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Ovarian Spigelian hernia: A radiological diagnosis
Radiography 18 (2012) 137e139
Contents lists available at SciVerse ScienceDirect
Radiography journal homepage: www.elsevier.com/locate/radi
Case report
Ovarian Spigelian hernia: A radiological diagnosis Ciaran Scott Hill*, Balvinder Chahil, Benjamin Marlow Basildon and Thurrock University Hospitals NHS Foundation Trust, Nethermayne, Basildon, Essex SS16 5NL, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 June 2011 Received in revised form 4 August 2011 Accepted 23 August 2011 Available online 13 September 2011
We describe that case of a 54 year old lady with achondroplasia who presented with ongoing left sided abdominal pain. Ultrasound and abdominal computerized tomography images demonstrated an enlarged left ovary and Fallopian tube trapped between the rectus abdominus and the lateral semilunar line under cover of the external oblique aponeurosis. A left sided salpingoophrectomy with mesh herniorrhaphy was performed and histological analysis confirmed the hernia contents were a hydrosalpinx and normal ovary. This case report presents the unusual radiographic images and intraoperative photographs of an ovarian Speglian hernia. Ó 2011 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keyword: Hernia
Introduction A 54 year old lady presented to her general practitioner with a 3 month history of ongoing left sided abdominal pain that was aggravated with coughing or straining. Her bowel and bladder function was normal. Her past medical history was significant for achondroplasia. At the age of 35 years she had twins delivered by a standard lower uterine segment Caesarean section in an otherwise uncomplicated pregnancy. There was no history of pelvic inflammatory disease. Two years later she underwent a limited midline laparotomy with bowel resection for a strangulated abdominal hernia, this was felt to have arisen due to an iatrogenic surgical defect in the anterior abdominal wall. The recovery was uncomplicated and she was well until this presentation.
was related to her previous surgeries although cases of iatrogenic Spigelian hernias, particularly after laparoscopic procedures, have been described.1 In our patient a left sided salpingoophrectomy with mesh herniorrhaphy was performed and histological analysis confirmed a hydrosalpinx and a normal ovary with no cellular atypia.
Discussion This is a rare case of an adult with an ovary and its associated Fallopian tube passage as a Spigelian hernia. Notably, the patient also carried a diagnosis of achondroplasia. A Spigelian hernia is
Findings and management When initially examined it was possible to elicit point tenderness along the left semilunar line that was associated with a cough impulse. The patient was referred for an ultrasound scan of the abdomen (Fig. 1) and subsequently to a general surgery clinic. A follow up CT of the abdomen with contrast was performed (Figs. 2e5). Following radiological diagnosis the patient underwent exploratory laparoscopic surgery. Intra-operative findings were of an enlarged left ovary (40 mm 40 mm) and Fallopian tube trapped between the rectus abdominus and the lateral semilunar line (Fig. 6) under cover of the external oblique aponeurosis. This is the same potential anatomical space in which bowel can be found in a Spigelian hernia. There was no radiological evidence that this * Corresponding author. Tel.: þ44 7812714391. E-mail address: [email protected] (C. S. Hill).
Figure 1. An ultrasound scan showing an 8 2 cm fluid filled structure just deep to the peritoneum within the abdominal cavity in the left lower abdomen. No vascular flow was seen. No other masses or fluid collections are seen. It was later defined as an enlarged left ovary and hydrosalpinx.
1078-8174/$ e see front matter Ó 2011 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.radi.2011.08.004
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C.S. Hill et al. / Radiography 18 (2012) 137e139
Figure 4. A low axial CT slice of the abdomen demonstrating an enlarged left Fallopian tube leading towards a defect in the internal oblique wall.
Figure 2. A coronal CT scan demonstrating an 8.7 2.9 4 cm fluid filled structure between the left external oblique and internal oblique muscles, just above the iliac crest. This structure is continuous with the fallopian tube and the uterus via a wide 3.6 cm defect in the left anterior abdominal wall. A vessel is also seen from adjacent to the cyst draining into the left renal vein, indicating this to be ovarian vein.
a visceral herniation into a slit-like ventral defect along the semilunar line. This is the point where the aponeurosis of the lateral abdominal muscles fuse at their medial edges with the lateral edge of the rectus abdominis sheath. The hernia is named after Adriaan van der Spieghel who described the semilunar line in 1645. Herniation through this line was not actually recognised until 1764 when the eponymous Speglian hernia was named by Josef Klinkosch.2
Figure 5. A high axial CT slice of the abdomen demonstrating the defect in the left semilunar line and an enlarged left ovary trapped in the space between the internal oblique and the aponeurosis of the external oblique.
