- Email: [email protected]
Incidence of occult inguinal and spigelian hernias during laparoscopy of other reasons
Original communications Incidence of occult inguinal and spigelian hernias during laparoscopy of other reasons Hannu Paajanen, MD, PhD, Seppo Ojala, MD, and Antti Virkkunen, MD, Mikkeli, Finland
Background. A true incidence of occult inguinal and Spigelian hernias in adult population is unknown. The frequency of incipient hernias was studied during laparoscopy of other abdominal diseases. Methods. The 201 laparoscopic procedures included 104 cholecystectomies, 55 fundoplications, 36 diagnostic, and 6 miscellaneous operations. There were 133 females and 68 males with a mean age of 53 ⫾ 14 years. The orifices of all inguinal and Spigelian hernias were carefully recorded at the beginning of laparoscopy by using 30° optic. Results. The overall frequency of unexpected hernias was 43 of 201 (21%) including 36 (18%) inguinal hernias, 5 (2%) Spigelian hernias and 2 (1%) ventral hernias. The number of hernias was higher in males than in females (P ⫽ .003). The most common finding was indirect inguinal hernia in 27 (13%) subjects. Usually hernia orifices were insignificant and only 5 of 201 laparoscopic hernioplasties were undertaken without any complications. Conclusions. Occult hernia orifices are commonly found in laparoscopic operation. Usually the defects are asymptomatic and hernioplasty is not needed. Herniation of Spigelian fascia is rare (⬍2%) in adults during laparoscopy. (Surgery 2006;140:9-12.) From the Department of General and Gastrointestinal Surgery, The Central Hospital of Mikkeli, Finland
Symptomatic inguinal hernias are found in about 16% of adult men and hernioplasty is one of the top 3 operative procedures in most western countries. Approximately 12,000 inguinal herniorrhaphies are carried out each year in Finland, over 80,000 operations in England, and over 800,000 in the United States.1–3 The frequency of incipient inguinal or Spigelian hernias is unknown in asymptomatic adult population, but occult hernia orifices are common in herniography or ultrasound studies of patients with inguinal pain.4,5 For example, of the 80 patients with inguinodynia undergoing peritoneography, 36 (45%) were diagnosed radio-
Accepted for publication January 20, 2006. Reprint requests: Dr. Hannu Paajanen, MD, Associate Professor of Surgery, Department of Surgery, Mikkeli Central Hospital, Porrassalmenkatu 35-37, 50100 Mikkeli, Finland. E-mail: [email protected] 0039-6060/$ - see front matter © 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2006.01.005
graphically to have inguinal hernias that were not detectable clinically.4 A clinical Spigelian hernia is rare but probably underdiagnosed. It develops through a defect present between abdominal muscles in a paramedian region lying 0 to 6 cm cranially from anterior superior iliac spines through so-called Spigelian fascia.6 With the growing use of laparoscopy, Spigelian hernias are sometimes diagnosed incidentally at the time of other elective procedures.7 Laparoscopy yields detection of small inguinal or Spigelian hernias that would otherwise be undetected by clinical examination.8 Our study was done to find the incidence of small occult inguinal hernias and defects in the Spigelian fascia in adult population diagnosed during laparoscopy of other abdominal diseases. MATERIALS AND METHODS This was a prospective laparoscopic study of 201 consecutive adult patients. There were 133 females and 68 males with a mean age 53 ⫾ 14 years. The operations included 104 laparoscopic cholecystecSURGERY 9
10 Paajanen et al
Surgery July 2006
Table. Incidence (%) of occult inguinal and Spigelian hernias
Number of hernias Inguinal hernias Lateral Medial Combined Spigelian hernias Ventral hernias
All (n ⫽ 201)
Males (n ⫽ 68)
Females (n ⫽ 133)
43 (21) 36 (18) 27 (13) 6 (3) 3 (1) 5 (2) 2 (1)
24 (35)* 22 (32)* 15 (22)* 5 (7) * 2 (3) 1 (1) 1 (1)
19 (14) 14 (11) 12 (9) 1 (1) 1 (1) 4 (3) 1 (1)
*P ⬍ .05.
