Spigelian hernia. A rare case of bilateral hernia and presentation of our experience

Introduction
Andrian Van der Spieghel (1578-1625), professor of anatomy and surgery at the University of Padua, defined the semilunar line as the line of transition between the muscle bundles and the aponeurosis of the transversus abdominis muscle. Klinklosch was first who described in 1746 the defect of the Spigelian hernia. Spiegel's hernia consists of a congenital or acquired defect of the transversus aponeurosis and occurs at the point of junction of the semilunar line and the arcuate line of Douglas. This area is weak and susceptible to herniation.
Spigelian hernia represents 1-2% of all abdominal hernias and can occur anywhere along the semicircular line of Douglas. The clinical diagnosis of Spigelian hernia can be difficult due to lack of consistent symptoms and signs. Bilateral Spigelian hernia is an extremely rare disease and since today few cases have been reported (1-5). Over the last fifteen years twelve cases of Spigelian hernias have been treated in our department. Purpose of our study is to present a rare case of bilateral Spigelian hernia and the clinical and surgical features of our series.
Bilateral Spigelian hernia case presentation
A forty-four year old female, librarian, heavy smoker with periodically spasm of coughing, presented a nine months history of progressive right lower quadrant pain, over the lateral border of the rectus muscle, opposite the iliac crest. In the three weeks just prior to admission, she had pain of similar nature and position on the left side. Both were aggravated by standing, coughing, somatic exercising and relieved by lying down. On physical examination she was slightly obese with point tenderness bilaterally and below the umbilicus over the lateral of the rectus muscle. No palpable defect or masses were noted. X-ray examination of the abdomen obtained in lateral position of the patient and ultrasonography were not of diagnostic value. Computed tomography documented a bilateral ventral hernia. (fig. 1)
The patient underwent surgical intervention through a transverse incision. During the operation, in both sides the external oblique aponeurosis was splitted and the hernial sac was prepared and excised. The content of the hernial sac was in both sides small intestine. The defects were closed with Nylon No 1 suture. Drainage in both sides was remained for two days. The patient had no complications after the surgery, made an uneventful recovery and after a period of follow up resumed her activities and remains asymptomatic.

Patients, Methods and results
We conducted a retrospective study of 15-years experience. Patients were scrutinized for presentation, work-up, therapy, and outcome. Twelve cases of Spigelian hernia occurred and surgically treated during the period 1988-2003. (table 1) Spigelian hernias were observed in 7 females and 5 males with mean age of 49.1 years (range 32-83 years). Predisposing factors were present in 9 of the 12 patients (75%) and included obesity, chronic constipation, chronic pulmonary disease and prior surgery. No risk factors were detected in 3 patients. In five patients (41.6%) the hernia was found in the left-side when in 6 patients was right-sided (50%) and in one case was bilateral (8.4%)
Symptoms most commonly included an intermittent mass [3 patients (25%)], pain [3 patients (25%)], pain with a mass [5 patients (33.3%)] and bowel obstruction [2 patient (16.6%)]. The pain, which was the most common symptom, was inconstant and not typical. The most frequent associated sign was local tenderness, found in 4 patients. In eight out of 12 patients (66,7%) the diagnosis was suspected pre-operatively. Ten of 12 patients (83.4%) were presented electively while two patients (16.6%) required emergent operations and were found to be incarcerated at the time of the operation. The defect was confirmed in all patients undergoing surgery, extending between the internal and external oblique layers in 9 out of 12 patients (75%) and passing through the external oblique layer in four of the 12 (25%). - one patient had a bilateral hernia. The clinical presentation was found to depend in relation to the contents of the hernial sac and the degree and type of herniation. The sac was empty in five patients (38.4%), contained greater omentum in four (30.7%), small intestine in three (23%), and sigmoid colon in one (7.7%). Spigelian hernias were repaired by primary suture closure (8 patients), prosthetic mesh application (Mersilene-2 patients) while in two cases primary suture closure with reinforcement of the aponeurosis of external obligue muscle with prosthetic Gore-Tex mesh was performed. The postopera-tive course was uncomplicated in all patients except of two patients who presented a postoperative local haematoma. All patients were postoperatively followed-up and no recurrence of the disease was observed.

Discussion
Although Spigelian hernias are unusual, they don't appear to be as uncommon as previously thought. Spigelian hernias can occur at any position within the extent of the fascia, from the eighth costal cartilage to the pubic tubercle. From the physical examination the Spigelian hernia has unspecific and variable presentation, which depends on the contests of the herniac sac and often is been misdiagnosed preoperatively. Usually is presented with intermittent mass, pain of the lower abdominal region or clinical findings of bowel obstruction. In differential diagnosis acute appendicitis, cholecystitis, tumors of the colon, diverticular disease of the colon, diseases of the ovaries and haematoma of the rectus sheath or other hernias are included (6).
Usually Spigelian hernia is unilateral and the case of bilateral is extremely rare (1-5). In regard with the age the lesion has been reported more often in patients from fifty to sixty years, is more common in women and is observed more frequently in the left side. Predisposing factors for this hernia as with other hernias it happens are obesity, chronic cough, constipation, trauma, prior surgery, ascites or sudden marked weight loss.
The value of conventional roentgenography is limited in indirect informations in cases of strangulated hernias. A real time high-resolution sonography is less invasive avoiding exposure to ionizing radiation and provides detailed images of the abdominal wall defect with a high diagnostic accuracy (4, 7, 8, 18, 21). Recent studies have reported the use of this technique preoperatively, for the reduction of incarcerated SH avoiding an urgent surgical intervention (9). Computed tomography offers specific informations for the abdominal defect, the size, the content of the sac and the relations with the around tissues (10-13).
Surgical repair is the unique treatment with low risk. Usually is performed through a transverse or oblique skin incision, to preserve the motor nerves. The external oblique aponeurosis is split in the direction of its fibers, the sac is reduced or excised and the defect is closed with non-absorbable suture, if necessary by overlapping internal oblique muscle and transverse aponeurosis. Rare complications that have referred are haematoma, focal abscess and ileus (10). Alternatively, prosthetic repair with mesh and laparoscopic repair have been used with competitive results and extraperitoneal laparoscopic treatment has been proposed as the technique of choice, of patient's diagnosed preoperatively (4, 10, 14-17, 19, 20).
The diagnosis of spigelian hernia presents greater difficulties than its treatment. It is small hernias and hernial orifices that are overlooked because they are masked by the subcutaneous fat and an intact external aponeurosis (20). From our experience in our department (1988-2003), twelve cases of spigelian hernia have been treated with anterior open hernioplasty, with no recurrence and with minimal reversible complications. Although laparoscopic repair has been used with competitive results we really believe that classic hernioplasty remains a therapeutical approach of high value and continue to merit serious consideration.

Conclusions
Spigelian hernia remains a rare disease with variable clinical expression that requires a high suspicion, particularly in small non-palpable hernias that are covered by the subcutaneous fat and the aponeurosis of the external oblique muscle. Repair with primary suture closure or defect reconstruction with prosthetic mesh, remains a reliable surgical approach.

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