Laparoscopic Spigelian Hernia Repair: A Systematic Review

Is there a link between Spigelian and inguinal hernias? A case series

INTRODUCTION

Spigelian hernias are among the rare primary ventral hernias. Diagnosis is often difficult, as many cases are asymptomatic. Spigelian and inguinal hernias are usually considered separately in current scientific literature. With this case series, we want to illustrate a possible relationship between the neighboring hernia types.

METHODS

In this article, we report on a case series of Spigelian hernias that were operated on in five hernia centers in the period from January 1st, 2021 to October 31st, 2023. We have summarized all patient characteristics with previous operations and the result of the secondary operation.

RESULTS

We report a case series with 24 Spigelian hernias, 15 of which have a connection to previous inguinal hernias. In these cases, however, it is not certain whether these are primarily overlooked or occult hernias or whether these Spigelian hernias have arisen secondarily, as a result of previous hernia surgery. With this case series, we would like to point out a possible connection between Spigelian hernia and inguinal hernia. Further studies are needed to shed more light on this entity and explain its genesis.

Outcomes After Spigelian Hernia Repair: A Nationwide Database Study

BACKGROUND

Spigelian hernia is a rare hernia of the abdominal wall. Due to lack of evidence, there is no standard recommendation for surgical technique of Spigelian hernia repair. The aim of this study was to evaluate the outcomes after open and laparoscopic, elective and emergency repair of Spigelian hernias on a nationwide basis.

METHODS

Nationwide data from the Danish Ventral Hernia Database and the National Patient Registry was assessed to analyze outcomes after Spigelian hernia repair. A total of 365 patients were operated for Spigelian hernia in Denmark from 2007 to 2018. Ninety-day readmission, 90-day reoperation and long-term operation for recurrence were evaluated, as well as possible differences between open and laparoscopic, and elective and emergency repairs.

RESULTS

Most of the patients (80.5%, 294/365) were operated by laparoscopic approach and 19.5% (71/365) were operated by open approach. Elective surgery was performed in 83.6% (305/365) of the patients and 16.4% (60/365) underwent emergency repair. There were no significant differences in 90-day readmission or reoperation rates between open or laparoscopic Spigelian hernia repairs, P = 0.778 and P = 0.531. Ninety-day readmission and 90-day reoperation rates were also comparable for elective versus emergency repair, P = 0.399 and P = 0.766. No difference was found in operation for recurrence rates between elective and emergency, nor open and laparoscopic Spigelian hernia repairs.

CONCLUSIONS

This study demonstrates that 16% of Spigelian hernia repairs are done in the emergency setting. Open and laparoscopic approach are comparable in terms of early readmission, reoperation, and recurrence rates.

Technical considerations for laparoscopic transabdominal preperitoneal repair of concurrent Spigelian-inguinal hernia complex: A case report and review of literature

Spigelian hernia with concurrent inguinal hernia is not uncommon. The hernia location makes conventional laparoscopic repair challenging and this is commonly repaired by the open method. We present the technical considerations and feasibility, as well as literature review, of such a hernia repaired via a minimally invasive fashion. We performed a laparoscopic transabdominal preperitoneal hernia repair for a 59-year-old woman who presented with symptomatic irreducible large Spigelian-inguinal complex hernia, with a hernia neck of 4 cm on computed tomography scan. The hernia contents were reduced transabdominally and subsequently, the preperitoneal space was created via a transabdominal preperitoneal method to allow for hernia defect closure and subsequent mesh placement. The patient was discharged on postoperative day 2 without complication. At 6 months follow-up, she had no complications or recurrence. With increased experience, the laparoscopic repair of complex Spigelian-inguinal concurrent hernias is safe and feasible.

Spigelian hernia: current approaches to surgical treatment-a review

BACKGROUND

Spigelian hernias (SpH) belong to the group of eponymous abdominal wall hernias. Major reasons for diagnostic difficulties are its low incidence reaching maximum 2% of abdominal wall hernias, a specific anatomical localization with intact external oblique aponeurosis covering the hernia sac and non-constant clinical presentation.

