Spigelian hernia: Rare or obscure?

Spigelian Hernia: Rare or Obscure? RICHARD

0.

OLSON, M.D. AND W.

CLAYTON DAVIS,

From the Department of Surgery, University of Nebraska College of Medicine, and the Surgical Service, Veterans Administration Hospital, Omaha, Nebraska 68105.

M.D., Omaha,

Nebrnskn

Physical examination showed only right lower abdominal tenderness. The patient was admitted for observation for possible acute appendicitis. When the abdominal findings did not progress, gastrointestinal roentgenograms and an intravenous pyelogram were taken; these showed nothing abnormal. On two occasions a mass 2 cm. in diameter presented in the right lower quadrant of the abdomen along the semilunar line. At operation a 2 cm. defect was found and repaired. The patient is free of symptoms with no recurrence after one year.

ITHIN the last two years six patients have come to the University of Nebraska Hospitals with Spigelian hernias. This hernia of the semilunar line was described by La Chausse [L] in 1746. It is considered an uncommon spontaneous hernia of the abdominal wall [Z-P]. Only about two hundred cases have been reported in the world medical literature [5-71. Most of these come from foreign countries w

CASE IV. The patient, a seventy-six year old man, was hospitalized complaining of a tender mass along the right rectus muscle. He noted he had lost several pounds in recent weeks but reported good health otherwise. The abdomen was soft, flat, and nontender with a suggestion of a defect along the right rectus muscle. Barium enema examination and proctosigmoidoscopy showed nothing abnormal At operation a 1.5 cm. defect along the semilunar line at the level of the umbilicus was found. The patient died during a complicated postoperative period. Postmortem examination showed extensive carcinoma of the extrahepatic bile ducts with generalized metastases.

[3,81. CASE REPORTS CASE I. The patient, a seventy-six year old man, was admitted to the hospital for psychiatric evaluation It was impossible to obtain an adequate history because of chronic schizophrenia. A review of his records showed that he had had four previous operations for repair of inguinal hernia. In 1963 he had a repair of a large left sided Spigelian hernia. On examination, he had a 7 by ‘I cm. recurrent left Spigelian hernia. This large hernia was repaired and has not recurred in the following two years.

CASE v. The patient, a forty-eight year old man, was hospitalized with a two week history of a productive cough. He reported a weight loss of thirty pounds in the preceding six months. Roentgenograms of the chest showed cavitary pulmonary lesions which proved to be tuberculous. Six months later, as the patient began to gain weight, he noted a bulge in his left lower abdomen which was painful on coughing. A 2 cm. mass was palpated along the left rectus border. Barium enema examination and proctosigmoidoscopy showed no abnormalities. At operation a 2 by 3 cm defect was repaired. There has been no evidence of recurrence in the first postoperative year.

CASE II. The patient, a forty-four year old woman, was hospitalized because of abdominal pain in the right lower quadrant for two weeks; this pain began after the patient lifted a washing machine. She had seen several physicians and had an extensive evaluation before the diagnosis was made. Physical examination showed scars from a previous appendectomy and an abdominal hysterectomy. There was tenderness along the lateral margin of the right rectus muscle. Finally the defect of a Spigelian hernia was found at the lateral border of the right rectus muscle below the umbilicus. At operation a 1.5 cm. defect was found and repaired. There is no recurrence after two years,

CASE VI. The patient, a seventy-one year old man, was admitted to the hospital for evaluation of chronic bronchitis and congestive heart failure. On physical examination a 3 cm. mass was noted in the left rectus muscle border below the level of the umbilicus. Roentgenographic evaluation included upper and lower gastrointestinal and gallbladder

CASE III. The patient, a thirty-four year old man, entered the hospital with complaints of abdominal pain in the right lower quadrant for two months. 842

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sxies, all of which revealed no abnormalities. After improvement in the patient’s general condition, a 1.5 cm. dciect was repaired. Ko recurrence has been noted tlrlring the four months since this operation.