Fig 1. Laparoscopic view of the left-sided 0.5 ⫻ 0.5 cm defect (arrows) in the Spigelian fascia. A star denotes rectus abdominis muscle and below the muscle is lateral umbilical fold (white arrow). This small defect was not repaired during laparoscopy.
tomies, 55 fundoplications, 36 diagnostic, 5 laparoscopic appendectomies, and 1 insertion of peritoneal catheter using laparoscopic technique. A careful clinical examination of the groin region was carried out on everybody, all patients with clinical hernias were excluded. Laparoscopic exploration of the inguinal region was considered safe and did not greatly increase the operative time. All operations were carried out by 3 senior consultant surgeons in laparoscopic operation. The surgeons had carried out over 100 laparoscopic inguinal hernioplasties (TAPP, TEP). All patients were informed that hernial orifices would be explored during laparoscopy, and a written consent was asked before operation. Permission to repair large hernias (⬎1 cm) was also obtained before laparoscopy. The patient was placed in Trendelenburg position and laparoscopy was carried out with 30° Olympus Optic to observe in more detail the anatomy of inguinal and lower abdominal region. The orifices of inguinal hernias (indirect, direct, and femoral) as well as defects in Spigelian fascia were recorded systematically within the first 5 minutes of laparoscopic procedure. The occult hernia was determined as a hole or open sinus tract (patent processus vaginalis) in a typical region.6,9,10 A marked peritoneal dimple or invagination in the region was also recorded as a positive finding (Fig). There is no definite cut-off value in operative literature for what kind of fascial defects are potentially harmful to patients. We recorded even small dimples and minor fascial defects or asymmetrical
notches to be incipient hernia or weakness of fascia. A laparoscopic hernioplasty was carried out by using TAP technique only when the hernial orifice was over 1 cm. The peritoneum was opened above the internal ring. After a dissection, a pre-shaped 10 ⫻ 15 cm polypropylene mesh (Prolene, Ethicon, Somerville, NJ) was fixed under the peritoneum with 3 to 6 staples anteriorly into transversalis fascia (Protack Stapler, Tyco Healthcare, Norwalk, Conn). The mesh was then covered with peritoneum. A statistical significance of the frequency of hernias between males and females was compared using Fischer exact test. The P value of less than .05 was considered significant. RESULTS The occult inguinal hernias and defects in the Spigelian fascia were observed in 21% of laparoscopies (Table). No hernias could be identified before or after operation on physical examination. The mean age of patients with incipient hernias (55 years) did not differ from the age of adults with normal inguinal anatomy (53 years). Indirect inguinal hernias were the most common abnormality. The incipient inguinal hernias were found more often in males than in females (P ⬍ .05). The hernia orifice were usually so narrow that hernioplasties were unnecessary. In only 5 cases the hernia sac was assessed clinically significant and repair was carried out. Inguinal hernias were bilateral in 18 cases, right-sided in 12 cases, and left-sided in 6 cases. Occult Spigelian hernias were significantly more uncommon than inguinal hernias and found only in 2% of laparoscopies. Four females and one male had defects in the Spigelian fascia. In 3 cases the defect was a very small dimple or weakness in a typical place (Fig). In 2 cases laparoscopic repair
Paajanen et al 11
Surgery Volume 140, Number 1
was carried out, due to a larger size hernia than seen in the Figure. All laparoscopic hernioplasties were carried out without any complications or recurrences thus far. DISCUSSION Diagnostic laparoscopy of inguinal region carried out before other abdominal procedures offers an opportunity for surgeons to examine incipient hernial orifices without any significant complications. Laparoscopy is the only technique to observe directly the orifices of even minor inguinal hernias in the area of internal ring.10 A thorough understanding of the groin anatomy is critical to a successful laparoscopic evaluation of internal ring and linea semilunaris. Our study indicated that small asymptomatic inguinal hernias were quite common