METHODS

A literature review was completed to summarize current knowledge on surgical treatment options and results.

RESULTS

SpH presents a high incarceration risk and therefore should be operated upon even if the patient is asymptomatic. Both laparoscopic and open repair approaches are validated by current guidelines with lesser postoperative complications and shorter hospital stay in favour of minimally invasive surgery, regardless of the technique used. Overall recurrence rate is very low.

CONCLUSION

All diagnosed SpH should be planned for elective operation to prevent strangulated hernia and, therefore emergency surgery. Both open and laparoscopic SpH treatment can be safely performed, depending on surgeon's experience. In most cases, a mesh repair is generally advised.

Transabdominal Preperitoneal (TAPP) for the Treatment of Spigelian hernias

Background And Objectives:

Spigelian hernias (SH) are a rare variant of abdominal wall defects that require prompt surgical intervention. With the advancement of abdominal wall surgery capabilities, there are several possible approaches of repairing SH. The aim of the study was to present our experience in performing laparoscopic or robotic transabdominal preperitoneal (TAPP) repairs of SH and discuss the advantages of TAPP in such hernias.

Methods:

Retrospective review of a prospectively maintained database of SH TAPP repairs between February 1, 2015 and February 29, 2020. Data included clinical details, size and location of fascial defect, presence of concomitant hernias, surgery duration, length of stay (LOS), mesh type, mesh size, and fixation method. Follow up visits at 1 month postoperative and telephone survey for pain assessment and subsequent hernia-related treatment.

Results:

During the study period 16 patients underwent TAPP SH repairs, 13 laparoscopically and 3 robotic. Seven (44%) patients had a concomitant inguinal hernia with 1 patient having bilateral inguinal defects. Mean surgery duration and mean LOS were 78 (range 41 – 120) minutes & 1.6 (range 1 – 3) days, respectively. Immediate postoperative complications included 2 seromas and 1 port-site hematoma. Mean telephone survey follow up was 17 months (range 3 – 49). Mean visual analogue scale scores were significantly lower at follow-up compared to discharge (1.9 vs 0.5, P = 0.0015).

Conclusion:

Advantages of TAPP SH repair include low postoperative chronic pain, potential low wound complications, intra-abdominal visualization of hernia contents, and repairing of concomitant inguinal hernias simultaneously.

Spigelian hernia: Our total extraperitoneal approach and a systematic review of the literature

INTRODUCTION

Spigelian hernia is a rare lateral ventral hernia traditionally repaired through open incision with extensive dissection. Three laparoscopic techniques have been reported in the literature: intraperitoneal onlay mesh (IPOM), transabdominal preperitoneal (TAPP), and total extraperitoneal (TEP). TEP is less popular than the other approaches. We evaluated TEP's safety and effectiveness and compared different laparoscopic techniques.

METHODS

All patients with Spigelian hernia who had undergone extended TEP (eTEP) repair with mesh in our center from January 2007 to February 2020 were studied. A three-port technique with a preperitoneal space created by telescope at the midline was adopted. A systematic review on laparoscopic mesh repair was performed by searching for "Spigelian hernia" and "laparoscopic" from 1999 to 2019 in the MEDLINE database.

RESULTS

Seven patients underwent eTEP repair for Spigelian hernia. Five presented with abdominal mass and underwent preoperative imaging. Two were diagnosed incidentally during TEP for inguinal hernia. The mean operative duration was 65 minutes (range, 40-93 minutes). There were no open conversions or intraoperative complications. The mean length of hospital stay was 1.4 days (range, 1-3 days). The mean follow-up period was 44.3 months. One patient developed seroma. There was no recurrence or chronic pain. We identified 197 laparoscopic mesh repairs reported in 41 articles. IPOM (n = 91) was the most popular approach, followed by TAPP (n = 70) and TEP (n = 36). Laparoscopic mesh repair of Spigelian hernia is safe and offers excellent outcomes.

CONCLUSION

We found the eTEP approach safe and effective for Spigelian hernia repair. IPOM, TAPP, and TEP are comparable.