Thi\ hernia is interestingly named after a man who never described it. Adriaan van der Spieghel (,.1dri~~us .S@gulius) (Fig. 1) was a Flemish anatomist who lived from 15’78 to lfi25. He was professor of anatomy at Padua 17,9]. the Italian university where Bassini was later to develop operations for inguinal hernias [lo]. Spieghel was the first to describe the semilunar lme now named for him. La Chausse in 1’7% was the first to divide ventral hernias into separate groups which included this hernia of the semilunar line. However, he believed that this type was of traumatic origin [8]. It was Klinklosch in 1’763 who recognized the spontaneous nature of these hernias and gave them their name “Spigel linea herniae” [II]. It is interesting to note that as of 1942 only four instances were reported in the American literature [3] and that since then less than one hundred cases have been added whereas the total in the world literature has risen to more than 200 17,121. INCIDENCE

Although the earliest authors thought that this hernia was more common in women [8], the sex incidence is now considered to be equal [4,6]. There is apparently no predilection as to the side of abdomen involved. The hernia has been reported in all ages [8,13]. In our series there were five male patients and one female patient. Their ages ranged from thirty-four to seventy-six years, and the hernias were evenly divided, three occurring on each side. ANATOMY

The anatomy of this hernia is of special interest. It occurs along the semilunar line of Spieghel. This line runs from the costal cartilage of the ninth rib to the pubic tubercle. It lies along the lateral edge of the rectus muscle where the aponeuroses of the abdominal wall muscles join to form the anterior and posterior sheaths [14]. The majority of these hernias occur in the lower third of this line in close proximity to the semicircular line [3,15,16]. It is here that the transversus abdominis muscle

FIG. 1. Adriaan van tier Spiexhcl / 1.57Xlfil’s3). Flemish anatomist who taught at I’adua. iReproduced with the publisher’s permission from Dorland’s Illustrated Medi16th etl. l’l~ilatlelpliia, I<932. W. R. cal Dictionary, Saunders Co. I

joins the anterior rather than the posterior sheath [I4]. Spigelian hernias have been reported above the level of the umbilicus [25,17]. These locations may be explained by the variable position of the semicircular line [14]. One of the hernias in our series was located at the level of the umbilicus (case TV). Spigelian hernias pass through the fibers of the transversus and internal oblique muscles. The hernia lies beneath the intact external oblique aponeurosis. It frequently spreads out beneath this layer and may seem to lie lateral to the semilunar line. These are the features which make it difficult to diagnose [4,1X ~201. This hernia is usually described as having a narrow neck and often presents with incarceration [9,16,21,22]. The sac may contain small intestine, colon, or omentum [3,6,23]. Sliding hernias have been described [3,1!~]. Some incarcerated hernias are of the Richter type 1221. In five of our patients the hernia lay at the semicircular line. Three were found to have a distinct upper margin, but the lower border was broad and ill defined. The remainder had distinct margins. ETIOLOGY

The etiology of Spigelian hernia has been discussed at some length in the literature. Sir Ashley Cooper [16,21] first attempted to delineate the anatomic deficiency leading to

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FIG. 2. CASE v. Location

of the hemia

this hernia. He believed that the space created by the nemovascular bundles in the internal oblique and transversus muscles was the sole cause. Since the reports of Anson and McVay [IF] and Zimmerman et al. [24], who have performed extensive cadaver dissections, authors have believed that the separation of the muscle fibers by fat-infiltrated septa in the internal oblique and transversus muscle was a major factor. Others [25] have noted that the internal oblique and transversus muscles, which are at angles in the upper part of the abdomen, are parallel in the region of the hernia. A final possible etiologic factor could be previous lower abdominal incisions. This has not been suggested previously. One of our patients had previous midline suprapubic and right lower quadrant gridiron incision and presented with a right Spigelian hernia. Another patient had had five previous operations for inguinal hernias. DIAGNOSIS

