New data of topographic anatomy of semilunar line (semilunar line by A. Spiegel)

Background. Today, a special place in surgical practice is the treatment of patients with spigelian hernias, which can be subcutaneous, interstitial, prepperitoneal, and make up 1% of all external hernias of the abdomen. The difficulty in diagnosing of spigelian hernias can lead to a serious complication – infringement of the hernia, which will require emergency surgical treatment. Therefore, the study of the typical, sexual and variant anatomy of the Spigelian line region is important in improving the diagnosis and treatment of such patients.The aim. To study the features of typical, sexual and variant anatomy of the Spigelian line region.Materials and methods. We examined 42 non-fixed corpses of persons of both sexes without signs of pathology of the anterior abdominal wall. Among them were 26 (54.2%) men and 22 (45.8%) women. At autopsy, we performed anatomical dissection of the semilunar line region. We measured the width of the aponeurotic stretch from the end of the transverse abdominal muscle fibers to the lateral edge of the rectus abdominis muscle at level corresponding to d. bicostarum, umbilical ring and d. bispinarum.Results. We identified four clusters corresponding to the variations in the shape of the semilunar line: tapering down (9.5%), uniform wide (19.0%), tapering up (28.6%) and wide in the middle (42.9%). We found that the semilunar line, tapering up, was significantly more often observed in women (83.3%), uniformly wide – in brachymorphic body type (75.0%), wide in the middle – in mesomorphic body type (66.07%), and the semilunar line, tapering down, was found only in men. Variants of the shape of the semilunar line, tapering up or down, were absent in persons of the brachymorphic body type. Semilunar line, tapering up, was found (without significant differences) in persons of the mesomorphic body type in 41.6%, in the persons of the brachymorphic body type – in 58.4%, and semilunar line, tapering down, was noted in persons with a dolichomorphic body type in 75.0%.Conclusion. New data may allow to predict the location, type of spigelian hernia, and also improve the diagnosis and treatment of spigelian hernia.

A case of incarcerated spigelian hernia causing small bowel obstruction

Spigelian hernias are rare anterior abdominal wall hernias in which the defect occur at the semilunar line lateral to rectus abdominis muscle. It mostly occurs in the lower half as posterior sheath is deficient in that region. Spigelian hernias are rare and moreover it is difficult to diagnose clinically. It constitutes about 0.12% of abdominal wall hernias. Even though it is rare, it is more prone for complications. It affects both sexes and sides equally. It is a diagnostic difficulty especially in obese patients as in our case where physical examination will often be inconclusive. Majority of the spigelian hernias are diagnosed intra operatively. Here in this case report, we present a case of obese 48 years old female who presented with abdominal pain and signs of intestinal obstruction which was found out to be an incarcerated spigelian hernia. Recently laparoscopic repair has been found to be safe and effective.

An unusual presentation and management of incarcerated Richter’s type of Spigelian hernia: a rare case report and review of literature

Spigelian hernias (SH) are one of the rare forms of ventral abdominal hernias which constitutes about 1-2%. SH occurs through the defect in the anterior abdominal wall adjacent to the semilunar line which occurs in the lower abdomen where the posterior sheath is deficient. The usual presentation of SH is a painful mass in mid abdomen above anterior superior iliac spine (ASIS). The diagnosis is made by means of ultrasound and computed tomography (CT). We report 69 years old female who is a known case of Parkinson’s disease and on medication presented with 2 days of sudden-onset right iliac fossa (RIF) associated with intermittent nausea, vomiting and also abdominal distension. O/E: Abdomen soft, tenderness in RIF with swelling above the line of ASIS. With the diagnosis of lateral abdominal wall hernia we took a CT scan that shows obstructed SH. Immediately she underwent surgery, intra-operative picture shows intraparietal hernia with Richter’s type and viable bowel. Abdominal wall is very weak and flimsy with no proper differentiation between the layers. Preperitoneal mesh repair was performed. The post-operative (post op) period was uneventful. Till now there was only 6 type of Richter’s SH reported. In this article we discuss a brief knowledge of SH and the management part of SH. We hope that this article will benefit among the surgeons in treating with SH.

Concomitant Anterior and Posterior Component Separations: Absolutely Contraindicated?

Many experts in abdominal wall reconstruction believe that the combination of simultaneous ipsilateral anterior component separation (ACS) and posterior component separation (PCS) is contraindicated. We performed ipsilateral endoscopic ACS and either endoscopic or open PCS-transversus abdominis release (TAR) in 5 fresh cadaver models. The full length of the semilunar line and the lateral abdominal wall remained well reinforced by 2 complete layers, comprising the internal oblique (IO) and TA muscles and their investing fasciae. Myofascial releases occurred 4 cm (median) apart. Additionally, we reviewed computed tomography images at 1 month and 1 year after PCS-TAR in 17 patients (30 PCS-TARs). Lateral displacement of the TA relative to the rectus abdominis (RA) was significant only at the superior mesenteric artery level, where it was <1 cm (median). Muscle mass changed minimally over time. Several studies showed that abdominal wall reconstruction after PCS-TAR results in compensatory muscular hypertrophy of the RA, external oblique (EO), and IO muscles and provides better quality of life and improved core physiology. These changes did not occur when the midline was not restored. Theoretically, endoscopic ACS-EO may be added to PCS-TAR to avoid partially bridged mesh repair in patients in whom complete midline restoration is impossible via PCS-TAR alone. Nevertheless, we advise most surgeons to perform a small-bridged repair instead of risking increased morbidity by attempting a highly complicated procedure.