in adult population, where as defects in Spigelian fascia were uncommon. The only previous study with 100 laparoscopic examinations in asymptomatic patients reported that the incidence of inguinal hernia was 13%.8 Because laparoscopy is used widely now in the treatment of patients with inguinal hernias, new interest has developed in the anatomy of the posterior inguinal region.9 Because fear of bleeding complications, we did not open the peritoneum overlying the inguinal floor to explore preperitoneal lipomas.9 Neither did we explore the orifice of obturator hernia. Diagnostic laparoscopy is frequently used to evaluate unexplained acute and chronic inguinal pain. Occult inguinal hernias occur in 30% to 45% of patients with persistent groin pain and without any evidence of hernia in clinical examination.4,11 Occult contralateral asymptomatic hernia may be found in 25% of patients in laparoscopic hernia repair as well.12-15 The conventional method to diagnose incipient inguinal hernias is peritoneography (herniography), in which contrast medium is injected into peritoneal cavity. Ultrasound is also a useful adjunct in evaluating the groin for hernias.5 Our study showed that a large number of minor hernias could be identified if the peritoneum is carefully examined. We do not know, however, whether some of these hernias will be symptomatic in the future? Therefore we decided to repair hernias over 1 cm of size. This is not based on any scientific data, and we were unable to determine any cut-off values in the operative literature. One small randomized series of incidental defects found on laparoscopic repair of groin hernia supports the simultaneous repair of contralateral asymptomatic hernia. In their study, Thumbe and Evans found that 28% of asymptomatic groin hernias progressed
to a symptomatic in 15 months of follow-up.16 In 2 other nonrandomized studies, repair of contralateral asymptomatic inguinal hernia was suggested as well, to reduce overall costs to the health care system and to eliminate any further work loss for the patient.11,14 Laparoscopic identification of hernial orifices followed by a thorough follow-up for 10 years allows us to find out a natural history of incipient inguinal hernias. Spigelian hernia occurs through a defect in the transversus abdominis aponeurosis or Spigelian fascia. This hernia presents most commonly at the level of the semicircular line.17,18 The overlying external oblique muscle and fascia remain intact, making it easier to detect even minor Spigelian defects using laparoscopy than clinical examination (Fig). The absence of typical hernia-like symptoms and the lack of physician experience with such hernias can make early recognition difficult without laparoscopic evaluation. Spigelian hernia can also be diagnosed by imaging techniques such as ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI).17,18 Repair can be carried out by primary suture, mesh, or laparoscopic techniques.6 A true incidence of Spigelian hernia in normal population is presently unknown. Our study indicated for the first time that the prevalence of incipient hernias in Spigelian fascia is about 2% in adult asymptomatic population. Previous studies have reported only the treatment of symptomatic Spigelian hernia, ie, an intermittent palpable mass or postural pain.6 Operative repair is recommended because bowel obstruction may occur if the hernia sac is large enough. We found only 2 cases where hernioplasty was assessed necessary. Both hernias were repaired using laparoscopic technique.18 Orifices of occult inguinal hernia are found in every fifth adult person undergoing laparoscopic operation for other reasons. Defects in the region of Spigelian hernia are uncommon in adult population. A clinical significance of these findings is presently unknown, and the surgeon should note in the medical records the presence of defect. A longitudinal follow-up study is needed to determine if any of the occult hernias will become symptomatic. The authors wish to thank Mrs. Lisa Kivela for revision of English. REFERENCES 1. Heikkinen T-J. Costs and early outcome of laparoscopic and open operation in three common surgical conditions. Doctoral Thesis, University of Oulu, Finland, 1998. 2. Cheek CM, Black NA, Devlin HB. Groin hernia surgery: a
12 Rege
3.
4.
5. 6. 7. 8.
