Spigelian hernia | |
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Other names | Lateral ventral hernia |
Transverse CT image of the abdomen in a patient with a Spigelian hernia (arrow). | |
Specialty | General surgery |
A Spigelian hernia is the type of ventral hernia that occurs through the Spigelian aponeurosis, which is the part of the aponeurosis of the transverse abdominal muscle bounded by the linea semilunaris (or Spigelian line) laterally and the lateral edge of the rectus abdominis muscle medially. [1] [2]
It is the protuberance of omentum, adipose tissue, or bowel in that weak space between the abdominal wall muscles, that ultimately pushes the intestines or superficial fatty tissue through a hole causing a defect. As a result, it creates the movement of an organ or a loop of intestine in the weakened body space that it is not supposed to be in. It is at this separation (aponeurosis) in the ventral abdominal region, that herniation most commonly occurs.
Spigelian hernias are rare compared to other types of hernias because they do not develop under abdominal layers of fat but between fascia tissue that connects to muscle. The Spigelian hernia is generally smaller in diameter, typically measuring 1–2 cm., and the risk of tissue becoming strangulated is high.
Individuals typically present with either intermittent pain, a lump or mass, all which are classic signs of a bowel obstruction. [3] The patient may have a protuberance when standing in an upright position although discomfort can sometimes be confused by its anatomical region for a peptic ulceration. [4] The bulge may be painful when the patient stretches but then goes away when they are lying down in a resting position. [5] However, a number of patients present with no obvious symptoms but vague tenderness along the area in which the Spigelian fascia is located. [6]
Ultrasound Imaging or a CT scan will provide better imaging for the detection of a hernia than an X-ray. [7] The ultrasound probe should move from lateral to medially, a hypoechoic mass should appear anteriorly and medially to the inferior epigastric artery during Valsalva maneuver. [8] The diagnosis of a Spigelian hernia is traditionally difficult if only given a history and physical examination. [9] People who are good candidates for elective Spigelian hernia surgery, after receiving an initial diagnostic consultation by a licensed medical professional, will be advised to see a physician to schedule surgery.
The Spigelian hernia can be repaired by either an open procedure or laparoscopic surgery because of the high risk of strangulation. [10] Surgery is straightforward, with only larger defects requiring a mesh prosthesis. In contrast to the laparoscopic intraperitoneal onlay mesh plan of action there is a significant higher risk associated with complications and recurrence rates during the period following a surgical operation. [11] A Spigelian hernia becomes immediately operative once the risk of incarceration is confirmed.[ citation needed ] Today, a Spigelian hernia can be repaired by doing robotic laparoscopy and most patients are discharged on the same day. This novel, uncomplicated approach to small Spigelian hernias combines the benefits of laparoscopic localization, reduction, and closure without the morbidity and cost associated with foreign material. [12] Mesh-free laparoscopic suture repair is an uncomplicated approach to small Spigelian hernias combined with the benefits of a closure without the anguish and cost associated with foreign material. [7] [13]
Adriaan van den Spiegel was an anatomist at the University of Padua during the 17th century. He became a professor of surgery in 1619 and was the first to describe this rare hernia in 1627. [14] The history of the Spigelian hernia was acknowledged in 1645, twenty years after Spiegel's death. In 1764, almost a century later, the Flemish anatomist, Josef Klinkosch, was acknowledged for recognizing and describing a hernia located in the Spigelian fascia, and coined the term Spigelian hernia. [15]
Raveenthiran described a new syndrome in which Spigelian hernia and cryptorchidism (undescended testis) occur together. [16] Some common complications of this distinct syndrome cryptorchidism are testicular torsion, and its link to testicular cancer. [17]
Laparoscopy is an operation performed in the abdomen or pelvis using small incisions with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.
A hernia is the abnormal exit of tissue or an organ, such as the bowel, through the wall of the cavity in which it normally resides. The term is also used for the normal development of the intestinal tract, referring to the retraction of the intestine from the extra-embryonal navel coelom into the abdomen in the healthy embryo at about 71⁄2 weeks.
An inguinal hernia or groin hernia is a hernia (protrusion) of abdominal cavity contents through the inguinal canal. Symptoms, which may include pain or discomfort especially with or following coughing, exercise, or bowel movements, are absent in about a third of patients. Symptoms often get worse throughout the day and improve when lying down. A bulging area may occur that becomes larger when bearing down. Inguinal hernias occur more often on the right than the left side. The main concern is strangulation, where the blood supply to part of the intestine is blocked. This usually produces severe pain and tenderness of the area.
Hernia repair is a surgical operation for the correction of a hernia—a bulging of internal organs or tissues through the wall that contains it. It can be of two different types: herniorrhaphy; or hernioplasty. This operation may be performed to correct hernias of the abdomen, groin, diaphragm, brain, or at the site of a previous operation. Hernia repair is often performed as an ambulatory procedure.
An umbilical hernia is a health condition where the abdominal wall behind the navel is damaged. It may cause the navel to bulge outwards—the bulge consisting of abdominal fat from the greater omentum or occasionally parts of the small intestine. The bulge can often be pressed back through the hole in the abdominal wall, and may "pop out" when coughing or otherwise acting to increase intra-abdominal pressure. Treatment is surgical, and surgery may be performed for cosmetic as well as health-related reasons.