Spigelian hernia-Our experience

Background; A Spigelian hernia is a very rare hernia which develops through the aponeurotic layer between the rectus abdominal muscles medially, and the semilunar line laterally. Aim: The aim of this study is to understand the clinical presentation and management of this rare hernia. Material and methods: This study was conducted over a period of five years in the Department of Surgery SKIMS Medical College Srinagar and included all the patients diagnosed as spigelian hernia. Results: During our study, we encountered only four cases of spigelian hernia, which included three females and one male. Conclusion: The spigelian hernia is a very rare hernia seen in adults and usually there is no notable swelling on examination. Although they are rare but there is a high risk of strangulation. JMS 2018: 21 (2):114-116

Spigelian hernia: a rare abdominal hernia

Spigelian hernia is a rare variety of abdominal wall hernia occurring through the spigelian fascia which is composed of the aponeurotic layer between rectus muscle medially and semilunar line laterally. Generally it is difficult to diagnose because of their location and non specific symptoms. Diagnosis is aided by ultrasonography and Computerized Tomography. Once the diagnosis is confirmed, it is repaired surgically as risk of incarceration is high. We reported this interesting case of spigelian hernia with associated port site hernia in a 53 year old female patient from Arwal district, Bihar who presented with occasional lower abdominal pain. The hernia was reduced and defect was repaired. Her recovery was uneventful.

Spigelian hernia - an unusual abdominal hernia: a case report and review of literature

Spigelian hernias are rare abdominal wall defects that occur at the semilunar line lateral to the rectus abdominis muscle. They are situated between the muscular layers of the abdominal wall and can be easily overlooked because of abdominal obesity. Generally difficult to diagnose because of their location and vague non-specific symptoms radiographic studies have been beneficial in confirming the diagnosis. The diagnosis has been considerably aided by the introduction of ultrasonography and Computed Tomography (CT). Once the diagnosis is made operative management is indicated due to chances of incarceration. We report a 48 years old patient from the IMS and SUM hospital, Bhubaneswar, Odisha, India who presented with colicky lower abdominal pain associated with a non-tender swelling above and lateral to the left inguinal canal. A diagnosis of Spigelian hernia was made and confirmed on exploration. The hernia was reduced and the defect repaired. His recovery was uneventful.

Spigelian Port-site Hernia, a Complication after Laparoscopic Cholecystectomy - a Clinical Case Report

Introduction: Spiegelian hernias are rare entities in abdominal wall pathology (2%). They occur in the semilunar line described by Adriaan van den Spiegel. Klinklosch (1764) defined it as a congenital or acquired defect of the transverse abdominal aponeurosis junction with the Douglas arch. Port-site hernias due to wrong placement of laparoscopic trocars in the right abdominal flank are rare, but possible complications of laparoscopic cholecystectomy. Case presentation: Our observation shows diagnostic and therapeutic aspects in a patient with port-site Spigelian hernia post laparoscopic cholecystectomy admitted in Surgical Clinic 1, County Emergency Clinical Hospital Tîrgu Mureș in the 28.01.2013 - 30.01.2013 period. Following surgery performed using an open approach, postoperative evolution was favorable, with no signs of recurrence at 9 months postoperatively. Conclusions: Spigelian port-site hernia post laparoscopic cholecystectomy is a very rare entity, iatrogeny being a certainty in its development

Spigelian Hernia: Surgical Anatomy, Embryology, and Technique of Repair

Spigelian hernia (1–2% of all hernias) is the protrusion of preperitoneal fat, peritoneal sac, or organ(s) through a congenital or acquired defect in the spigelian aponeurosis (i.e., the aponeurosis of the transverse abdominal muscle limited by the linea semilunaris laterally and the lateral edge of the rectus muscle medially). Mostly, these hernias lie in the “spigelian hernia belt,” a transverse 6-cm-wide zone above the interspinal plane; lower hernias are rare and should be differentiated from direct inguinal or supravescical hernias. Although named after Adriaan van der Spieghel, he only described the semilunar line (linea Spigeli) in 1645. Josef Klinkosch in 1764 first defined the spigelian hernia as a defect in the semilunar line. Defects in the aponeurosis of transverse abdominal muscle (mainly under the arcuate line and more often in obese individuals) have been considered as the principal etiologic factor. Pediatric cases, especially neonates and infants, are mostly congenital. Embryologically, spigelian hernias may represent the clinical outcome of weak areas in the continuation of aponeuroses of layered abdominal muscles as they develop separately in the mesenchyme of the somatopleura, originating from the invading and fusing myotomes. Traditionally, repair consists of open anterior herniorraphy, using direct muscle approximation, mesh, and prostheses. Laparoscopy, preferably a totally extraperitoneal procedure, or intraperitoneal when other surgical repairs are planned within the same procedure, is currently employed as an adjunct to diagnosis and treatment of spigelian hernias. Care must be taken not to create iatrogenic spigelian hernias when using laparoscopy trocars or classic drains in the spigelian aponeurosis.

Rare form of intestinal obstruction strangulation

Rare forms of strangulated intestinal obstruction constantly attract the attention of surgeons. The latter include impinged internal hernias in the inner ring of inguinal and femoral canals, under the ligament of Treitz, in the ring of the vermiform process, in the diaphragm orifices, semilunar line, and obturator foramen. These forms occur in 1-2% of all cases of strangulated intestinal obstruction.