9. 10.
systematic review. Ann R Coll Surg Engl 1998;80(Suppl 1):S1-20. Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United States in 2003. Surg Clin NA 2003;83:1045-52. Heise CP, Sproat IA, Starling JR. Peritoneography (herniography) for detecting occult inguinal hernia in patients with inguinodynia. Ann Surg 2002;235:140-4. Lilly MC, Arregui ME. Ultrasound of the inguinal floor for evaluation of hernias. Surg Endosc 2002;16:659-62. Larson DW, Farley DR. Spigelian hernias: repair and outcome for 81 patients. World J Surg 2002;26:1277-81. DeMatteo RP, Morris JB, Broderick G. Incidental laparoscopic repair of a Spigelian hernia. Surgery 1994;115:521-2. Watson DS, Sharp KW, Vasquez JM, Richards WO. Incidence of inguinal hernias during laparoscopy. South Med J 1994;87:23-5. Avisse C, Delattre J-F, Flament J-B. The inguinal rings. Surg Clin NA 2000;80:49-69. Annibali R, Camps J, Nagan RF, et al. Anatomical considerations for laparoscopic inguinal herniorrhaphy. In: Arregui ME, Fitzgibbons RJ, Katkhouda N, editors. Principles of laparoscopic surgery: basic and advanced techniques. New York: Springer-Verlag; 1995. p. 409-25.
Surgery July 2006
11. Sayad P, Abdo Z, Cacchione R, Ferzli G. Incidence of incipient contralateral hernia during laparoscopic hernia repair. Surg Endosc 2000;14:543-5. 12. Koehler RH. Diagnosing the occult contralateral inguinal hernia. Surg Endosc 2002;16:512-20. 13. O’Rourke A, Zell JA, Varkey-Zell TT, et al. Laparoscopic diagnosis and repair of asymptomatic bilateral inguinal hernias. Am J Surg 2002;183:15-9. 14. Crawford DL, Hiatt JR, Phillips EH. Laparoscopy identifies unexpected groin hernias. Am Surg 1998;64:976-8. 15. Woodward AM, Choe EU, Flint LM, Ferrara JJ. The incidence of secondary hernias diagnosed during laparoscopic total extraperitoneal inguinal herniorrhaphy. J Laparoendosc Adv Surg Tech 1998;8:33-8. 16. Thumbe VK, Evans DS. To repair or not to repair incidental defects found on laparoscopic repair of groin hernia: early results of a randomized control trial. Surg Endosc 2001;15:47-9. 17. Vos DI, Scheltinga MR. Incidence and outcome of surgical repair of Spigelian hernia. Br J Surg 2004;91:640-4. 18. Moreno-Egea A, Carrasco L, Girela E, et al. Open vs laparoscopic repair of spigelian hernia: a prospective randomized trial. Arch Surg 2002;137:1266-8.
