Twelve years of experience treating Spigelian hernia Francesco A. Polistina, MD,a Greta Garbo, MD,b Paolo Trevisan, MD,c and Mauro Frego, PhD,a Monselice, Padua, and Florence, Italy
Background and aims. A Spigelian hernia (SH) is an acquired ventral hernia that most commonly occurs in the Spigelian belt. Patients may experience pain or a bulge in the abdominal area, but in most cases there are no symptoms. If left untreated the hernia may become strangulated, which could lead to bowel obstruction. Material and methods. We reviewed 28 surgical patients with SH between January 2002 and December 2013. We evaluated the incidence of complications, recurrences, and the length of hospital stay with comorbidities, body mass index, clinical presentation, and operative techniques. Results. The 28 patients included 10 males and 18 females, with a mean age of 67 years. Seven patients (26.9%) received emergency operations, and the remaining patients received elective operations. An ‘‘open-direct’’ operative approach was used in 16 cases and a laparoscopic approach in 12. The overall complication rate was 7.6% and the recurrence rate was 3.8% with a median follow-up of 3 years. The median hospital stay was 1 day (range, 1–7). Only the presence of local complications at diagnosis showed a significant impact on length of hospital stay. None of the considered variables had a significant impact on hernia recurrence. Conclusion. No differences were noted among the operative techniques, wound infections, complications rate, and length of hospital stay. Laparoscopy seems to cause more early postoperative pain that reverses in about 2 weeks. (Surgery 2015;157:547-50.) From the Department of General Surgery,a Monselice Hospital, Monselice; School of Surgery,b Padua University, Padua; and Department of Surgery,c Centro Oncologico Fiorentino, Florence, Italy
SPIGELIAN HERNIA (SH), also known as abdominal lateral hernia, was named after the Belgian anatomist Adriaan van den Spieghel, who first described the anatomy of the Spigelian line in the early 1600s. The first clinical report about SH was published by J. T. Klinkosch in 1764.1 SH is the protrusion of preperitoneal fat, peritoneal sac, or organs through a congenital or acquired defect in the Spigelian aponeurosis. Embryologically, SH may represent the clinical outcome of weaknesses in the fusion area of aponeuroses of layered abdominal muscles as they develop separately in the mesenchyme of the somatopleure, originating from the invading and fusing myotomes.2 SH is estimated to occur in .05). Laparoscopic procedures showed no difference in pain evaluation compared with direct repair on postoperative days 1 and 3. At the 1 week evaluation, open-direct repair showed significantly greater pain compared with both laparoscopic and open-direct procedure (mean value, 5.60 ± 2.07 vs 3.08 ± 1.83 [SE, 1.011; P < .005]; mean value, 5.60 ± 2.07 vs 1.18 ± 0.60 [SE, 0.658; P < .0001]). At the 1-month follow-up, there was no difference among the groups. These data are confirmed by the higher, albeit not significant, analgesic consumption recorded in patients from groups B and C in the first postoperative week. On univariate analysis, the presence of local complications at the diagnosis (strangulation, bowel perforation, or both) was found to have a strongly significant impact on the duration of hospital stay (P < .0001). BMI and associated comorbidities did not attain significant values, which was also true for the applied operative procedure. No significant impacts were outlined for any of the tested variables on SH recurrence. DISCUSSION Diagnosis of SH can be difficult and the presence of SH should be suspected in every case of otherwise unexplained chronic abdominal pain, especially in obese patients.6,7 Although diagnosis is made primarily at the clinical examination, an abdominal wall ultrasonography, computed tomography, or both may be required in some cases.8,9 Most studies addressing SH are case reports or series. The only prospective series was done by Malazgirt et al,10 who reported on a consecutive series of 34 patients with data collected on a multicentric basis, focusing on clinical features, operative procedure, and outcome of the operations. With regard to clinical presentation and operations performed, our data do not substantially differ from those of Malazgirt et al, although we do report a shorter hospital stay (1 vs 4.1 days). Moreover, our data do not substantially differ from that reported by Larson et al4 in the largest published series available from the Mayo Clinic, which included 81 consecutive patients. Herein we investigated the relationship between BMI, comorbidities, and clinical features of hernia on duration of hospital stay and recurrences. Our data show that the presence of complicated SH was the only factor that strongly influenced hospital stay, whereas obesity, comorbidities, and operative technique did not affect overall outcome and