Regulatory science for hernia mesh: Current status and future perspectives

Regulatory science for medical devices aims to develop new tools, standards and approaches to assess the safety, effectiveness, quality and performance of medical devices. In the field of biomaterials, hernia mesh is a class of implants that have been successfully translated to clinical applications. With a focus on hernia mesh and its regulatory science system, this paper collected and reviewed information on hernia mesh products and biomaterials in both Chinese and American markets. The current development of regulatory science for hernia mesh, including its regulations, standards, guidance documents and classification, and the scientific evaluation of its safety and effectiveness was first reported. Then the research prospect of regulatory science for hernia mesh was discussed. New methods for the preclinical animal study and new tools for the evaluation of the safety and effectiveness of hernia mesh, such as computational modeling, big data platform and evidence-based research, were assessed. By taking the regulatory science of hernia mesh as a case study, this review provided a research basis for developing a regulatory science system of implantable medical devices, furthering the systematic evaluation of the safety and effectiveness of medical devices for better regulatory decision-making. This was the first article reviewing the regulatory science of hernia mesh and biomaterial-based implants. It also proposed and explained the concepts of evidence-based regulatory science and technical review for the first time.

MDCT imaging in Spigelian hernia, clinical, and surgical implications

OBJECTIVE

Spigelian hernia is an uncommon congenital or acquired defect in the transversus abdominis aponeurosis with non-specific symptoms posing a diagnostic challenge. There is a paucity of radiology literature on imaging findings of Spigelian hernia. The objective of this study is to explore the role of MDCT in evaluating Spigelian hernia along with clinical and surgical implications.

MATERIALS AND METHODS

In this IRB approved, HIPAA compliant retrospective observational analysis MDCT imaging findings of 43 Spigelian hernias were evaluated by two fellowship-trained radiologists. Imaging features evaluated were: presence of Spigelian hernia, laterality, relation to "hernia belt" (between 0 and 6 cm cranial to an imaginary axial line between both anterior superior iliac spines), the hernia neck and sac sizes, hernia content, and other coexistent hernias (umbilical, incisional, inguinal). Patient's demographics (age, gender, BMI, conditions with increased intra-abdominal pressure) were also recorded for any correlation.

RESULTS

60% (26/43) of Spigelian hernias were located below the hernia belt while 33% (14/43) within the hernia belt and 7% (3/43) above the hernia belt. The most common subtype of Spigelian hernia encountered was interparietal (84%). The mean hernia neck diameter was 3.4 cm, mean hernia sac volume was 329 cc. Hernia content included: fat (43/43) bowel (23/43), fluid (3/43). 3 patients had no clinical history provided, the remaining 37 patients' clinical presentation was asymptomatic in 73% (27/37), acute abdominal pain in 5% (2/37) and chronic abdominal pain in 22% (8/37). None of the hernia were incarcerated and none of the patients underwent emergent surgery. No significant correlation was noted between Spigelian hernia and causes of increased intra-abdominal pressure. 90% of our patients had other abdominal hernias. 30.9 was the mean BMI (20.8-69.1).

CONCLUSION

Most of the Spigelian hernia occurred below the traditionally described hernia belt and the majority are of interparietal subtype that can be best diagnosed with MDCT in contrast to physical examination.

Laparoscopic modified lateral transabdominal preperitoneal approach for Spigelian hernia repair: An easier approach to a rare condition

INTRODUCTION

Both laparoscopic and open approaches are well accepted for spigelian hernia (SH) repair. Several techniques for SH repair are described in literature. In our study, eight patients underwent laparoscopic SH repair. A modified lateral TAPP approach was used in four cases and then compared with the conventional TAPP approach.

METHODS

From January 2015 to January 2017, eight cases of SH were treated using the laparoscopic TAPP approach. Four cases underwent surgery by the conventional laparoscopic TAPP approach (group I). For the other four, modified lateral approach transabdominal preperitoneal technique was used (group II). Postoperative pain, operative time, length of hospital stay, and complications were compared between the groups. Patients were followed up for a minimum period of 1 year.