Femoral hernias are hernias which occur just below the inguinal ligament, when abdominal contents pass through a naturally occurring weakness in the abdominal wall called the femoral canal. Femoral hernias are a relatively uncommon type, accounting for only 3% of all hernias. While femoral hernias can occur in both males and females, almost all develop in women due to the increased width of the female pelvis. Femoral hernias are more common in adults than in children. Those that do occur in children are more likely to be associated with a connective tissue disorder or with conditions that increase intra-abdominal pressure. Seventy percent of pediatric cases of femoral hernias occur in infants under the age of one.
An incisional hernia is a type of hernia caused by an incompletely-healed surgical wound. Since median incisions in the abdomen are frequent for abdominal exploratory surgery, ventral incisional hernias are often also classified as ventral hernias due to their location. Not all ventral hernias are from incisions, as some may be caused by other trauma or congenital problems.
The fascia of Scarpa is the deep membranous layer (stratum membranosum) of the superficial fascia of the abdomen. It is a layer of the anterior abdominal wall. It is found deep to the fascia of Camper and superficial to the external oblique muscle.
A bowel resection or enterectomy is a surgical procedure in which a part of an intestine (bowel) is removed, from either the small intestine or large intestine. Often the word enterectomy is reserved for the sense of small bowel resection, in distinction from colectomy, which covers the sense of large bowel resection. Bowel resection may be performed to treat gastrointestinal cancer, bowel ischemia, necrosis, or obstruction due to scar tissue, volvulus, and hernias. Some patients require ileostomy or colostomy after this procedure as alternative means of excretion. Complications of the procedure may include anastomotic leak or dehiscence, hernias, or adhesions causing partial or complete bowel obstruction. Depending on which part and how much of the intestines are removed, there may be digestive and metabolic challenges afterward, such as short bowel syndrome.
The arcuate line of rectus sheath is a line of demarcation corresponding to the free inferior margin of the posterior layer of the rectus sheath inferior to which only the anterior layer of the rectus sheath is present and the rectus abdominis muscle is therefore in direct contact with the transversalis fascia. The arcuate line is concave inferior-wards.
Post herniorrhaphy pain syndrome, or inguinodynia is pain or discomfort lasting greater than 3 months after surgery of inguinal hernia. Randomized trials of laparoscopic vs open inguinal hernia repair have demonstrated similar recurrence rates with the use of mesh and have identified that chronic groin pain (>10%) surpasses recurrence (<2%) and is an important measure of success.
The linea semilunaris is described by Adriaan van den Spiegel described the Linea Semilunaris as the line forming and marking the transition from muscle to aponeurosis in the transversus abdominis muscle of the abdomen. It needs to be distinguished from the lateral border of the rectus abdominis muscle sheath which is often wrongly described as semilunar line. The lateral border of the rectus sheath is part of the recently described EIT ambivium to more precisely describe this important part of the anterior abdominal wall. The EIT ambivium is formed by the Musculus Obliquus Externus (MOE), the Musculus Obliquus Internus (MOI) and the Musculus Transversus Abdominis (TA). Understanding the interrelationship between the lateral muscles and the medial compartment is of paramount importance for surgeons to understand the surgical anatomy.
Adriaan van den Spiegel, name sometimes written as Adrianus Spigelius, was a Flemish anatomist born in Brussels. For much of his career he practiced medicine in Padua, and is considered one of the great physicians associated with the city. At Padua he studied anatomy under Girolamo Fabrici.
Diastasis recti, or rectus abdominis diastasis, is an increased gap between the right and left rectus abdominis muscles. The increased distance between the muscles is created by the stretching of the linea alba, a connective collagen sheath created by the aponeurosis insertions of the transverse abdominis, internal oblique, and external oblique. This condition has no associated morbidity or mortality. Physical therapy is often required to repair this separation and surgery is an option for more severe cases. Standard exercise rarely results in complete healing of the separated muscles.
An obturator hernia is a rare type of hernia, encompassing 0.07-1% of all hernias, of the pelvic floor in which pelvic or abdominal contents protrudes through the obturator foramen. The obturator foramen is formed by a branch of the ischial as well as the pubic bone. The canal is typically 2-3 centimeters long and 1 centimeters wide, creating a space for pouches of pre-peritoneal fat.
Pyloromyotomy is a surgical procedure in which a portion of the muscle fibers of the pyloric muscle are cut. This is typically done in cases where the contents from the stomach are inappropriately stopped by the pyloric muscle, causing the stomach contents to build up in the stomach and unable to be appropriately digested. The procedure is typically performed in cases of "hypertrophic pyloric stenosis" in young children. In most cases, the procedure can be performed with either an open approach or a laparoscopic approach and the patients typically have good outcomes with minimal complications.
De Garengeot's hernia is a rare subtype of an incarcerated femoral hernia. This eponym may be used to describe the incarceration of the vermiform appendix within a femoral hernia. This mechanism is contrasted with the Amyand hernia, in which the appendix protrudes through an inguinal hernia.
A surgical incision is a cut made through the skin and soft tissue to facilitate an operation or procedure. Often, multiple incisions are possible for an operation. In general, a surgical incision is made as small and unobtrusive as possible to facilitate safe and timely operating conditions and recovery.
Inguinal hernia surgery is an operation to repair a weakness in the abdominal wall that abnormally allows abdominal contents to slip into a narrow tube called the inguinal canal in the groin region.
Surgical mesh is a medical implant made of loosely woven mesh, which is used in surgery as either a permanent or temporary structural support for organs and other tissues. Surgical mesh can be made from both inorganic and biological materials and is used in a variety of surgeries, although hernia repair is the most common application. It can also be used for reconstructive work, such as in pelvic organ prolapse or to repair physical defects created by extensive resections or traumatic tissue loss.