Central Annals of Emergency Surgery Bringing Excellence in Open Access

Case Report *Corresponding author Zi Qin NG, Department of , Royal Perth Hospital, 188B Wanneroo Road, Yokine, Western Strangulated Small Bowel in a Australia, Australia 6060; Tel: 61452510855; Email:

Submitted: 24 January 2017 Spigelian and a Review Accepted: 15 March 2017 Published: 17 March 2017 of the Literature Copyright © 2017 Zi Qin et al. Zi Qin NG*, Willy LOW, Pradeep Subramanian, and Joel Stein OPEN ACCESS Department of General Surgery, Royal Perth Hospital, Australia

Keywords Abstract • Spigelian hernia • Strangulation Spigelian hernia was named after the Belgian anatomist Adriaan van den Spieghel • Bowel resection who first described the semilunar line in 1645. Spigelian hernia remains an exceedingly • Hernia repair rare abdominal wall defect amongst all the abdominal wall . It has a reported incidence of 0.2 to 2% in the literature. Clinical diagnosis of Spigelian hernia remains a challenge to all clinicians due to its vague and non-specific signs and symptoms. As a consequence, most patients often present to the emergency department with incarceration of Spigelian hernia as the first visit. The risk of strangulation of Spigelian hernia is thought to be ranged between 17 to 24%. Computed tomography is the most helpful imaging tool in diagnosing Spigelian hernia and guide pre-operative planning. Herein, we report a case of a 78-year-old man who presented with strangulated loop of small bowel in a right-sided Spigelian hernia in the setting of newer anticoagulation (Factor Xa inhibitor). We also aimed toreview the literature with a focus on emergency approaches for incarcerated Spigelian hernia.

ABBREVIATIONS described the pain as intermittent, burning in nature and radiates SH: Spigelian Hernia; COPD: Chronic Obstructive Pulmonary toonset right of lower abdominal quadrant. Therepain whilst was nowalking in ora local vomiting. store. He Disease; CT: Computer Tomography; TEPP: Transabdominal opened his bowels the day before and denied any recent change Extraperitoneal Patch; TAPP: Transabdominal Preperitoneal; in bowel habits. There was no history of chronic abdominal pain IPOM: Intraperitoneal Onlay Mesh history included right repair, type 2 diabetes INTRODUCTION or lump over the past one year. Other significant past medical Spigelian hernia was credited to the Belgian anatomist pulmonarymellitus, previous disease stroke, (COPD). a trial fibrillation in which he takes a Factor Xa inhibitor for stroke prevention and chronic obstructive 1764.Adriaan Spigelian van den hernia Spieghel (SH) whoremains first a describedrare entity the of abdominal semilunar On examination, his vital signs were normal. His abdomen wallline inhernias 1645, with although a reported it was incidence first reported of 2% by [1]. Klinkosch The clinical in was soft and tender around right lower quadrant. A mass was also palpable at the right lower quadrant. Biochemistry examination revealed mildly raised white cell count (13 x 10*9/L) and lactate manifestation is usually non-specific and can be easily missed of 2.4mmol/L). The computed tomography (CT) of abdomen/ standardand a significant for the managementproportion of ofpatient SHs. Over present the withpast decade,incarceration there pelvis demonstrated strangulated small bowel loops within a hasof SH been in their advancement first visit in [2]. minimally Surgical interventioninvasive techniques is the gold for right SH (Figure 1, 2 and 3). repair of SHs with reasonably good outcomes. Nevertheless, the A midline exploratory laparotomy was performed which data has been restricted to mostly elective repairs of SH. Herein; found 20cm of incarcerated ischaemic small bowel in right SH. we report the management of a case of strangulated small bowel Intraoperatively, the hernia was reduced and ischemic small in a Spigelian hernia in the setting of a newer anticoagulation bowel was resected with side-to-side anastomosis with a GIATM (Factor Xa inhibitor). We also aimed to review the literature with anemphasis on the emergency surgical approaches for was closed with interrupted 1/0 Nylon sutures. The patient made incarcerated SHs. anstapler uneventful (Covidien, recovery US Surgical, post-operatively. Norwalk, CT). The Spigelian defect CASE PRESENTATION Review of the literature 78-year-old man presented with one-day history of sudden A literature search was performed with the databases that