RESULT

Among the eight cases, the mean age was 52 years in group I and 50 years in group II, mean defect size was 23 mm in group I and 28 mm in group II, mean length of hospital stay was 1.50 days in group I and 1.25 days in group II, and operative time was 61 minutes in group I and 51 minutes in group II. There was no remarkable difference in complications or length of hospital stay between the groups. The groups were comparable in all other parameters, but the lateral approach was ergonomically better for the surgeon.

CONCLUSION

Of the approaches described for laparoscopic SH repair, the modified lateral TAPP approach is more convenient because it provides better and more adequate lateral and inferior space access and is ergonomically better for surgeons.

Ipsilateral Spigelian hernia: just an infrequent variant?

Spigelian hernias are generally considered to occur through solitary defects in the fascial layers of the anterior abdominal wall in the 'Spigelian hernia belt' but can be found anywhere along the line of the linea semilunaris. They are uncommon in children and in adults thought to be acquired and associated with obesity. We describe an unusual case of Spigelian herniation previously unreported and possibly previously unrecognised.

Laparoscopic totally extraperitoneal and transabdominal preperitoneal approaches are equally effective for spigelian hernia repair

INTRODUCTION

Spigelian hernias (SH) are rare intraparietal abdominal wall hernias occurring just medial to the semilunar line. Several small series have reported on laparoscopic SH repair and both totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) approaches have been described. However, there are limited outcome data including both of these techniques. We present the largest series to date of laparoscopic SH repair comparing both popular approaches.

METHODS

Consecutive patients (n = 77) undergoing laparoscopic SH repair from 2009 to 2019 were identified from a prospectively managed quality database. All procedures were performed at a single institution. Patients were divided based on laparoscopic approach used, TEP group (n = 37) and TAPP group (n = 40). Comparison of patient demographics, surgical characteristics, and post-operative complications between TAPP and TEP groups was made using the Wilcoxon rank-sum and Fisher's exact tests.

RESULTS

Individuals undergoing TAPP had higher mean BMI (29.3 ± 5.4 vs. 26.3 ± 5.6 kg/m²; p = 0.019) and were more likely to have had prior abdominal surgery (65% vs 24.3%, (p < 0.001). Mean procedure length was 77 ± 45 min for TAPP repairs and 48 ± 21 for TEP repairs (p = 0.001). TAPP repairs had a significantly longer median LOS than TEP (25 vs. 7 h; p < 0.001). Days of narcotic use were significantly shorter after TEP repair than for TAPP (0 vs. 3; p = 0.007) and return to ADL was significantly shorter after TEP repair than for TAPP (5 vs. 7 days; p = 0.016. There were no significant differences in readmission, reoperations, SSI, or recurrence between the two groups.

CONCLUSION

Our large series revealed that both preperitoneal laparoscopic approaches, TEP, and TAPP, for SH repair are equally safe, effective, and can be performed on an outpatient basis. Therefore, we suggest that the approach used for repair should be based on surgeon experience, preference, and individual patient factors.

EHS and AHS guidelines for treatment of primary ventral hernias in rare locations or special circumstances

Background

Rare locations of hernias, as well as primary ventral hernias under certain circumstances (cirrhosis, dialysis, rectus diastasis, subsequent pregnancy), might be technically challenging. The aim was to identify situations where the treatment strategy might deviate from routine management.

Methods

The guideline group consisted of surgeons from the European and Americas Hernia Societies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used in formulating the recommendations. The Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists were used to evaluate the quality of full‐text papers. A systematic literature search was performed on 1 May 2018 and updated 1 February 2019. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was followed.

Results

Literature was limited in quantity and quality. A majority of the recommendations were graded as weak, based on low quality of evidence. In patients with cirrhosis or on dialysis, a preperitoneal mesh repair is suggested. Subsequent pregnancy is a risk factor for recurrence. Repair should be postponed until after the last pregnancy. For patients with a concomitant rectus diastasis or those with a Spigelian or lumbar hernia, no recommendation could be made for treatment strategy owing to lack of evidence.

