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Laparoscopic diagnosis and repair of spigelian hernia: Report of a case and technique
Laparoscopic diagnosis and repair of spigelian hernia: Report of a case and technique James E. Carter, MD, PhD, and Craig Mizes, MD Mission Viejo, California Spig~lia~ hernia is an uncommon hernia of the abdominal wall. We report a case of acquired spigelian hernia .dlagno.sed and treated by laparoscopy. With more extensive use of laparoscopy to evaluate abdominal pain, the diagnosis of spigelian hernia can be made and repair accomplished without need for open exploratory surgery. (AM J OBSTET GVNECOL 1992;167:77-8.)
Key words: Spigelian hernia, laparoscopy, abdominal wall defect
Spigelian hernia is an uncommon defect of the abdominal wall. Bogojavlensky introduced laparoscopic treatment of inguinal and femoral hernias by preperitoneal patch repair at the 1989 meeting of the American Association of Gynecological Laparoscopists. In 1990 Popp' published a case of endoscopic patch repair in a female patient. We report the first case of spigelian hernia diagnosed and treated by laparoscopic techniques. Case report A 72-year-old woman was evaluated for a complaint of splitting lower abdominal pain of many years' duration, which had become progressively worse. She first noticed the pain about 6 months after abdominal hysterectomy performed in 1968 through a midline incision. In 1967 she had a tubal ligation through a minilaparotomy Pfannenstiel incision. Physical examination outlined an area of tenderness along the left side of the abdominal wall. No fascial defect was felt. A small umbilical hernia was noted, which the patient stated was there from birth. A computed tomographic scan revealed a liver abnormality for which a liver biopsy was recommended. Diagnostic approach. We performed laparoscopy to determine the source of the pain and to evaluate and perform a biopsy of the liver. The midclavicular line 2 em below the right lowest rib margin was chosen as the puncture site for the 5 mm diagnostic laparoscope. This provided access to the liver for biopsy and for a full view of the umbilical hernia and lower pelvis.
Fro,,!, the Department of Obstetrics and Gynecology, University of California Irvme, UCI Medical Center. Received for publication December 9, 1991; revised January 13, 1992; accepted January 23, 1992. Reprint requests: James E. Carter, MD, PhD, 26732 Crown Valley Parkway, Ste. 541, Mission Viejo, CA 92691.
611136680
The umbilical view revealed a 3 x 4 em umbilical hernia defect with no adhesions. The infraumbilical ~egion revealed a large omental adhesion herniating mto a 10 em defect in the semilunar line. The laparoscope was inserted into the gaping hernia. Palpation of the abdominal wall above the defect confirmed that the anterior abdominal wall was intact. Surgical approach. Laparoscopic repair of the spigelian hernia required port sites for instrument insertion, which allowed triangulation and laparoscopic suturing of the defect: the midclavicular line 3 em below the costal margin, 4 em above the umbilicus in the midline, and 5 em lateral to the umbilicus at that level. The herniated omental tissues were bluntly and sharply dissected from within the defect. Bleeding was controlled with bipolar coagulation at 40 W. Once the defect was free of its omental contents, the abdominal wall was carefully inspected. No defect of the wall itself was visualized. Repair of the hernia was then accomplished by laparoscopic placement of No. 1 Vicryl sutures on a CT 2 needle in an interrupted-figure-eight pattern. Ten sutures effected complete closure. Ties were accomplished with the extracorporeal knotting procedure of Semm2 with the Marlow knot pusher. The 45-degree, 5 mm Cook Ob/Gyn endoscopic needle driver (Kenh053130) facilitated suturing on the anterior abdominal wall. The umbilical hernia was closed in a similar fashion. Laparoscopic suturing on the anterior abdomen was facilitated by: (1) placement of suture and camera ports on the far contralateral side from the defect so the opposite anterior wall could be viewed and the needle delivered to the suturing site; (2) establishment and maintenance of 15 mm Hg pneumoperitoneum to assure a dome-shaped abdominal cavity; (3) external manipulation of the abdominal wall to bring both sides of the defect into full view; (4) use of the 45-degree-angle Cook needle driver to facilitate reverse acute-angle suturing; (5) suture lubrication to facilitate sliding each throw of the knot.
77
78
Carter and Mizes
Comment The hernia described by Andrian van der Spieghel (1578-1625) is one of the less common anterior abdominal wall hernias. The spigelian hernia occurs through congenital or acquired defects in the spigelian fascia of the transverse abdominis aponeurosis lying between the semilunar line and lateral edge of the rectus muscle. In 1764 Klinklosch named it Spieghel's linear hernia. Spangen detailed its anatomic aspects in 1976. In 1984 Spangen reviewed the published material on spigelian hernias and found that 744 patients had required surgery. No reports of laparoscopic repair have been made. Many reports of spigelian hernia emphasize the difficulty in making the diagnosis. The nonspecific symp-
July 1992 Am.J Obstet Gynecol
toms and intramural location are contributing factors. Although uncommon, spigelian hernias are a source of abdominal pain. Many require emergency surgery. Laparoscopic evaluation of abdominal pain can allow diagnosis before laparotomy. With the technique described here spigelian hernias can be repaired laparoscopically and open exploratory surgery can be avoided. REFERENCES 1. Popp LW. Endoscopic patch repair of inguinal hernia in a female patient. Surg Endosc 1990;4:10-2. 2. Semm K. Advances in pelviscopic surgery. Prog Clin Bioi Res 1982;112:127-49.