Spontaneous Spigelian hernias are rare, they constitute 1e2% of all hernias, they also tend to be small and therefore they carry a high risk of strangulation. As a result the accepted management is primary aponeurotic closure by anterior herniorraphy without
Figure 3. A sagittal CT slice of the abdomen demonstrating the left ovary and enlarged fallopian tube lateral to the internal oblique and covered by the external oblique aponeurosis. The inferior portion of the lesion appears to have septa, in theatre this was found to be due to folding of the enlarged Fallopian tube.
Figure 6. The left ovary and hydrosalpinx is demonstrated after intraoperative mobilisation. The superior aspect of the uterus is visible in the background.
C.S. Hill et al. / Radiography 18 (2012) 137e139
undue delay.3,4 This can be performed in a mesh-free fashion either open or laparoscopically.5e7 Spigleian hernias can be congenital or acquired, in this case it is difficult to anatomically link either the previous laparotomy or Caesarean section with the presence of this hernia. The contents of a Spegelian hernia is typically bowel but other contents have been described. There is a previous case report of an ovarian Spigelian hernia, however it was in a child less than 1 year old with no apparent genetic aberrations.8 A serous papillary carcinoma of the ovary has also been described as an unusual content of a Speglian hernia.9 In male infants there has been documentation of a relatively strong relationship between cryptororchadism and Spigelian hernias. In a significant proportion of many of these cases the testes are to be found in the hernia sac. There have been several attempts to describe this as a new clinical entity.10e12 There have been no similar suggestions to name the association of an ovarian Speglian hernia, this is presumably because its extreme rarity and lack of recognition. Of note, there is no known association of achondroplasia with Spiglian hernias. At 2 months post-operatively the patient remains well. Funding No funding/grants were received for this work.
139
References 1. Morrison C, Wemyss-Holden S, Iswariah H, Maddern GJ. Lateral laparoscopic port sites should all be closed. Surgical Endoscopy 2003;16(9):1364e8. 2. Skandalakis PN, Zoras O, Skandalakis JE, Mirilas P. Spigelian hernia: surgical anatomy, embryology, and technique of repair. The American Surgeon 2006;72(1):42e8. 3. Larson DW, Farley DR. Spigelian hernias: repair and outcome for 81 patients. World Journal of Surgery 2002;26(10):1277. 4. Vos D, Scheltinga M. Incidence and outcome of surgical repair of spigelian hernia. British Journal of Surgery 2004;91(5):640e4. 5. Bittner JG, Edwards MA, Shah MB, MacFadyen BV, Mellinger JD. Mesh-free laparoscopic Spigelian hernia repair. The American Surgeon 2008;74(8):713e20. 6. Celdr$n A, SeÒaris J, MaÒas J, Frieyro O. The open mesh repair of Spigelian hernia. The American Journal of Surgery 2007;193(1):111e3. 7. Patle NM, Tantia O, Sasmal PK, Khanna S, Sen B. Laparoscopic repair of Spigelian hernia: our experience. Journal of Laparoendoscopic & Advanced Surgical Techniques;20(2):129e133. 8. Walton J, Bass J. Spigelian hernias in infants: report of two cases. Canadian Journal of Surgery 1995;38(1):95. Journal canadien de chirurgie. 9. Allewaert S, De Man R, Bladt O, Roelens J. Spigelian hernia with unusual content. Abdominal Imaging 2005;30(6):677e8. 10. Rushfeldt C, Oltmanns G, Vonen B. Spigelian-cryptorchidism syndrome: a case report and discussion of the basic elements in a possibly new congenital syndrome. Pediatric Surgery International 2010;26(9):939e42. Pediatric surgery international:1e4. 11. Al-Salem AH. Congenital spigelian hernia and cryptorchidism: cause or coincidence? Pediatric Surgery International 2000;16(5):433e6. 12. Durham MM, Ricketts RR. Congenital spigelian hernias and cryptorchidism. Journal of Pediatric Surgery 2006;41(11):1814e7.