Conclusion

This is the first European and American guideline on the treatment of umbilical and epigastric hernias in patients with special conditions, including Spigelian and lumbar hernias. All recommendations were weak owing to a lack of evidence. Further studies are needed on patients with rectus diastasis, Spigelian and lumbar hernias.

Spigelian Hernia: Case Series and Review of the Literature

Background

Spigelian hernia (SH) is an uncommon ventral abdominal hernia. Traditionally repaired with an open technique, the laparoscopic approach is becoming more common and widely described in the literature. We hold that the transabdominal preperitoneal (TAPP) approach restores the anatomy and prevents complications such as seroma. We present a series of SH repair carried out at a single district general hospital over the past 13 years and a review of the literature.

Methods

A retrospective case note review identified SH repaired between January 2005 and March 2018 at The Queen Elizabeth Hospital, King's Lynn, Norfolk, UK. A Medline search for 'Spigelian hernia' and 'laparoscopic' revealed 41 papers for review.

Results

33 patients underwent repair of SH. We found that the TAPP repair with a mesh is anatomically the most sound repair, with all the added benefits of keyhole surgery, i.e. reduced hospital stay, quicker recovery, and fewer infections. Our complication rates matched those described in the literature.

Conclusions

Several operative techniques have been described to repair SH. We favour the laparoscopic TAPP approach which is safe, aids in confirming the correct diagnosis, and has all the benefits of keyhole surgery.

Elective laparoscopic totally extraperitoneal repair for Spigelian hernia: A case series of four patients

INTRODUCTION

Spigelian hernia (SH) is uncommon. Clinical diagnosis may be difficult, but computed tomography (CT) can help to establish the diagnosis. Laparoscopic repair is increasingly performed because it is associated with low morbidity rates. Laparoscopic approaches include transabdominal preperitoneal (TAPP), intraperitoneal onlay mesh (IPOM), and totally extraperitoneal (TEP). Here, we report our experiences of TEP repair for SH.

METHODS

A retrospective review was performed on all patients with SH who underwent elective laparoscopic TEP repair from 2007 to 2017 at Tung Wah Hospital, Hong Kong.

RESULTS

Four patients with SH were identified in the study period: three with a preoperative diagnosis of SH confirmed by CT scan and one diagnosed incidentally during TEP repair for inguinal hernia. The patients' mean age was 66.8 years (range, 55.0-82.0 years). The mean BMI was 22.8 kg/m² (range, 20.8-23.6 kg/m² ). The mean size of the SH defect was 2.0 cm (range, 0.5-3.0 cm). The mean operative time was 59 min (range, 40-86 min). Concomitant direct inguinal hernia was found in one patient and repaired simultaneously. All patients were discharged on postoperative day 1. One patient developed seroma, which subsided on conservative management. At a mean follow-up of 36 months (range, 2-108 months), there was no recurrence.

CONCLUSION

Laparoscopic repair for SH is preferred over the open approach as it is associated with a low morbidity rate and a short hospital stay. In our experience, TEP technique is safe and effective in laparoscopic SH repair.

Spigelian hernia in gynaecology

Background

A Spigelian hernia is a rare hernia through the Spigelian fascia between the rectus muscle and the semilunar line. This hernia is well known in surgery. Symptoms vary from insidious to localised pain, an intermittent mass and/or a bowel obstruction.

Results

The Spigelian hernia is poorly known in gynaecology. Spigelian hernias may be causally related to secondary trocar insertion. This review is written to increase awareness in gynaecology and is illustrated by a case report in which the diagnosis was missed for 4 years even by laparoscopy. Smaller hernias risk not to be diagnosed and will thus not be treated. Even larger Spigelian hernias might not be recognised and treated appropriately.

Conclusions

The gynaecologist should consider a Spigelian hernia in women with localised pain in the abdominal wall lateral of the rectus muscle some 5 cm below the umbilicus. Smaller hernias can be closed by laparoscopy without a mesh. Larger hernias require a mesh repair.