Cite this article: Zi Qin NG, Willy LOW, Pradeep S, Joel S (2017) Strangulated Small Bowel in a Spigelian Hernia and a Review of the Literature. Ann Emerg Surg 2(2): 1011. Zi Qin et al. (2017) Email:

Central Bringing Excellence in Open Access included Medline with PubMed, Ovid, Embase, and Google Scholar to identify articles on the emergency management of

search: “Spigelian hernia”, “strangulation”, “bowel resection” and “herniaSpigelian repair”. hernia. The The references following of keywordsthe articles were obtained used from for the search were reviewed by title and followed by abstract review. The last search was performed up to January 10, 2017. DISCUSSION Definition, and incidence Spigelian hernias are ventral hernias that occur through the Spigelian fascia which is comprised of the aponeurotic layer Figure 1 Axial view of CT scan showing herniated small bowel loop in a right between the rectus muscles medially and the semilunar line Spigelian hernia (arrow). area between the lateral border of the rectus abdominis muscle andlaterally. the medial Spigelian border fascia or is the defined transversus as the sword abdominis blade-shaped muscle. Majority of them are inferior to the arcuate line and superior to the inferior epigastric vessels. The reported incidence in the literature ranges from 0.2 to 2% amongst the abdominal wall hernias [1,3]. It is most commonly seen in the middle age group and more frequently in females with a ratio of 1.4:1 [1-4]. Bilateral synchronous SHs have also been reported [3,5-9]. Etiology, pathophysiology and risk factors A small number of cases of SH especially in the younger

[3]. SHs found in the adults are usually acquired inpopulation nature and may various be congenital predisposing in origin factors and often have arebeen linked reported with in the literature: COPD, obesity, previous abdominal surgery, previous hernias, prior abdominal trauma and rapid weight loss Figure 2 Coronal view of CT scan showing incarcerated small bowel loops [2,10]. Some authors have suggested there is a nature history of in a right Spigelian hernia. The adjacent soft tissue edema is suggestive of progression. SH may initially begin with a small split in the fascial strangulation (arrow). layer of the semilunar line with extraperitoneal fat herniating through only. With time, these small hernias enlarge and develop a peritoneal sac and may explain that SH appears to be more common in older age group [3]. A loop of small bowel is the most commonly expected organ found in SH [11]. Other visceral organs have also been infrequently described in the SH such as colon [3,12,13] [14-16], ovary, testicle, endometrial tissue and omentum [3,9]. Interestingly, several case reports have reported simultaneous repair of other hernias such as umbilical [17] and inguinal hernias [9]. Clinical presentation

SymptomsThe diagnosis such asof a chronic SH is notoriously intermittent known abdominal to be challenging pain and occasionaldue to its vague bulge and at non-specific abdominal clinical wall may manifestations be obtained [18,19]. from the history [3]. The presence of pain in these patients varies from 31% to 86% of cases [20]. Occasionally, the patients may present with small or large [21,22]. Clinical

protruding through the transversus abdominis muscle but the overlyingexamination external is usually oblique also fascia difficult remains as explained intact [18,19]. by the As hernia such, a few retrospective studies have shown that clinical examination could only establish the diagnosis in 50 to 64% of cases [1,23]. Right Spigelian hernia containing small bowel loop in sagittal view Figure 3 Even with history and clinical examination, the diagnosis of of CT scan.

SH could only be achieved in 74% of cases [1]. More strikingly, Ann Emerg Surg 2(2): 1011 (2017) 2/5 Zi Qin et al. (2017) Email:

Central Bringing Excellence in Open Access

transabdominal partially extraperitoneal repair [3,26,31]. It [10]. remains controversial of which laparoscopic technique should Perrakis and colleagues diagnosed 75% of SHs intraoperatively be the gold standard and the data has been largely limited to the Diagnosis elective SH repair [2-4,31-34]. Table (1) summarizes the different laparoscopic approaches and illustrates the it’s pros and cons. Amongst all, IPOM is the most popular technique due to its 24%)Due [3,18]. to its difficultyUltrasound in diagnosisof the abdominal and usually wall small could hernia be useful neck, simplicity and shorter operating time [32]. Minimal dissection is ina significant demonstrating number a defect of patients in the present Spigelian with aponeurosis incarceration [18,21]. (17 to However, it is operator-dependent and the authors believe it permitsneeded toconcomitant obtain a good management working space of other and hernias it allows or placementpathology role of ultrasound was greatly limited by pain on examination of larger mesh without any difficulty in extending it. It also [10].is more Another beneficial author in thereported non-emergency the use of setting.ultrasound In a tostudy, provide the direct visualization for the reduction of SH successfully [24]. CT to[17,35-37]. bowel coming However, in contact. there is With a potential newer riskand ofimproved mesh-related mesh abdomen/pelvis yields further details in excluding alternative propertiescomplications such suchas a composite as erosion, mesh, fistulation complications and infectionare extremely due pathology and more importantly the exact location of the defect, rare [38]. TAPP is the next most commonly performed technique. the size and the sac contents could be achieved [18,19,25,26]. It is usually more suitable in cases with large and complex SH Thus, it aids in preoperative planning. and shares some characteristics of both IPOM and TEP. TEP is Management requires more extensive dissection and hence longer operating There has been no consensus regarding the best operative time.the least It may utilized not betechnique suitable due for to large its technical SH as larger difficulty. mesh It might also technique for Spigelian hernia repair given its infrequent not be able to be accommodated. It has the advantage of avoiding occurrence. Traditionally, open surgical repair is the procedure disturbance of intraperitoneal organs over IPOM and TAPP. of choice in both elective and emergency settings. It can be approached either through a transverse incision across the SH or difference between IPOM and TEP for the repair of SH [33]. a midline laparotomy, each having its advantages and challenges Moreno-Egea et al., concluded that there was no significant (Table 1). For the transverse incision across the SH, the repair Only a few cases of incarcerated SHs in the literature have can be performed via primary tissue repair [1,19], pre-shaped been managed laparoscopically – primary suture repair [2], IPOM polypropylene umbrella plug [27], mesh placement between the [39,40], TEP [21,41]. This could be explained by its rarity and external and internal oblique muscles [28] and mesh placement technical challenge associated with learning. It may be easier to preperitoneally [29]. Importantly, in some cases by transverse incision, the SH may not be easily detected and may require adequate. Nonetheless, there has been no formal study to assess extension of the excision. In certain circumstances, it may be thelearn learning IPOM as curve usually of the being individual proficient techniques, in laparoscopic although surgery a recent is more desirable to perform a midline laparotomy especially in study suggested a steeper learning curve with TEP [33]. emergency setting. It allows accurate assessment of the viability The choice of mesh remains an area of contention. Various types of mesh have been used such as polypropylene mesh incarceration of rare organs that may necessitate resection and [11,13,31,41], Prolene [10] and composite prosthesis comprised reconstruction.of the sac contents In our andpatient, provides we elected flexibility to perform in dealing a midline with laparotomy due to concerns of small bowel necrosis. Given that robust data to support which is the ideal mesh. One of the main the patient was also on a Factor Xa inhibitor, we envisaged that concernsof a sandwich with mesh of polyester repair - infection fiber mesh could [21,39] be avoided but there with is TEP no further abdominal exposure may be required for haemostasis if bleeding occurs. mayand TAPP.not always This be also necessary eliminates in small the riskhernias of complicationsand primary suture from was described by Carter and colleagues in 1992 [30], there has repairmesh like is usuallyadhesions adequate and/or [18]. fistulas Another [29]. However, unanswered mesh question repair In the past decade, since the first laparoscopic repair of SH is the ideal distance of overlap around the defect. Some authors reduce the morbidity and attempt to implement the technique in suggested at least 5 cm of overlap around the circumference of been blossoming interest in exploring several modifications to of less tissue trauma from smaller incision, better cosmetic case due to the concern of bacterial translocation in the setting of emergency setting. Minimally invasive surgery has the benefits bowelthe defect resection. is sufficient No cases [33]. of Mesh mesh repair repair was have not been performed performed in our in hospital stay. The only randomized trial comparing open versus patients requiring bowel resection in the literature [2,42]. laparoscopicoutcome, less repairpost-operative of SH in pain, the literaturequicker recovery concluded and thatshorter the Long-term outcome and the length of stay [26]. However, there was no difference in From the review of the literature, the overall recurrence rate thelaparoscopic post-operative group significantly complications. reduced Some the authors morbidity also of advocate patients of SH is varies and ranges from 5 to 14 % [18,33]. Majority of for laparoscopic repair to avoid disrupting the physiological these cases were repaired by primary suture repair. In a series behavior and mechanics of abdominal wall through scarring in of 70 patients undergoing open primary suture repair, there were 3 recurrences (4.3%) which subsequently underwent are: totally extraperitoneal (TEP) repair, intraperitoneal onlay further repair with no further recurrence [1]. There has been meshopen surgery(IPOM), trans [2]. The abdominal modifications preperitoneal that have (TAPP) been repair described and no recurrence of SH in any of the laparoscopic approaches with