Invited commentary: Incidence of occult inguinal and spigelian hernias during laparoscopy for other reasons Robert V. Rege, MD, Dallas, Tex From the Southwestern Medical Center
Surgeons most often deal with a hernia when a patient presents with pain or discomfort, or with a “bulge” in the abdominal wall. Until recently, surgical dogma dictated that every hernia be repaired because of the risk of complications. This approach, however, has been questioned, leading to a large multi-institutional study sponsored by the
Accepted for publication February 18, 2006. Reprint requests: Robert V. Rege, MD, 5323 Harry Hines Blvd, Dallas, TX 75390-9031. E-mail: robert.rege@utsouthwestern. edu. Surgery 2006;140:12-3. 0039-6060/$ - see front matter © 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2006.02.015
American College of Surgeons comparing watchful waiting to prophylactic repair of asymptomatic inguinal hernias. Results of this study1 were published recently. Before this study, very little was actually known about the natural history of an asymptomatic hernia left untreated, although studies indicate that the incidence of incarceration is actually quite low.2 There is also very little evidence about factors associated with increase in the size of the hernia, development of symptoms, or progression to complications. Such questions now have even more significance with the development of high-resolution imaging and laparoscopy, which are capable of identifying even small incidental defects in the abdominal wall. Should all asymptomatic, incidental defects be repaired when found? What size of the defect
Background. A true incidence of occult inguinal and Spigelian hernias in adult population is unknown. The frequency of incipient hernias was studied during laparoscopy of other abdominal diseases. Methods. The 201 laparoscopic procedures included 104 cholecystectomies, 55 fundoplications, 36 diagnostic, and 6 miscellaneous operations. There were 133 females and 68 males with a mean age of 53 ⫾ 14 years. The orifices of all inguinal and Spigelian hernias were carefully recorded at the beginning of laparoscopy by using 30° optic. Results. The overall frequency of unexpected hernias was 43 of 201 (21%) including 36 (18%) inguinal hernias, 5 (2%) Spigelian hernias and 2 (1%) ventral hernias. The number of hernias was higher in males than in females (P ⫽ .003). The most common finding was indirect inguinal hernia in 27 (13%) subjects. Usually hernia orifices were insignificant and only 5 of 201 laparoscopic hernioplasties were undertaken without any complications. Conclusions. Occult hernia orifices are commonly found in laparoscopic operation. Usually the defects are asymptomatic and hernioplasty is not needed. Herniation of Spigelian fascia is rare (⬍2%) in adults during laparoscopy. (Surgery 2006;140:9-12.) From the Department of General and Gastrointestinal Surgery, The Central Hospital of Mikkeli, Finland
Symptomatic inguinal hernias are found in about 16% of adult men and hernioplasty is one of the top 3 operative procedures in most western countries. Approximately 12,000 inguinal herniorrhaphies are carried out each year in Finland, over 80,000 operations in England, and over 800,000 in the United States.1–3 The frequency of incipient inguinal or Spigelian hernias is unknown in asymptomatic adult population, but occult hernia orifices are common in herniography or ultrasound studies of patients with inguinal pain.4,5 For example, of the 80 patients with inguinodynia undergoing peritoneography, 36 (45%) were diagnosed radio-
Accepted for publication January 20, 2006. Reprint requests: Dr. Hannu Paajanen, MD, Associate Professor of Surgery, Department of Surgery, Mikkeli Central Hospital, Porrassalmenkatu 35-37, 50100 Mikkeli, Finland. E-mail: [email protected] 0039-6060/$ - see front matter © 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2006.01.005
graphically to have inguinal hernias that were not detectable clinically.4 A clinical Spigelian hernia is rare but probably underdiagnosed. It develops through a defect present between abdominal muscles in a paramedian region lying 0 to 6 cm cranially from anterior superior iliac spines through so-called Spigelian fascia.6 With the growing use of laparoscopy, Spigelian hernias are sometimes diagnosed incidentally at the time of other elective procedures.7 Laparoscopy yields detection of small inguinal or Spigelian hernias that would otherwise be undetected by clinical examination.8 Our study was done to find the incidence of small occult inguinal hernias and defects in the Spigelian fascia in adult population diagnosed during laparoscopy of other abdominal diseases. MATERIALS AND METHODS This was a prospective laparoscopic study of 201 consecutive adult patients. There were 133 females and 68 males with a mean age 53 ⫾ 14 years. The operations included 104 laparoscopic cholecystecSURGERY 9
10 Paajanen et al
Surgery July 2006
Table. Incidence (%) of occult inguinal and Spigelian hernias
Number of hernias Inguinal hernias Lateral Medial Combined Spigelian hernias Ventral hernias
All (n ⫽ 201)
Males (n ⫽ 68)
Females (n ⫽ 133)
43 (21) 36 (18) 27 (13) 6 (3) 3 (1) 5 (2) 2 (1)
24 (35)* 22 (32)* 15 (22)* 5 (7) * 2 (3) 1 (1) 1 (1)
19 (14) 14 (11) 12 (9) 1 (1) 1 (1) 4 (3) 1 (1)
*P ⬍ .05.