Contents lists available at SciVerse ScienceDirect
Radiography journal homepage: www.elsevier.com/locate/radi
Case report
Ovarian Spigelian hernia: A radiological diagnosis Ciaran Scott Hill*, Balvinder Chahil, Benjamin Marlow Basildon and Thurrock University Hospitals NHS Foundation Trust, Nethermayne, Basildon, Essex SS16 5NL, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 June 2011 Received in revised form 4 August 2011 Accepted 23 August 2011 Available online 13 September 2011
We describe that case of a 54 year old lady with achondroplasia who presented with ongoing left sided abdominal pain. Ultrasound and abdominal computerized tomography images demonstrated an enlarged left ovary and Fallopian tube trapped between the rectus abdominus and the lateral semilunar line under cover of the external oblique aponeurosis. A left sided salpingoophrectomy with mesh herniorrhaphy was performed and histological analysis confirmed the hernia contents were a hydrosalpinx and normal ovary. This case report presents the unusual radiographic images and intraoperative photographs of an ovarian Speglian hernia. Ó 2011 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keyword: Hernia
Introduction A 54 year old lady presented to her general practitioner with a 3 month history of ongoing left sided abdominal pain that was aggravated with coughing or straining. Her bowel and bladder function was normal. Her past medical history was significant for achondroplasia. At the age of 35 years she had twins delivered by a standard lower uterine segment Caesarean section in an otherwise uncomplicated pregnancy. There was no history of pelvic inflammatory disease. Two years later she underwent a limited midline laparotomy with bowel resection for a strangulated abdominal hernia, this was felt to have arisen due to an iatrogenic surgical defect in the anterior abdominal wall. The recovery was uncomplicated and she was well until this presentation.
was related to her previous surgeries although cases of iatrogenic Spigelian hernias, particularly after laparoscopic procedures, have been described.1 In our patient a left sided salpingoophrectomy with mesh herniorrhaphy was performed and histological analysis confirmed a hydrosalpinx and a normal ovary with no cellular atypia.
Discussion This is a rare case of an adult with an ovary and its associated Fallopian tube passage as a Spigelian hernia. Notably, the patient also carried a diagnosis of achondroplasia. A Spigelian hernia is
Findings and management When initially examined it was possible to elicit point tenderness along the left semilunar line that was associated with a cough impulse. The patient was referred for an ultrasound scan of the abdomen (Fig. 1) and subsequently to a general surgery clinic. A follow up CT of the abdomen with contrast was performed (Figs. 2e5). Following radiological diagnosis the patient underwent exploratory laparoscopic surgery. Intra-operative findings were of an enlarged left ovary (40 mm 40 mm) and Fallopian tube trapped between the rectus abdominus and the lateral semilunar line (Fig. 6) under cover of the external oblique aponeurosis. This is the same potential anatomical space in which bowel can be found in a Spigelian hernia. There was no radiological evidence that this * Corresponding author. Tel.: þ44 7812714391. E-mail address: [email protected] (C. S. Hill).
Figure 1. An ultrasound scan showing an 8 2 cm fluid filled structure just deep to the peritoneum within the abdominal cavity in the left lower abdomen. No vascular flow was seen. No other masses or fluid collections are seen. It was later defined as an enlarged left ovary and hydrosalpinx.
1078-8174/$ e see front matter Ó 2011 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.radi.2011.08.004
138
C.S. Hill et al. / Radiography 18 (2012) 137e139
Figure 4. A low axial CT slice of the abdomen demonstrating an enlarged left Fallopian tube leading towards a defect in the internal oblique wall.
Figure 2. A coronal CT scan demonstrating an 8.7 2.9 4 cm fluid filled structure between the left external oblique and internal oblique muscles, just above the iliac crest. This structure is continuous with the fallopian tube and the uterus via a wide 3.6 cm defect in the left anterior abdominal wall. A vessel is also seen from adjacent to the cyst draining into the left renal vein, indicating this to be ovarian vein.
a visceral herniation into a slit-like ventral defect along the semilunar line. This is the point where the aponeurosis of the lateral abdominal muscles fuse at their medial edges with the lateral edge of the rectus abdominis sheath. The hernia is named after Adriaan van der Spieghel who described the semilunar line in 1645. Herniation through this line was not actually recognised until 1764 when the eponymous Speglian hernia was named by Josef Klinkosch.2
Figure 5. A high axial CT slice of the abdomen demonstrating the defect in the left semilunar line and an enlarged left ovary trapped in the space between the internal oblique and the aponeurosis of the external oblique.