Ann Emerg Surg 2(2): 1011 (2017) 3/5 Zi Qin et al. (2017) Email:

Central Bringing Excellence in Open Access

Table 1: A comparison of the different open and laparoscopic approaches for management of Spigelian hernia. Approach Incision & Repair Common Advantages Unique Advantages Disadvantages Transverse incision & -Bigger incision causing - primary suture repair - Technique is more widely more tissue trauma With mesh (preperitoneal) exposed to the general surgical - and potentially higher community. complication rates

situation where organs Midline laparotomy & - Simple and cost-effective Allows flexibility in - More post-operative pain Open that necessitate complex primary suture repair - Accurate assessment of resection and reconstruction. -Unable to viability of sac contents and With mesh (intraperitoneal - of other hernias (in cases of onlay) managetransverse incidental incision) findings deal with unexpected findings. Maybe feasible only in Simple, safe, cost-effective, selected cases of small SH Primary suture repair reproducible due to the need for tension- free repair. -Suitable for large and Transabdominal - Less tissue trauma by smaller complex SH. preperitoneal (TAPP) patch intraperitoneal organ injury incision -Allows assessment of repair and adhesionsPotential risk formation. of viability of sac contents. - Better cosmetic outcome -Technically more challenging and requires - Less post-operative pain, experience. Avoids entry into peritoneal Total Extraperitoneal cavity and hence disturbance (TEPP) patch repair hospital stay -Longer operating time, of intraperitoneal organs. quicker recovery and shorter more-Smaller extensive surgical dissection. field.

Laparoscopic -Other abdominal wall localizes the Spigelian hernia hernias maybe missed. - Accurately and quickly site -Technically simpler than other laparoscopic techniques. Intraperitoneal onlay mesh -Requires less experience. (IPOM) related complications such (including the scroll Potential risk of mesh- -Shorter operative time. technique) -Broader surgical field. infection. as erosion, fistulation and of other hernias discovered -Allowsintraoperatively. concurrent fixation a follow-up ranges from 6 to 32 months [2,8,26,38,41,43-46]. 3. Nonetheless, the available evidence should be interpreted with Contemporary thoughts on the management of Spigelian hernia. Webber V, Low C, Skipworth RJ, Kumar S, de Beaux AC, Tulloh B. caution as the duration of follow-up is usually short. Hernia. 2017. 4. Polistina FA, Garbo G, Trevisan P, Frego M. Twelve years of experience In conclusion, the diagnosis of SH requires a high degree treating Spigelian hernia. Surgery. 2015; 157: 547-550. of clinical suspicion especially in patients presenting with unexplained chronic abdominal pain. CT scan remains the most 5. sensitive diagnostic tool for SH. There is currently no agreed hernias: experience of 26 consecutive cases in 24 patients. Eur J Surg. 2001;Klimopoulos 167: 631-633. S, Kounoudes C, Validakis A, Galanis G. Low spigelian consensus on the best approach for repair of SH although there is a trend towards laparoscopic repair in the past decade due to 6. Spigelian hernia. A rare case of bilateral hernia and presentation of Safioleas M, Stamatakos M, Moulakakis K, Safioleas P, Skandalakis P. appearance, lesser post-operative pain and most importantly our experience. Chirurgia (Bucur). 2007; 102: 429-432. similarits various outcomes. benefits Similarly, of quicker the convalescence, use of mesh is better still an cosmetic area of 7. Ng JW. A case of small spigelian hernias successfully treated by contention. The newer anticoagulants used over the past few a simple laparoscopy-assisted technique. Surg Laparosc Endosc years may pose a new challenge to emergency surgery but Percutan Tech. 2004; 14: 300-303. fortunately in our case haemostasis was easily achieved. 8. Spigelian hernias: a prospective analysis of baseline parameters and REFERENCES surgicalMalazgirt outcome Z, Topgul of K,34 Sokmen consecutive S, Ersin patients. S, Turkcapar Hernia. AG, 2006; Gok 10: H, et326- al. 1. Larson DW, Farley DR. Spigelian hernias: repair and outcome for 81 330. patients. World J Surg. 2002; 26: 1277-1281. 9. 2. incarcerated Spigelian hernia in a patient with bilateral Spigelian Vannahme M, Monkhouse SJ. Acute management of a unilateral repair of spigelian hernias: two case reports and a review of the hernias. Ann R Coll Surg Engl. 2013; 95: e89-91. Leff DR, Hassell J, Sufi P, Heath D. Emergency and elective laparoscopic literature. Surg Laparosc Endosc Percutan Tech. 2009; 19: e152-155. 10.