Polistina et al 549
recurrence rate. We found that with a mean follow-up of >3 years only 3 patients experienced recurrence (10.7%), which is consistent with data from other reported series. Interestingly, all 3 patients who recurred were operated on in an acute setting. The most recent reports focus on the laparoscopic approach, showing good results in terms of low recurrence rate and short hospital stay.11-13 However, these data do not substantially differ from those reported by others focusing on an open approach.14-17 The present study includes data from 3 different operative techniques to repair SH, and for each operative technique our results are consistent with previous reports. Because laparoscopy grants minimal access, the literature suggests that the procedure reduces the rate of wound infection, even though the reported rates of infection are similar for open and laparoscopic techniques.11-15 Postoperative pain is less after laparoscopic procedures as compared with open approaches.15,17 The lack of well-described pain measurement systems in other studies makes it difficult to compare them with the postoperative pain data presented herein. Nevertheless, we outlined an early reversal of postoperative trends. As seen in the first postoperative week, the subjective pain was greater patients undergoing elective laparoscopy versus those patients who underwent elective open operations, and the data remained unaltered for the first postoperative week reverting at the 1-month control. Conversely, patients undergoing an open mesh positioning showed a very fast decrease in pain intensity, whereas patients undergoing direct repair showed a trend in postoperative pain evolution similar to those who underwent laparoscopic procedures. Despite the possibility of a type 2 error owing to the small sample, these findings are likely the result of a few cases of very intense postoperative pain caused by the implant of steel-helical fasteners into the posterior muscular fascia that spontaneously resolved after approximately 2 weeks as the local inflammatory response gradually reverted. These unique findings should be tested by well-designed, prospective trials to completely investigate the interactions between tacks and biological structures. Based on these data, complications are usually associated with emergency surgery and often require associated procedures, like bowel resections, which may prolong postoperative recovery of patients. Obesity of any grade and comorbidities do not seem to influence the operation’s outcome, regardless of technique. The choice of operative technique also does not seem to affect outcome,
550 Polistina et al
and this is consistent with data reported by others. Newly introduced laparoscopic procedures seem to reduce the wound infection rates,12,15,16 but increase at least transiently postoperative pain and related analgesic consumption. In the present series, laparoscopic procedures seem to be superior to open repair given that there were no recurrences or infections in laparoscopic repair, but there were 2 or 3 recurrences and 5 infections in open repair---even if these data did not attain significance, probably owing to the limited sample size. As the overall rate of SH diagnosis increases owing to instrumental investigations for unrelated causes, we recognize the lack of precise guidelines to decide which patients are fit for surgical repair and which are fit for simple observation. Surgery should be prescribed for obese patients because they seem to have a greater rate of complications if untreated.7 Moreover, in the absence of an accepted guideline, consolidated results from long-term observational study, or both, we recommend empirically operating on all symptomatic patients, including those with the bowel contained inside the hernia sac and, generally, those meeting the criteria for general hernia treatment. REFERENCES 1. Klinkosch JT. Programma Quo Divisionem Herniarum, Novumque Herniae Ventralis Specium Proponit. Rotterdam: Benam; 1764. 2. Dabbas N, Adams K, Pearson K, Royle GT. Frequency of abdominal wall hernias: is classical teaching out of date? JRSM Short Rep 2011;104:135. 3. Skandalakis PN, Zoras O, Skandalakis JE. Mirilas P Spigelian hernia: surgical anatomy, embryology, and technique of repair. Am Surg 2006;72:42-8.
