-striped muscular fibres [4].
In addition, there are, in 48% of the cases, defects in the
internal oblique muscle, occupied by fatty tissue. The
presence of the defects associated with upper insertion of
the muscle in 36.8% of the cases seriously questions the
efficacy of the muscular bound [4].
Here, the mechanical cause prevails over multi-factorial
causes of hernia. As a fact, hard labour that rural popula-
tions and manual workers undergo mix with the age and the
weight of the internal saccular viscera to favour weakening
of the inguinal canal’s posterior wall and its widening. In
Sanders’ series, 66% of patients had voluminous hernia of
H3 or H4 type (according to the clinical classification of
the defined by Kingsnorth et al. [5]).
Conclusion
Hernias of the abdominal wall are frequently seen among
African populations because of some important risk
factors. This reported case had an uncommon clinical
presentation that suggested a priori a lateral ventral hernia,
or Spiegel’s hernia. However, the final diagnosis was a rare
case of weakness of the posterior wall of the inguinal canal
that creates a space for a large parietal defect.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
References
1. Sanders DL, Porter CS, Mitchell KCD, Kingsnorth AN (2008) A
prospective cohort study comparing the African and European
hernia. Hernia 12:527–529
2. Mittal T, Kumar V, Khullar R, Sharma A, Soni V, Baijal M et al
(2008) Diagnosis and management of Spigelian hernia: a review of
literature and our experience. J Minim Access Surg 4:95–98
3. Mohta A, Gupta CR (2009) Inguinal hernia masquerading as a
Spigelian hernia in a child. Hernia 13:327–328
4. Anson BJ, Morgan EH, McVay CB (1960) Surgical anatomy of the
inguinal region based upon a study of 500 body-halves. Surg
Gynecol Obstet 111:707–725
5. Kingsnorth AN (2004) A clinical classification for patients with
inguinal hernia. Hernia 8:283–284
Hernia (2011) 15:579–581 581
123


A clinical classiﬁcation for patients with inguinal hernia.

A prospective cohort study comparing the African and European hernia.

Diagnosis and management of Spigelian hernia: a review of literature and our experience.

Inguinal hernia masquerading as a Spigelian hernia in a child.

Surgical anatomy of the inguinal region based upon a study of 500 body-halves.

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Indirect inguinal hernia masquerading as a Spigelian hernia

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