Perrakis A, Velimezis G, Kapogiannatos G, Koronakis D, Perrakis Ann Emerg Surg 2(2): 1011 (2017) 4/5 Zi Qin et al. (2017) Email:

Central Bringing Excellence in Open Access

E. Spigel hernia: a single center experience in a rare hernia entity. 30. Carter JE, Mizes C. Laparoscopic diagnosis and repair of spigelian Hernia. 2012; 16: 439-444. hernia: report of a case and technique. Am J Obstet Gynecol. 1992; 167: 77-78. 11. in a spigelian hernia. Hernia. 2004; 8: 384-386. 31. Tsalis K, Zacharakis E, Lambrou I, Betsis D. Incarcerated small bowel of a spigelian hernia: a case report and literature review. JSLS. 2004; 12. 8:Martell 269-274. EG, Singh NN, Zagorski SM, Sawyer MA. Laparoscopic repair abdominal wall injury: a case report. Hernia. 2007; 11: 67-69. Topal E, Kaya E, Topal NB, Sahin I. Giant spigelian hernia due to 32. 13. Laparoscopic management of spigelian hernias. Surg Laparosc Endosc obstructing colon carcinoma. Hernia. 2008; 12: 87-89. Skouras C, Purkayastha S, Jiao L, Tekkis P, Darzi A, Zacharakis E. Miller R, Lifschitz O, Mavor E. Incarcerated Spigelian hernia mimicking Percutan Tech. 2011; 21: 76-81. 14. 33. Moreno-Egea A, Campillo-Soto A, Morales-Cuenca G. Which should unusual Spigelian hernia involving the appendix: a case report. Cases be the gold standard laparoscopic technique for handling Spigelian J.Thomasset 2010; 3: 22. SC, Villatoro E, Wood S, Martin A, Finlay K, Patterson JE. An hernias? Surg Endosc. 2015; 29: 856-862. 15. 34. abdominal pain due to and an incarcerated spigelian JG, et al. Laparoscopic Spigelian Hernia Repair: A Series of 40 Patients. hernia.Lin PH, Am Koffron Surg. 2000; AJ, Heilizer 66: 725-727. TJ, Lujan HJ. Right lower quadrant SurgKelly LaparoscME, Courtney Endosc D, McDermott Percutan Tech. FD, Heeney 2015; 25: A, Maguire e86-89. D, Geoghegan 16. 35. Fisher BL. Video-assisted Spigelian hernia repair. Surg Laparosc strangulation of the small bowel and appendix. Hernia. 2003; 7: 156- Endosc. 1994; 4: 238-240. 157.Onal A, Sokmen S, Atila K. Spigelian hernia associated with 36. 17. Amendolara M. Video laparoscopic treatment of Spigelian hernias. treated laparoscopically]. Rozhl Chir. 1999; 78: 610-612. Surg Laparosc Endosc. 1998; 8: 136-139. Teleky R, Duda M, Brezina L. [Spigelian hernia and cholecystolithiasis 37. Strand L, Larsen JF. [Laparoscopic surgery of Spiegelian hernia]. 18. Spangen L. Spigelian hernia. World J Surg. 1989; 13: 573-580. 19. Spangen L. Spigelian hernia. Surg Clin North Am. 1984; 64: 351-366. 38. UgeskrSaber AA, Laeger. Elgamal 2002; MH, 164: Rao 1223-1224. AJ, Osmer RL, Itawi EA. Laparoscopic 20. Moreno-Egea A, Flores B, Girela E, Martin JG, Aguayo JL, Canteras M. spigelian hernia repair: the scroll technique. Am Surg. 2008; 74: 108- Spigelian hernia: bibliographical study and presentation of a series of 112. 28 patients. Hernia. 2002; 6: 167-170. 39. 21. intraperitoneal onlay mesh repair of incarcerated spigelian hernia. bowel obstruction. South Med J. 2010; 103: 567-569. JSLS.Subramanya 2010; 14: MS, 275-278. Chakraborty J, Memon B, Memon MA. Emergency Bastidas JG, Khan AR, LeBlanc KA. Spigelian hernia as a cause of small 22. Vos DI, Scheltinga MR. Incidence and outcome of surgical repair of 40. spigelian hernia. Br J Surg. 2004; 91: 640-644. Laparoscopic intraperitoneal mesh repair of Spigelian hernia: A case report.Yoshida Asian D, Itoh J Endosc S, Kinjo Surg. N, Harimoto 2015; 8: N, 477-479. Maruyama S, Kawanaka H, et al. 23. Stirnemann H. [The Spigelian hernia: missed? rare? puzzling diagnosis?]. Chirurg. 1982; 53: 314-317. 41. incarcerated Spigelian hernia. J Laparoendosc Adv Surg Tech A. 2005; 24. Blaivas M. Ultrasound-guided reduction of a Spigelian hernia in a 15:Yau 57-59. KK, Siu WT, Chau CH, Yang GP, Li MK. A laparoscopic approach for