Key words: Spigelian hernia, laparoscopy, abdominal wall defect
Spigelian hernia is an uncommon defect of the abdominal wall. Bogojavlensky introduced laparoscopic treatment of inguinal and femoral hernias by preperitoneal patch repair at the 1989 meeting of the American Association of Gynecological Laparoscopists. In 1990 Popp' published a case of endoscopic patch repair in a female patient. We report the first case of spigelian hernia diagnosed and treated by laparoscopic techniques. Case report A 72-year-old woman was evaluated for a complaint of splitting lower abdominal pain of many years' duration, which had become progressively worse. She first noticed the pain about 6 months after abdominal hysterectomy performed in 1968 through a midline incision. In 1967 she had a tubal ligation through a minilaparotomy Pfannenstiel incision. Physical examination outlined an area of tenderness along the left side of the abdominal wall. No fascial defect was felt. A small umbilical hernia was noted, which the patient stated was there from birth. A computed tomographic scan revealed a liver abnormality for which a liver biopsy was recommended. Diagnostic approach. We performed laparoscopy to determine the source of the pain and to evaluate and perform a biopsy of the liver. The midclavicular line 2 em below the right lowest rib margin was chosen as the puncture site for the 5 mm diagnostic laparoscope. This provided access to the liver for biopsy and for a full view of the umbilical hernia and lower pelvis.
Fro,,!, the Department of Obstetrics and Gynecology, University of California Irvme, UCI Medical Center. Received for publication December 9, 1991; revised January 13, 1992; accepted January 23, 1992. Reprint requests: James E. Carter, MD, PhD, 26732 Crown Valley Parkway, Ste. 541, Mission Viejo, CA 92691.
611136680
The umbilical view revealed a 3 x 4 em umbilical hernia defect with no adhesions. The infraumbilical ~egion revealed a large omental adhesion herniating mto a 10 em defect in the semilunar line. The laparoscope was inserted into the gaping hernia. Palpation of the abdominal wall above the defect confirmed that the anterior abdominal wall was intact. Surgical approach. Laparoscopic repair of the spigelian hernia required port sites for instrument insertion, which allowed triangulation and laparoscopic suturing of the defect: the midclavicular line 3 em below the costal margin, 4 em above the umbilicus in the midline, and 5 em lateral to the umbilicus at that level. The herniated omental tissues were bluntly and sharply dissected from within the defect. Bleeding was controlled with bipolar coagulation at 40 W. Once the defect was free of its omental contents, the abdominal wall was carefully inspected. No defect of the wall itself was visualized. Repair of the hernia was then accomplished by laparoscopic placement of No. 1 Vicryl sutures on a CT 2 needle in an interrupted-figure-eight pattern. Ten sutures effected complete closure. Ties were accomplished with the extracorporeal knotting procedure of Semm2 with the Marlow knot pusher. The 45-degree, 5 mm Cook Ob/Gyn endoscopic needle driver (Kenh053130) facilitated suturing on the anterior abdominal wall. The umbilical hernia was closed in a similar fashion. Laparoscopic suturing on the anterior abdomen was facilitated by: (1) placement of suture and camera ports on the far contralateral side from the defect so the opposite anterior wall could be viewed and the needle delivered to the suturing site; (2) establishment and maintenance of 15 mm Hg pneumoperitoneum to assure a dome-shaped abdominal cavity; (3) external manipulation of the abdominal wall to bring both sides of the defect into full view; (4) use of the 45-degree-angle Cook needle driver to facilitate reverse acute-angle suturing; (5) suture lubrication to facilitate sliding each throw of the knot.
77
78
Carter and Mizes
Comment The hernia described by Andrian van der Spieghel (1578-1625) is one of the less common anterior abdominal wall hernias. The spigelian hernia occurs through congenital or acquired defects in the spigelian fascia of the transverse abdominis aponeurosis lying between the semilunar line and lateral edge of the rectus muscle. In 1764 Klinklosch named it Spieghel's linear hernia. Spangen detailed its anatomic aspects in 1976. In 1984 Spangen reviewed the published material on spigelian hernias and found that 744 patients had required surgery. No reports of laparoscopic repair have been made. Many reports of spigelian hernia emphasize the difficulty in making the diagnosis. The nonspecific symp-
July 1992 Am.J Obstet Gynecol
toms and intramural location are contributing factors. Although uncommon, spigelian hernias are a source of abdominal pain. Many require emergency surgery. Laparoscopic evaluation of abdominal pain can allow diagnosis before laparotomy. With the technique described here spigelian hernias can be repaired laparoscopically and open exploratory surgery can be avoided. REFERENCES 1. Popp LW. Endoscopic patch repair of inguinal hernia in a female patient. Surg Endosc 1990;4:10-2. 2. Semm K. Advances in pelviscopic surgery. Prog Clin Bioi Res 1982;112:127-49.