Surgery March 2015
4. Larson DW, Farley DR. Spigelian hernias: repair and outcome for 81 patients. World J Surg 2002;26:1277-81. 5. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373-83. 6. Yau KK, Siu WT, Chan KL, Li KW. A man with recurrent lower abdominal pain: Spigelian hernia. Surg Laparosc Endosc Percutan Tech 2008;18:106-8. 7. Lau B, Kim H, Haigh PI, Tejiran T. Obesity increases the odds of acquiring and incarcerating noninguinal abdominal wall hernia. Am Surg 2012;78:1118-21. 8. Gough VM, Vella M. Timely computed tomography scan diagnoses Spigelian hernia: a case study. Ann R Coll Surg Engl 2009;91:W9-10. 9. Habib E, Elhadad A. Spigelian hernia long considered as diverticulitis: CT scan diagnosis and laparoscopic treatment. Computed tomography. Surg Endosc 2003; 17:159. 10. Malazgirt Z, Topgul K, Sokmen S, Ersin S, Turkcapar AG, Gok H, et al. Spigelian hernias: a prospective analysis of baseline parameters and surgical outcome of 34 consecutive patients. Hernia 2006;10:326-30. 11. Novell F, Sanchez G, Sentis J, Visa J, Novell J, Novell Costa F. Laparoscopic management of Spigelian hernia. Surg Endosc 2000;14:1189. 12. Patle NM, Tantia O, Sasmal PK, Khanna S, Sen B. Laparoscopic repair of Spigelian hernia: our experience. J Laparoendosc Adv Surg Tech A 2010;20:129-33. 13. Subramanya MS, Chakraborty J, Memon B, Memon MA. Emergency intraperitoneal onlay mesh repair of incarcerated Spigelian hernia. JSLS 2010;14:275-8. 14. Celdran A, Se~ naris J, Ma~ nas J, Frieyro O. The open mesh repair of Spigelian hernia. Am J Surg 2007;193:111-3. 15. Mittal T, Kumar V, Khullar R, Sharma A, Soni V, Baijal M, et al. Diagnosis and management of Spigelian hernia: a review of literature and our experience. J Minim Access Surg 2008;4:95-8. 16. Majeski J. Open and laparoscopic repair of Spigelian hernia. Int Surg 2009;94:365-9. 17. Vos DI, Scheltinga MR. Incidence and outcome of surgical repair of Spigelian hernia. Br J Surg 2004;91:640-4.
Background and aims. A Spigelian hernia (SH) is an acquired ventral hernia that most commonly occurs in the Spigelian belt. Patients may experience pain or a bulge in the abdominal area, but in most cases there are no symptoms. If left untreated the hernia may become strangulated, which could lead to bowel obstruction. Material and methods. We reviewed 28 surgical patients with SH between January 2002 and December 2013. We evaluated the incidence of complications, recurrences, and the length of hospital stay with comorbidities, body mass index, clinical presentation, and operative techniques. Results. The 28 patients included 10 males and 18 females, with a mean age of 67 years. Seven patients (26.9%) received emergency operations, and the remaining patients received elective operations. An ‘‘open-direct’’ operative approach was used in 16 cases and a laparoscopic approach in 12. The overall complication rate was 7.6% and the recurrence rate was 3.8% with a median follow-up of 3 years. The median hospital stay was 1 day (range, 1–7). Only the presence of local complications at diagnosis showed a significant impact on length of hospital stay. None of the considered variables had a significant impact on hernia recurrence. Conclusion. No differences were noted among the operative techniques, wound infections, complications rate, and length of hospital stay. Laparoscopy seems to cause more early postoperative pain that reverses in about 2 weeks. (Surgery 2015;157:547-50.) From the Department of General Surgery,a Monselice Hospital, Monselice; School of Surgery,b Padua University, Padua; and Department of Surgery,c Centro Oncologico Fiorentino, Florence, Italy
SPIGELIAN HERNIA (SH), also known as abdominal lateral hernia, was named after the Belgian anatomist Adriaan van den Spieghel, who first described the anatomy of the Spigelian line in the early 1600s. The first clinical report about SH was published by J. T. Klinkosch in 1764.1 SH is the protrusion of preperitoneal fat, peritoneal sac, or organs through a congenital or acquired defect in the Spigelian aponeurosis. Embryologically, SH may represent the clinical outcome of weaknesses in the fusion area of aponeuroses of layered abdominal muscles as they develop separately in the mesenchyme of the somatopleure, originating from the invading and fusing myotomes.2 SH is estimated to occur in .05). Laparoscopic procedures showed no difference in pain evaluation compared with direct repair on postoperative days 1 and 3. At the 1 week evaluation, open-direct repair showed significantly greater pain compared with both laparoscopic and open-direct procedure (mean value, 5.60 ± 2.07 vs 3.08 ± 1.83 [SE, 1.011; P < .005]; mean value, 5.60 ± 2.07 vs 1.18 ± 0.60 [SE, 0.658; P < .0001]). At the 1-month follow-up, there was no difference among the groups. These data are confirmed by the higher, albeit not significant, analgesic consumption recorded in patients from groups B and C in the first postoperative week. On univariate analysis, the presence of local complications at the diagnosis (strangulation, bowel perforation, or both) was found to have a strongly significant impact on the duration of hospital stay (P < .0001). BMI and associated comorbidities did not attain significant values, which was also true for the applied operative procedure. No significant impacts were outlined for any of the tested variables on SH recurrence. DISCUSSION Diagnosis of SH can be difficult and the presence of SH should be suspected in every case of otherwise unexplained chronic abdominal pain, especially in obese patients.6,7 Although diagnosis is made primarily at the clinical examination, an abdominal wall ultrasonography, computed tomography, or both may be required in some cases.8,9 Most studies addressing SH are case reports or series. The only prospective series was done by Malazgirt et al,10 who reported on a consecutive series of 34 patients with data collected on a multicentric basis, focusing on clinical features, operative procedure, and outcome of the operations. With regard to clinical presentation and operations performed, our data do not substantially differ from those of Malazgirt et al, although we do report a shorter hospital stay (1 vs 4.1 days). Moreover, our data do not substantially differ from that reported by Larson et al4 in the largest published series available from the Mayo Clinic, which included 81 consecutive patients. Herein we investigated the relationship between BMI, comorbidities, and clinical features of hernia on duration of hospital stay and recurrences. Our data show that the presence of complicated SH was the only factor that strongly influenced hospital stay, whereas obesity, comorbidities, and operative technique did not affect overall outcome and
Polistina et al 549
recurrence rate. We found that with a mean follow-up of >3 years only 3 patients experienced recurrence (10.7%), which is consistent with data from other reported series. Interestingly, all 3 patients who recurred were operated on in an acute setting. The most recent reports focus on the laparoscopic approach, showing good results in terms of low recurrence rate and short hospital stay.11-13 However, these data do not substantially differ from those reported by others focusing on an open approach.14-17 The present study includes data from 3 different operative techniques to repair SH, and for each operative technique our results are consistent with previous reports. Because laparoscopy grants minimal access, the literature suggests that the procedure reduces the rate of wound infection, even though the reported rates of infection are similar for open and laparoscopic techniques.11-15 Postoperative pain is less after laparoscopic procedures as compared with open approaches.15,17 The lack of well-described pain measurement systems in other studies makes it difficult to compare them with the postoperative pain data presented herein. Nevertheless, we outlined an early reversal of postoperative trends. As seen in the first postoperative week, the subjective pain was greater patients undergoing elective laparoscopy versus those patients who underwent elective open operations, and the data remained unaltered for the first postoperative week reverting at the 1-month control. Conversely, patients undergoing an open mesh positioning showed a very fast decrease in pain intensity, whereas patients undergoing direct repair showed a trend in postoperative pain evolution similar to those who underwent laparoscopic procedures. Despite the possibility of a type 2 error owing to the small sample, these findings are likely the result of a few cases of very intense postoperative pain caused by the implant of