Fig 1. Laparoscopic view of the left-sided 0.5 ⫻ 0.5 cm defect (arrows) in the Spigelian fascia. A star denotes rectus abdominis muscle and below the muscle is lateral umbilical fold (white arrow). This small defect was not repaired during laparoscopy.
tomies, 55 fundoplications, 36 diagnostic, 5 laparoscopic appendectomies, and 1 insertion of peritoneal catheter using laparoscopic technique. A careful clinical examination of the groin region was carried out on everybody, all patients with clinical hernias were excluded. Laparoscopic exploration of the inguinal region was considered safe and did not greatly increase the operative time. All operations were carried out by 3 senior consultant surgeons in laparoscopic operation. The surgeons had carried out over 100 laparoscopic inguinal hernioplasties (TAPP, TEP). All patients were informed that hernial orifices would be explored during laparoscopy, and a written consent was asked before operation. Permission to repair large hernias (⬎1 cm) was also obtained before laparoscopy. The patient was placed in Trendelenburg position and laparoscopy was carried out with 30° Olympus Optic to observe in more detail the anatomy of inguinal and lower abdominal region. The orifices of inguinal hernias (indirect, direct, and femoral) as well as defects in Spigelian fascia were recorded systematically within the first 5 minutes of laparoscopic procedure. The occult hernia was determined as a hole or open sinus tract (patent processus vaginalis) in a typical region.6,9,10 A marked peritoneal dimple or invagination in the region was also recorded as a positive finding (Fig). There is no definite cut-off value in operative literature for what kind of fascial defects are potentially harmful to patients. We recorded even small dimples and minor fascial defects or asymmetrical
notches to be incipient hernia or weakness of fascia. A laparoscopic hernioplasty was carried out by using TAP technique only when the hernial orifice was over 1 cm. The peritoneum was opened above the internal ring. After a dissection, a pre-shaped 10 ⫻ 15 cm polypropylene mesh (Prolene, Ethicon, Somerville, NJ) was fixed under the peritoneum with 3 to 6 staples anteriorly into transversalis fascia (Protack Stapler, Tyco Healthcare, Norwalk, Conn). The mesh was then covered with peritoneum. A statistical significance of the frequency of hernias between males and females was compared using Fischer exact test. The P value of less than .05 was considered significant. RESULTS The occult inguinal hernias and defects in the Spigelian fascia were observed in 21% of laparoscopies (Table). No hernias could be identified before or after operation on physical examination. The mean age of patients with incipient hernias (55 years) did not differ from the age of adults with normal inguinal anatomy (53 years). Indirect inguinal hernias were the most common abnormality. The incipient inguinal hernias were found more often in males than in females (P ⬍ .05). The hernia orifice were usually so narrow that hernioplasties were unnecessary. In only 5 cases the hernia sac was assessed clinically significant and repair was carried out. Inguinal hernias were bilateral in 18 cases, right-sided in 12 cases, and left-sided in 6 cases. Occult Spigelian hernias were significantly more uncommon than inguinal hernias and found only in 2% of laparoscopies. Four females and one male had defects in the Spigelian fascia. In 3 cases the defect was a very small dimple or weakness in a typical place (Fig). In 2 cases laparoscopic repair
Paajanen et al 11
Surgery Volume 140, Number 1
was carried out, due to a larger size hernia than seen in the Figure. All laparoscopic hernioplasties were carried out without any complications or recurrences thus far. DISCUSSION Diagnostic laparoscopy of inguinal region carried out before other abdominal procedures offers an opportunity for surgeons to examine incipient hernial orifices without any significant complications. Laparoscopy is the only technique to observe directly the orifices of even minor inguinal hernias in the area of internal ring.10 A thorough understanding of the groin anatomy is critical to a successful laparoscopic evaluation of internal ring and linea semilunaris. Our study indicated that small asymptomatic inguinal hernias were quite common