Am J Emerg Med. 2002; 20: 59-61. 42. Foster D, Nagarajan S, Panait L. Richter-type Spigelian hernia: A case difficult case: an unusual use of bedside emergency ultrasonography. report and review of the literature. Int J Surg Case Rep. 2015; 6: 160- 25. Balthazar EJ, Subramanyam BR, Megibow A. Spigelian hernia: CT and 162. ultrasonography diagnosis. Gastrointest Radiol. 1984; 9: 81-84. 43. 26. Moreno-Egea A, Carrasco L, Girela E, Martin JG, Aguayo JL, Canteras a spigelian hernia. Surgery. 1994; 115: 521-522. M. Open vs laparoscopic repair of spigelian hernia: a prospective DeMatteo RP, Morris JB, Broderick G. Incidental laparoscopic repair of randomized trial. Arch Surg. 2002; 137: 1266-1268. 44.

27. Sanchez-Montes I, Deysine M. Spigelian hernias: a new repair (ePTFE)Appeltans mesh. BM, Surg Zeebregts Endosc. CJ, 2000; Cate 14: Hoedemaker 1189. HO. Laparoscopic technique using preshaped polypropylene umbrella plugs. Arch Surg. repair of a Spigelian hernia using an expanded polytetrafluoroethylene 1998; 133: 670-672. 45. Habib E, Elhadad A. Spigelian hernia long considered as : CT scan diagnosis and laparoscopic treatment. Computed tomography. 28. Celdran A, Senaris J, Manas J, Frieyro O. The open mesh repair of Surg Endosc. 2003; 17: 159. Spigelian hernia. Am J Surg. 2007; 193: 111-113. 46. Iswariah H, Metcalfe M, Morrison CP, Maddern GJ. Facilitation of open 29. spigelian hernia repair by laparoscopic location of the hernial defect. Preperitoneal mesh repair of spigelian hernias under local anesthesia: Surg Endosc. 2003; 17: 832. descriptionMalazgirt Z, and Dervisoglu clinical evaluation A, Polat C, of Guneren a new technique. E, Guven Hernia. H, Akpolat 2003; T. 7: 202-205.

Cite this article Zi Qin NG, Willy LOW, Pradeep S, Joel S (2017) Strangulated Small Bowel in a Spigelian Hernia and a Review of the Literature. Ann Emerg Surg 2(2): 1011.

Ann Emerg Surg 2(2): 1011 (2017) 5/5