steel-helical fasteners into the posterior muscular fascia that spontaneously resolved after approximately 2 weeks as the local inflammatory response gradually reverted. These unique findings should be tested by well-designed, prospective trials to completely investigate the interactions between tacks and biological structures. Based on these data, complications are usually associated with emergency surgery and often require associated procedures, like bowel resections, which may prolong postoperative recovery of patients. Obesity of any grade and comorbidities do not seem to influence the operation’s outcome, regardless of technique. The choice of operative technique also does not seem to affect outcome,
550 Polistina et al
and this is consistent with data reported by others. Newly introduced laparoscopic procedures seem to reduce the wound infection rates,12,15,16 but increase at least transiently postoperative pain and related analgesic consumption. In the present series, laparoscopic procedures seem to be superior to open repair given that there were no recurrences or infections in laparoscopic repair, but there were 2 or 3 recurrences and 5 infections in open repair---even if these data did not attain significance, probably owing to the limited sample size. As the overall rate of SH diagnosis increases owing to instrumental investigations for unrelated causes, we recognize the lack of precise guidelines to decide which patients are fit for surgical repair and which are fit for simple observation. Surgery should be prescribed for obese patients because they seem to have a greater rate of complications if untreated.7 Moreover, in the absence of an accepted guideline, consolidated results from long-term observational study, or both, we recommend empirically operating on all symptomatic patients, including those with the bowel contained inside the hernia sac and, generally, those meeting the criteria for general hernia treatment. REFERENCES 1. Klinkosch JT. Programma Quo Divisionem Herniarum, Novumque Herniae Ventralis Specium Proponit. Rotterdam: Benam; 1764. 2. Dabbas N, Adams K, Pearson K, Royle GT. Frequency of abdominal wall hernias: is classical teaching out of date? JRSM Short Rep 2011;104:135. 3. Skandalakis PN, Zoras O, Skandalakis JE. Mirilas P Spigelian hernia: surgical anatomy, embryology, and technique of repair. Am Surg 2006;72:42-8.
Surgery March 2015
4. Larson DW, Farley DR. Spigelian hernias: repair and outcome for 81 patients. World J Surg 2002;26:1277-81. 5. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373-83. 6. Yau KK, Siu WT, Chan KL, Li KW. A man with recurrent lower abdominal pain: Spigelian hernia. Surg Laparosc Endosc Percutan Tech 2008;18:106-8. 7. Lau B, Kim H, Haigh PI, Tejiran T. Obesity increases the odds of acquiring and incarcerating noninguinal abdominal wall hernia. Am Surg 2012;78:1118-21. 8. Gough VM, Vella M. Timely computed tomography scan diagnoses Spigelian hernia: a case study. Ann R Coll Surg Engl 2009;91:W9-10. 9. Habib E, Elhadad A. Spigelian hernia long considered as diverticulitis: CT scan diagnosis and laparoscopic treatment. Computed tomography. Surg Endosc 2003; 17:159. 10. Malazgirt Z, Topgul K, Sokmen S, Ersin S, Turkcapar AG, Gok H, et al. Spigelian hernias: a prospective analysis of baseline parameters and surgical outcome of 34 consecutive patients. Hernia 2006;10:326-30. 11. Novell F, Sanchez G, Sentis J, Visa J, Novell J, Novell Costa F. Laparoscopic management of Spigelian hernia. Surg Endosc 2000;14:1189. 12. Patle NM, Tantia O, Sasmal PK, Khanna S, Sen B. Laparoscopic repair of Spigelian hernia: our experience. J Laparoendosc Adv Surg Tech A 2010;20:129-33. 13. Subramanya MS, Chakraborty J, Memon B, Memon MA. Emergency intraperitoneal onlay mesh repair of incarcerated Spigelian hernia. JSLS 2010;14:275-8. 14. Celdran A, Se~ naris J, Ma~ nas J, Frieyro O. The open mesh repair of Spigelian hernia. Am J Surg 2007;193:111-3. 15. Mittal T, Kumar V, Khullar R, Sharma A, Soni V, Baijal M, et al. Diagnosis and management of Spigelian hernia: a review of literature and our experience. J Minim Access Surg 2008;4:95-8. 16. Majeski J. Open and laparoscopic repair of Spigelian hernia. Int Surg 2009;94:365-9. 17. Vos DI, Scheltinga MR. Incidence and outcome of surgical repair of Spigelian hernia. Br J Surg 2004;91:640-4.