in adult population, where as defects in Spigelian fascia were uncommon. The only previous study with 100 laparoscopic examinations in asymptomatic patients reported that the incidence of inguinal hernia was 13%.8 Because laparoscopy is used widely now in the treatment of patients with inguinal hernias, new interest has developed in the anatomy of the posterior inguinal region.9 Because fear of bleeding complications, we did not open the peritoneum overlying the inguinal floor to explore preperitoneal lipomas.9 Neither did we explore the orifice of obturator hernia. Diagnostic laparoscopy is frequently used to evaluate unexplained acute and chronic inguinal pain. Occult inguinal hernias occur in 30% to 45% of patients with persistent groin pain and without any evidence of hernia in clinical examination.4,11 Occult contralateral asymptomatic hernia may be found in 25% of patients in laparoscopic hernia repair as well.12-15 The conventional method to diagnose incipient inguinal hernias is peritoneography (herniography), in which contrast medium is injected into peritoneal cavity. Ultrasound is also a useful adjunct in evaluating the groin for hernias.5 Our study showed that a large number of minor hernias could be identified if the peritoneum is carefully examined. We do not know, however, whether some of these hernias will be symptomatic in the future? Therefore we decided to repair hernias over 1 cm of size. This is not based on any scientific data, and we were unable to determine any cut-off values in the operative literature. One small randomized series of incidental defects found on laparoscopic repair of groin hernia supports the simultaneous repair of contralateral asymptomatic hernia. In their study, Thumbe and Evans found that 28% of asymptomatic groin hernias progressed
to a symptomatic in 15 months of follow-up.16 In 2 other nonrandomized studies, repair of contralateral asymptomatic inguinal hernia was suggested as well, to reduce overall costs to the health care system and to eliminate any further work loss for the patient.11,14 Laparoscopic identification of hernial orifices followed by a thorough follow-up for 10 years allows us to find out a natural history of incipient inguinal hernias. Spigelian hernia occurs through a defect in the transversus abdominis aponeurosis or Spigelian fascia. This hernia presents most commonly at the level of the semicircular line.17,18 The overlying external oblique muscle and fascia remain intact, making it easier to detect even minor Spigelian defects using laparoscopy than clinical examination (Fig). The absence of typical hernia-like symptoms and the lack of physician experience with such hernias can make early recognition difficult without laparoscopic evaluation. Spigelian hernia can also be diagnosed by imaging techniques such as ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI).17,18 Repair can be carried out by primary suture, mesh, or laparoscopic techniques.6 A true incidence of Spigelian hernia in normal population is presently unknown. Our study indicated for the first time that the prevalence of incipient hernias in Spigelian fascia is about 2% in adult asymptomatic population. Previous studies have reported only the treatment of symptomatic Spigelian hernia, ie, an intermittent palpable mass or postural pain.6 Operative repair is recommended because bowel obstruction may occur if the hernia sac is large enough. We found only 2 cases where hernioplasty was assessed necessary. Both hernias were repaired using laparoscopic technique.18 Orifices of occult inguinal hernia are found in every fifth adult person undergoing laparoscopic operation for other reasons. Defects in the region of Spigelian hernia are uncommon in adult population. A clinical significance of these findings is presently unknown, and the surgeon should note in the medical records the presence of defect. A longitudinal follow-up study is needed to determine if any of the occult hernias will become symptomatic. The authors wish to thank Mrs. Lisa Kivela for revision of English. REFERENCES 1. Heikkinen T-J. Costs and early outcome of laparoscopic and open operation in three common surgical conditions. Doctoral Thesis, University of Oulu, Finland, 1998. 2. Cheek CM, Black NA, Devlin HB. Groin hernia surgery: a
12 Rege
3.
4.
5. 6. 7. 8.
