Spigel’s hernia is a rare type of ventral hernia with an incidence of 0.1-2%. We report his case of non-strangling left lower abdominal Spiegel’s hernia and its management. She was a 74-year-old woman who complained of progressively worsening left flank pain with dysuria and frequency associated with pyelonephritis. Incidentally, a CT scan of her abdomen and pelvis showed a left Spiegel hernia involving a medium-sized small intestine without strangulation. After that, she started having worsening abdominal pain in her area. The hernia was repaired on the same day of her admission by laparoscopic laparoscopic onlay her mesh plus repair. Spigel hernias have elusive clinical manifestations. Although rare, the risk of acute complications is high and should be considered in the differential diagnosis of abdominal hernia.
prologue
Spigel’s hernia is a rare variation of ventral hernia, accounting for 0.1-2% of all cases of abdominal hernia. [1]A Spiegel’s hernia is a herniation or protrusion of the preperitoneal fat, peritoneal sac, or organ due to a defect in the Spiegel’s aponeurosis, the tendon layer between the inner rectus abdominis muscle and the outer meniscus. Formed by the fusion of the internal oblique and transversus abdominis aponeurosis, the Spiegel aponeurosis/fascia is an inherently weak area of the abdominal wall.This makes herniation more likely from this area with increased intra-abdominal pressure [2]These predisposing factors include obesity, chronic obstructive pulmonary disease (COPD), abdominal trauma, and abdominal surgery. [1]Most cases of spiegel hernia are acquired, but cases of congenital spiegel hernia have been described in the literature. This is thought to be due to weaker areas of the aponeurosis of the abdominal muscles that form during embryogenesis.
Clinically, this type of hernia is located deep in the external oblique aponeurosis, which allows it to avoid detection and palpation on physical examination. [3]As such, patients may present in emergency situations following acute complications such as imprisonment, strangulation, or bowel obstruction. From a management perspective, this type of hernia is not suitable for conservative treatment due to the high potential for complications. [3]Surgical repair remains the standard of care in emergency and non-emergency situations. This paper reports a case of left lower quadrant Spiegel hernia that was successfully treated using a laparoscopic approach.
case presentation
A 74-year-old woman with a history of obesity, hypertension, diabetes mellitus, pulmonary sarcoidosis, transient ischemic attack, and previous abdominal surgery (bladder surgery, hysterectomy, and tubal ligation) had a progressive loss of the left flank. He was taken to the emergency department due to aggravation. She had several days of pain with dysuria and frequent urination. She presented with systemic symptoms of fever, chills, and sweats and complained of her nausea and abdominal pain.On her physical examination, palpation of her left flank induced mild tenderness. IV ceftriaxone was administered in an acute setting.
Laboratory studies showed the following data: total white blood cell count 23,400 WBC/µL (N: 4500-11,000 WBC/µL), hemoglobin 11.9 g/dL, platelets 163,000 platelets/µL, sodium 137 mmol/L L, potassium 3.4 mmol/L, and chloride 100 mmol/L. Computed tomography (CT) of the abdomen and pelvis with IV contrast coincidentally revealed a left Spiegel’s hernia involving a medium-sized small intestine (Fig. 1). During the stay, there was no evidence of abdominal swelling or lumps, and abdominal pain began to increase in the left lower quadrant where the hernia was localized. CT also found pyelonephritis and bilateral kidney stones, explaining the patient’s primary complaint of pain in the left flank and the presence of systemic symptoms. Laparoscopic intraperitoneal onlay mesh (IPOM) plus repair recommendations were made. We explained the procedure to the patient and obtained informed consent.
Surgery was performed under general and local anesthesia, and patients received appropriate IV antibiotics within 1 hour of skin incision. Intraoperatively, a spring-loaded needle was placed at Palmer’s point in the left subcostal region and the abdomen was insufflated with gas to her 15 mmHg. Next, a 5 mm trocar he placed in the right upper quadrant with the Optiview (Ethicon, Raritan, New Jersey) method, followed by his two additional 5 mm trocars in the right hemi-abdomen. Note the lower left abdomen. There was a 3.5 cm defect just lateral to the inferior epigastric vessel, corresponding to a CT-visualized Spiegel hernia. The underlying small intestine was viable with no evidence of perforation or gangrene. Decided to repair. Using a trocar site closure device with absorbable sutures, two figure-eight sutures were placed to primarily close the defect, followed by he placed 13.5 cm of mesh and a metal It was fixed to the abdominal wall with spiral tacks. The hernia sac was dissected, removed, and sent as a specimen prior to closure. The surgical field was hemostasis at the end of the case. The pneumoperitoneum was degassed and subsequently anesthetized with a local anesthetic. There were no intraoperative complications. Pathology confirmed that the specimen consisted of fibrous adipose tissue with a mesothelium consistent with a hernial sac. During the postoperative period, the patient experienced an episode of vomiting on the 2nd postoperative day and had zero oral intake until transitioned to a liquid diet on the 4th postoperative day. A complete liquid diet was started on the 7th day after the operation, and a solid diet was started on the 8th day after the operation. Analgesics were administered as needed and IV vancomycin and ceftriaxone were continued. Her white blood cell count decreased from 23,400 WBC/μL to 18,700 WBC/μL from the day of admission to the 2nd postoperative day. This was an inadvertent effect of vancomycin, and vancomycin was discontinued and replaced with a 14-day ceftriaxone-only course. By postoperative day 5, her WBC count had stabilized at her 8000 WBC/μL, indicating that her active pyelonephritis was in remission. With resolution of her infection at 6900 WBC/μL and adequate healing of her surgical incision site, she was discharged on postoperative day 9. Postoperatively, the patient was readmitted for reasons related to her genitourinary problems, but no hernia recurrence has been identified at the time of her writing.
