Strangulated sliding spigelian hernia: A case report

Abstract

Introduction: Spigelian hernia is uncommon and frequently presents with features of intestinal obstruction. Clinical diagnosis is difficult in patients without obvious abdominal mass and a computed tomography scan is very helpful in making diagnosis. We report a patient who presented with a strangulated sliding left sided spigelian hernia who was pre-operatively diagnosed and successfully managed surgically.

Presentation of case: A 56-year-old woman was to referred to the surgical emergency unit of our institution with abdominal swelling and pain of three days. There was no abdominal distension or fever and had no history of recurrent abdominal pains, abdominal swelling or surgery. Examination revealed a middle aged woman with a tender mass measuring about 10 cm by 8 cm in the left iliac fossa region of the abdomen. Bowel sounds were hyperactive and digital rectal examination revealed an empty rectum consistent with the diagnosis of acute intestinal obstructions. Investigations done by the patient at the referring hospital included a computed tomography (CT) scan which was suggestive of an obstructed Spigelian hernia with the sac containing a small bowel loop and mesentery. She had emergency herniorrhaphy and findings were herniation through a facial defect of about 5 cm by 4 cm along the lateral border of the rectus sheath with the hernia sac containing sero-sanguineous peritoneal fluid, gangrenous ileal segment and part of herniated urinary bladder forming the lower wall of the sac. Resection of gangrenous bowel with an end to end anastomosis was carried out, viable contents of the sac were reduced and defect repaired with interrupted non absorbable sutures to approximate the internal oblique and transversus abdominis to rectus sheath. In addition, nylon darning from inguinal ligament to the rectus sheath was also done. Her post-operative recovery was satisfactory and she remained well six months after surgery.

Conclusion: Pre-operative diagnosis of strangulated Spigelian hernia is difficult but can be aided by a CT. The use of nylon darning to re-inforce the repair can be rewarding where mesh cannot be used or unavailable.

Keywords: Nylon darn; Strangulated sliding spigelian hernia.

Fig. 1

Mass in the lower left abdomen.

Fig. 2

Ultrasound showing the mass appearing cystic.

Fig. 3

Computerized axial tomographic scan showing the hernia.

Fig. 4

Spigelian hernal sac.

Fig. 5

Strangulated segment of ileum.

Fig. 6

Viable bladder forming part of the wall of sac.

Fig. 7

Nylon darn.

Fig. 8

Closure of the external oblique aponeurosis.