Spontaneous Spigelian hernias are rare, they constitute 1e2% of all hernias, they also tend to be small and therefore they carry a high risk of strangulation. As a result the accepted management is primary aponeurotic closure by anterior herniorraphy without
Figure 3. A sagittal CT slice of the abdomen demonstrating the left ovary and enlarged fallopian tube lateral to the internal oblique and covered by the external oblique aponeurosis. The inferior portion of the lesion appears to have septa, in theatre this was found to be due to folding of the enlarged Fallopian tube.
Figure 6. The left ovary and hydrosalpinx is demonstrated after intraoperative mobilisation. The superior aspect of the uterus is visible in the background.
C.S. Hill et al. / Radiography 18 (2012) 137e139
undue delay.3,4 This can be performed in a mesh-free fashion either open or laparoscopically.5e7 Spigleian hernias can be congenital or acquired, in this case it is difficult to anatomically link either the previous laparotomy or Caesarean section with the presence of this hernia. The contents of a Spegelian hernia is typically bowel but other contents have been described. There is a previous case report of an ovarian Spigelian hernia, however it was in a child less than 1 year old with no apparent genetic aberrations.8 A serous papillary carcinoma of the ovary has also been described as an unusual content of a Speglian hernia.9 In male infants there has been documentation of a relatively strong relationship between cryptororchadism and Spigelian hernias. In a significant proportion of many of these cases the testes are to be found in the hernia sac. There have been several attempts to describe this as a new clinical entity.10e12 There have been no similar suggestions to name the association of an ovarian Speglian hernia, this is presumably because its extreme rarity and lack of recognition. Of note, there is no known association of achondroplasia with Spiglian hernias. At 2 months post-operatively the patient remains well. Funding No funding/grants were received for this work.
139
References 1. Morrison C, Wemyss-Holden S, Iswariah H, Maddern GJ. Lateral laparoscopic port sites should all be closed. Surgical Endoscopy 2003;16(9):1364e8. 2. Skandalakis PN, Zoras O, Skandalakis JE, Mirilas P. Spigelian hernia: surgical anatomy, embryology, and technique of repair. The American Surgeon 2006;72(1):42e8. 3. Larson DW, Farley DR. Spigelian hernias: repair and outcome for 81 patients. World Journal of Surgery 2002;26(10):1277. 4. Vos D, Scheltinga M. Incidence and outcome of surgical repair of spigelian hernia. British Journal of Surgery 2004;91(5):640e4. 5. Bittner JG, Edwards MA, Shah MB, MacFadyen BV, Mellinger JD. Mesh-free laparoscopic Spigelian hernia repair. The American Surgeon 2008;74(8):713e20. 6. Celdr$n A, SeÒaris J, MaÒas J, Frieyro O. The open mesh repair of Spigelian hernia. The American Journal of Surgery 2007;193(1):111e3. 7. Patle NM, Tantia O, Sasmal PK, Khanna S, Sen B. Laparoscopic repair of Spigelian hernia: our experience. Journal of Laparoendoscopic & Advanced Surgical Techniques;20(2):129e133. 8. Walton J, Bass J. Spigelian hernias in infants: report of two cases. Canadian Journal of Surgery 1995;38(1):95. Journal canadien de chirurgie. 9. Allewaert S, De Man R, Bladt O, Roelens J. Spigelian hernia with unusual content. Abdominal Imaging 2005;30(6):677e8. 10. Rushfeldt C, Oltmanns G, Vonen B. Spigelian-cryptorchidism syndrome: a case report and discussion of the basic elements in a possibly new congenital syndrome. Pediatric Surgery International 2010;26(9):939e42. Pediatric surgery international:1e4. 11. Al-Salem AH. Congenital spigelian hernia and cryptorchidism: cause or coincidence? Pediatric Surgery International 2000;16(5):433e6. 12. Durham MM, Ricketts RR. Congenital spigelian hernias and cryptorchidism. Journal of Pediatric Surgery 2006;41(11):1814e7.