Because the hernia stays beneath the intact external oblique aponeurosis, it is difficult to palpate. It is this feature which leads to errors in diagnosis [7,20,26]. The hernia may imitate gallbladder disease, acute appendicitis, or intermittent small bowel obstruction. Many patients with symptoms due to Spigelian hernias have undergone multiple diagnostic studies and needless operations. Others are thought to have functional complaints [7,26]. Intermittent abdominal pain with point tenderness or a mass along the rectus border suggests the diagnosis. It may be necessary to have the patient strain or lift in order to demonstrate the hernia. Roentgenographic studies may also be helpful. Barium enema

examination has been diagnostic in several instances [5,6,23]. Two of our patients were studied extensively before the diagnosis was established. There are conditions which seem to predispose to the hernia. They occur more frequently in patients who have reasons for increased intra-abdominal pressure [9,16], heavy laborers and persons with the various pulmonary, urologic, and gastrointestnal outlet obstructions. They are also common in multiparous women [26] and patients who have recently lost a significant amount of weight [4,5]. Our patients demonstrate most of these factors. We wish to emphasize, however, that the two patients with a history of weight loss also had serious underlying systemic diseases, tuberculosis and intra-abdominal malignancy. We [27,28] have previously reported that inguinal hernias may be the presenting symptom of more serious systemic diseases. We would strongly recommend that pulmonary, urologic, and gastrointestinal evaluations be considered in patients with Spigelian hernias. OPERATION It has been said that repair of these hernias is simple, results are excellent, and recurrence is unknown [5,7,24]. One of our six patients had recurrence of a Spigelian hernia. We believe this to be the first reported instance. In the repair the incision is made transversely over the suspected defect. (Fig. 2.) The external oblique muscle is then divided in the direction of its fibers. The sac is usually encountered at this point, presenting through the internal oblique and transversus muscles. (Fig. 3.) The sac frequently is covered by a layer of properitoneal fat [9,24]. The sac is composed of peritoneum presenting under attenuated transversalis fascia [3]. It has been stated that the classic direct inguinal hernia is probably a special form of Spigelian hernia presenting medial to the inferior epigastric vessels [18,29]. We believe that the repair of Spigelian hernia requires repair of the transversalis fascia. (Fig. 4.) Other repairs have been used for these defects including fascial flaps [9] and Mayo type repairs [24]. COMMENTS

The title of this paper asks the question: “Spigelian hernia-rare or obscure?” Since finding six patients with this diagnosis in a two year The American

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prrio(l. KC believe these hernias may well be more obscure than rare. We urge that this diagnosis should be considered when a patient In-ese.nth \vith a mass or intermittent pain or tenderness in the lower part of the abdomen. It is of added significance if there is a history of \veight loss or heavy straining. The importance of considering this diagnosis is emphasized when we realize that many of these patients are thought to have functional disease and later present with incarceration, strangulation, and intestinal obstruction. Hopefully these complications can be avoided. We must rule out organic diseases to the best of our ability. Too often the patient proves that our original impressions are wrong. IVc would also suggest that careful thought bc given to abolish eponyms as much as possible, especially when they are misleading or incorrect. Several other names have been propo& for this hernia including spontaneous lateral ventral hernia of the linea semilunaris which admittedly is cumbersome but more accurately describes the condition. We wish to emphasize that Spieghel never described the hernia. We would not suggest, however, that it be called La Chausse hernia.

Spi:gelian hernia5 mdtcate that tnan_v factor\ may predispose to this obscure hernia. As stated by O-Aer, “;1 physician cannot make a diagnosis. unless he first thinks of the disease.” Let us hoDe that this hernia will be discovered on more occasions than is presentiy reported REFERENCES

1. LA CHAI’SSE, B. 1. ChirUrg. de I~crilia \.cntrdl. Halleri Diswt. Chir. Selecta. totu Iii. 1Xi. 2. I;OOSIZ .I. R-. Hernia in the linea srrniluwris. :lnn. .%ug.. 1:35:875, 1952.

3. RIVER. L. I’. Spig-elian hernia, spontalwous lateral ventral hernia through the scmiluuar lirle. 1171ff. surg., 116: 105, 191”. 4. 5. ti. i. 8. 9.

10. 11. 1”.