9. 10.
systematic review. Ann R Coll Surg Engl 1998;80(Suppl 1):S1-20. Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United States in 2003. Surg Clin NA 2003;83:1045-52. Heise CP, Sproat IA, Starling JR. Peritoneography (herniography) for detecting occult inguinal hernia in patients with inguinodynia. Ann Surg 2002;235:140-4. Lilly MC, Arregui ME. Ultrasound of the inguinal floor for evaluation of hernias. Surg Endosc 2002;16:659-62. Larson DW, Farley DR. Spigelian hernias: repair and outcome for 81 patients. World J Surg 2002;26:1277-81. DeMatteo RP, Morris JB, Broderick G. Incidental laparoscopic repair of a Spigelian hernia. Surgery 1994;115:521-2. Watson DS, Sharp KW, Vasquez JM, Richards WO. Incidence of inguinal hernias during laparoscopy. South Med J 1994;87:23-5. Avisse C, Delattre J-F, Flament J-B. The inguinal rings. Surg Clin NA 2000;80:49-69. Annibali R, Camps J, Nagan RF, et al. Anatomical considerations for laparoscopic inguinal herniorrhaphy. In: Arregui ME, Fitzgibbons RJ, Katkhouda N, editors. Principles of laparoscopic surgery: basic and advanced techniques. New York: Springer-Verlag; 1995. p. 409-25.
Surgery July 2006
11. Sayad P, Abdo Z, Cacchione R, Ferzli G. Incidence of incipient contralateral hernia during laparoscopic hernia repair. Surg Endosc 2000;14:543-5. 12. Koehler RH. Diagnosing the occult contralateral inguinal hernia. Surg Endosc 2002;16:512-20. 13. O’Rourke A, Zell JA, Varkey-Zell TT, et al. Laparoscopic diagnosis and repair of asymptomatic bilateral inguinal hernias. Am J Surg 2002;183:15-9. 14. Crawford DL, Hiatt JR, Phillips EH. Laparoscopy identifies unexpected groin hernias. Am Surg 1998;64:976-8. 15. Woodward AM, Choe EU, Flint LM, Ferrara JJ. The incidence of secondary hernias diagnosed during laparoscopic total extraperitoneal inguinal herniorrhaphy. J Laparoendosc Adv Surg Tech 1998;8:33-8. 16. Thumbe VK, Evans DS. To repair or not to repair incidental defects found on laparoscopic repair of groin hernia: early results of a randomized control trial. Surg Endosc 2001;15:47-9. 17. Vos DI, Scheltinga MR. Incidence and outcome of surgical repair of Spigelian hernia. Br J Surg 2004;91:640-4. 18. Moreno-Egea A, Carrasco L, Girela E, et al. Open vs laparoscopic repair of spigelian hernia: a prospective randomized trial. Arch Surg 2002;137:1266-8.
Invited commentary: Incidence of occult inguinal and spigelian hernias during laparoscopy for other reasons Robert V. Rege, MD, Dallas, Tex From the Southwestern Medical Center
Surgeons most often deal with a hernia when a patient presents with pain or discomfort, or with a “bulge” in the abdominal wall. Until recently, surgical dogma dictated that every hernia be repaired because of the risk of complications. This approach, however, has been questioned, leading to a large multi-institutional study sponsored by the
Accepted for publication February 18, 2006. Reprint requests: Robert V. Rege, MD, 5323 Harry Hines Blvd, Dallas, TX 75390-9031. E-mail: robert.rege@utsouthwestern. edu. Surgery 2006;140:12-3. 0039-6060/$ - see front matter © 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2006.02.015
American College of Surgeons comparing watchful waiting to prophylactic repair of asymptomatic inguinal hernias. Results of this study1 were published recently. Before this study, very little was actually known about the natural history of an asymptomatic hernia left untreated, although studies indicate that the incidence of incarceration is actually quite low.2 There is also very little evidence about factors associated with increase in the size of the hernia, development of symptoms, or progression to complications. Such questions now have even more significance with the development of high-resolution imaging and laparoscopy, which are capable of identifying even small incidental defects in the abdominal wall. Should all asymptomatic, incidental defects be repaired when found? What size of the defect