discussion
Spigel’s hernia is a rare type of hernia that accounts for 0.1-2% of all abdominal wall defects. [1]The incidence in men and women is about the same, but it occurs more frequently in women, usually between the ages of 40 and 70. [1,4,5]In addition, it tends to be localized on the left side [1,6], as seen in this case report.Risk factors include obesity, COPD, abdominal surgery, abdominal trauma, and other causes of increased intra-abdominal pressure [1]In our report, the patient was found to be morbidly obese and had a history of abdominal surgery, particularly bladder surgery, tubal ligation, and hysterectomy.
From a clinical point of view, the diagnosis is made because in the early stages the symptoms are nonspecific, ranging from vague abdominal pain to a visible or palpable lump to features of confinement with or without features of strangulation. it is difficult to put down. [1,7,8]This vague and sometimes asymptomatic symptom is due to masking of the defect by thick subcutaneous fat and a tough aponeurosis of the external oblique muscle (Fig. 1) [7]This presents a diagnostic challenge as clinical signs generally appear at a later stage as the size of the hernia increases, subsequently increasing the risk of entrapment and related complications. [1]Specifically, fibrous bands of Spiegel’s fascia can form a “hard neck”, which increases the risk of strangulation. This risk has been reported to be 2-14%. [7,9]The risk of imprisonment is reported to be 24-27%. [7,10,11]Therefore, CT and ultrasound imaging are important for early detection and prompt surgical intervention. CT is recommended to determine the location, size, and contents of the hernial sac defect to guide surgical management. [1]In the case of this patient, she also presented with asymptomatic symptoms, which were likely complicated by superimposed kidney problems, making it difficult to determine the source of her pain. However, it was only after he was hospitalized that the abdominal pain in his left lower abdomen began to worsen. Therefore, if her pyelonephritis did not lead to hospitalization, she was likely to miss the hernia until acute complications occurred.
Surgery remains the mainstay of treatment for spiegel hernias, which can be repaired using either an open or laparoscopic approach, depending on the patient’s characteristics, the type of hernia, and the experience of the surgeon. [12,13]Over the past two decades, the laparoscopic approach has become the method of choice, not only for repair but also as a definitive diagnostic tool for patients with ambiguous findings on ultrasound or CT. [8]The laparoscopic approach also has the added benefit of reducing hospital stay, potential for postoperative infection, and morbidity. [8]Laparoscopic techniques include IPOM, total extraperitoneal patch (TEP) approach, transabdominal preperitoneal (TAPP) approach, and laparoscopic suture techniques. There are no clear guidelines for favoring one technique over the other, but the most common approach is he IPOM due to its ease of learning and safety advantages. [8]According to recent European Hernia Society (EHS) guidelines, mesh repair is recommended regardless of whether an open or laparoscopic approach is chosen due to its low recurrence rate. [14,15]A variation of the IPOM technique is IPOM-plus, the surgical method of choice for patients. Employs the same principle as IPOM, with the addition of suture closure, resulting in a lower recurrence rate compared to IPOM. [16].
Conclusion
Diagnosis of Spiegel hernia is often delayed due to the lack of specific and consistent physical findings. As such, an indicator of high clinical suspicion is required due to the potential for life-threatening complications. Our patient presented asymptomatically and was hospitalized for a urogenital infection at the appropriate time, allowing rapid repair of the hernia. , if the images are inconclusive, diagnostic laparoscopy may provide nearly 100% accuracy. According to the literature, surgical repair remains the mainstay of treatment. In this case presentation, the optimal form of management was her IPOM plus repair by laparoscopy. Spiegel hernias are rare, but they carry a high risk of acute complications and should be considered in the differential diagnosis of abdominal hernias.