SUMMARY

Six patients with spontaneous lateral ventral hernias of the linea semilunaris who presented during a two year period are reported. Symptoms of point tenderness, or a mass and a history of straining, weight loss, or multiparity should suggest this hernia. Two patients with 1.01.llii. I)ecembr,’ 1068

13. 14. 15 16

REAI), R. Observations on the etiology of spigclian hernia. &17zn.Szcrg., 1.52: 100~. 19fiO. HODES, 1’. J. aud PLISKIN. M. Spiselian hernia. PEnlzS?‘I*LIuYI?‘u Ucd., 71: 31. l%i8. Nv~us, L. M. and HARKIXS, H. N. Hernias, p. 3.50. Philadelphia. 1964. J. B. Lippincott Co HALLOIVAY. J. I;. Spontaneous latrrai ventral hernia. .-inn. S~rg.. i5: fi77. 192. BAII~EV. D. Spigeliau hernia, report of five cases and review of the literature. Hr,‘l. .I. .Curg.. 44: 50“. 1957. RAVITCH,M. M. aud HITZRW, J. M. Operations for in&la1 hernia. Surgery, 48: 139. 1960. KLINKL~~CH, J. T. Cited iu Halloway, 1. I(. [8]. HARLESS. M. S. and HIRSUI, J. E. Sdigelian or spontaneous lateral ventral hernia. _4w1. J. Surg., 100: 515. 1960. HURWIT’T.E. S. and BORRO\V,M. Bilateral spigelian hernias in childhood. Surgwp, 37: 963, 1955. MCKAY. C. B. and _%NSON.B. J. The composition of the rectus sheath. Annl. Kec-.. 77: 218, 1940. MILLER, T. J. and LABREE. R. H. Lateral ventral or Spigelian hernia. Ifinn. Xed., -G: 344, 1960. COOPER. .I. I’. The .Inatomy and Surgical Treat-

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Olson and Davis ment of Abdominal Hernia, p, 300. Philadelphia, 1844. Lea and Blanchard. WAKELY, C. and CHILDS, P. Spigelian hernia. Lancet, 1: 1290, 1951. SHACKLEFORD,R. Surgery of the Alimentary Tract, p. 2195. Philadelphia, 1955. W. B. Saunders Co. STRODE, J. E. Spigelian hernia. 5’. Clin. North America, 43: 1379, 1963. LARSON, E. E. Spigelian hernia. Am. J. Surg., 82: 103, 1951. COOPER, A. P. Lectures on Principles and Practice of Surgery, vol. III, p. 89. Boston, 1828. Simkin and Marshal. LEIS, H. P., MERSHEIMER, W. L., and WINFIELD, J. M. Spontaneous lateral ventral hernia. Surgery, 43 : 328, 1958. STRAUS, F. H. and ALEXANDER, M. J. Diagnostic sign of interstitial hernia of the linea semilunaris. Illinois M. J., 103: 353, 1953.

24. ZIMMERMAN,L. M., ANSON, B. J., MORGAN, E. H., and MCVAY, C. B. Ventral hernia due to normal banding of the abdominal muscles. Surg. Gynec. 6” Obst., 78: 535, 1944. 25. MERSHEIMER, W. L., WINFIELD, J. M., and RucGERO, W. F. Spontaneous lateral ventral hernia. Arch. Sup., 63: 39, 1951. 26. HIBBARD, L. T. and SCHUMANN,W. R. The spigelian hernia in gynecology. Am. J. Obst. & Gynec., 83: 1439, 1962. 27. TEREZIS, N. L., DAVIS, W. C., and JACKSON, F. C. Carcinoma of the colon associated with inguinal hernia. New England J. Med., 268: 774, 1963. 28. MAXWELL. 1. W.. DAVIS. W. C.. and TACKSON. F. C. colon &rcinomg and inguinai hernia. S. Clin. North America, 45: 1165, 1965. 29. PERRIGARD, G. E. Superior linea semilunaris hernia, subjacent to arcuate line. Canad. M. A. J., 57: 575, 1947.

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