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Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 23-27

Laparoscopic transabdominal preperitoneal repair in the management of Spiegelian hernia – A three-patient case series and review of the literature

Hospital Angeles del Carmen, Department of Minimally Invasive and Robotic Surgery, Guadalajara, México

Date of Submission10-Jul-2020
Date of Decision15-Jul-2020
Date of Acceptance25-Aug-2020
Date of Web Publication22-Feb-2021

Correspondence Address:
Dr. Héctor Alí Valenzuela Alpuche
Tarascos 3469 Int. 217 Condominio Profesional Del Carmen, Colonia Frac. Monraz, Guadalajara, Jalisco
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_29_20

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BACKGROUND: Spiegel hernia (SH) is a rare type of primary ventral hernia. Surgery has been performed by open or minimally invasive means with no current gold standard due to a shortage of current evidence. We advocate for the transabdominal preperitoneal approach (TAPP) for its cost effective outcome. We present a series of 3 cases operated using the TAPP approach in the past 5 years, carried out by a single surgeon, and a review of the literature.
METHODS: A retrospective analysis of a case series of 3 patients' operations between January 2015 and June 2020. TAPP repair was found to be a safe and effective anatomical repair with all the added benefits of laparoscopic surgery such as reduced hospital stay, quicker recovery, and fewer surgical site occurrences.
CONCLUSIONS: Several operative techniques have been described to repair Spiegel hernia but in our particular practice we felt laparoscopic TAPP approach was the safest and with a more predictable outcome due to the authors familiarity with it.

Keywords: Hernia, Spiegel, transabdominal preperitoneal

How to cite this article:
Valenzuela Alpuche HA. Laparoscopic transabdominal preperitoneal repair in the management of Spiegelian hernia – A three-patient case series and review of the literature. Int J Abdom Wall Hernia Surg 2021;4:23-7

How to cite this URL:
Valenzuela Alpuche HA. Laparoscopic transabdominal preperitoneal repair in the management of Spiegelian hernia – A three-patient case series and review of the literature. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2022 Jan 19];4:23-7. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/1/23/309977

  Introduction Top

The  Spigelia More Detailsn hernia (SH) is a rare type of hernia that appears in the semilunar line, named after the Belgian anatomist Adriaan Van Den Spiegel who first described the semilunar line. This hernia can often be misdiagnosed as abdominal fat or lipoma by those not familiar with it because it does not go through all the layers of the abdominal wall.[1] It has a variable incidence ranging from 0.1% to 2%.[2] It is known to be more common in female gender on the left semilunar line and appears in individuals over 50 years of age.[3] The only effective treatment is a surgical repair, and laparoscopic surgery has been the method of choice to be carried out because of all the known benefits of minimally invasive surgery, as exemplified by Carter and Mizes who published the first laparoscopic case in 1992.[4]

The purpose of this study is to present our short case series of three patients who underwent a laparoscopic transabdominal preperitoneal (TAPP) repair and analyze the current way in which SHs are being treated around the world.

  Patients and Methods Top

We carried out a retrospective analysis of all the patients with hernias treated by minimally invasive means in the time period between January 2015 and June 2020. Information gathered included patient's gender, comorbidities, and characteristics of the hernia such as location and size and whether surgery was urgent or elective. All hernias were diagnosed using abdominal computed tomography (CT) scans. All the surgical procedures were performed by the same surgeon, and it was a standard practice that patients would be under general anesthesia, prepped in the supine position with both arms tucked by their sides, and the technique used was laparoscopic TAPP repair.

Case 1

A 76-year-old female was admitted in the emergency room for acute abdominal pain that started 1 day prior to admission and was associated with an absence of bowel movements and gas, nausea, bilioenteric vomiting, and an incapacity to have any sort of oral intake. She was initially treated by a local general practitioner with antispasmodic and nausea medication, but as the patient's symptoms worsened, she decided to seek a second opinion.

The patient had a body mass index (BMI) of 32 kg/m2, suffered controlled high blood pressure, had been a smoker from her 20s until about 15 years prior, and had two cesarean sections as well as an umbilical hernia repair during her childhood. Blood analysis revealed leukocytes of 11,000, hemoglobin of 13.2, glucose of 110, and procalcitonin of 0.9 with normal kidney function.

On physical examination, the patient's heart rate was 110, and the rest of her vital signs were within normal ranges. Her abdomen was mildly distended with active struggle peristalsis and a palpable painful lump was felt on her left semilunar line close to the inguinal area, which later was confirmed to be an SH on a plain CT scan.

Exploratory laparoscopy was performed which revealed partial incarceration of the sigmoid colon which with a gentle traction of the distal nonobstructed bowel was reduced back into the abdomen [Figure 1]. After ensuring that there was no irreversible bowel injury, the decision was made to perform a TAPP with closure of the 3-cm hernial defect with number 1 polypropylene suture, and a simple heavyweight 15 × 20 polypropylene mesh was used for reinforcement with metallic penetrating fixation, with a total operative time of 120 min [Figure 2].
Figure 1: Incarcerated  Spiegelian hernia More Details

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Figure 2: The mesh placed

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The patient was offered a liquid diet on postoperative day 1 and as her bowel resumed normal activity, oral intake progressed to bland diet, and she was discharged on postoperative day 3 reporting for follow-up consultation asymptomatically 10 days after surgery as well as week 3, 12, and 6 months afterward.

Case 2

A 57-year-old female with a nonsymptomatic palpable and visible lump on her left lower quadrant chose to have a physical examination and diagnosis.

The patient's only comorbidity was obesity with a BMI of 31 kg/m2. She was a nonsmoker and was not taking medication for any other conditions. She stated that she had felt this lump growth over the past couple of months and therefore decided to have it examined [Figure 3].
Figure 3: Computed tomography scan with Spiegelian hernia

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Blood analysis revealed no abnormalities, and CT scan report showed a 3 × 3 SH on the lower left semilunar line with incarcerated preperitoneal fat, for which elective surgery was scheduled [Figure 4].
Figure 4: Noncomplicated Spiegelian hernia

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A TAPP hernia repair was performed, creating a wide flap of peritoneum and a complete hernia sac reduction; the defect measured 3 cm and its closure was achieved by means of a number 1 V-Loc™ running suture and a 15 × 20 ProGrip™ mesh used for reinforcement with no additional fixation and a total operative time of 90 min.

The patient resumed oral intake the evening of the procedure and was discharged home the following morning with a prescription of 25 mg ketoprofen TID for 3 days with an uneventful outcome during her follow-up 6th month after the surgery.

Case 3

An 86-year-old male with very symptomatic right inguinal hernia came in for a surgeon's evaluation. Past medical history involved a robotic prostatectomy in 2008, three cardiac stents in 2012, and a cistostomy in 2019 for irreversible urethral stenosis. On physical examination, the patient had a BMI of 21 kg/m2, a small indirect right inguinal hernia, and a lump on the lower right semilunar line that later on was confirmed to be an SH through CT scan [Figure 5].
Figure 5: Computed tomography scan and patient comparison

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After a comprehensive cardiology workup, a decision was made to repair both hernias in the same operation. A 3-cm indirect inguinal hernia and a 4-cm SH were identified, so a more proximal and wider flap was created to include both hernial defects in the same repair using a 20 × 20 macroporous simple polypropylene mesh fixated with a combination of penetrating fixation and surgical glue with a total operative time of 150 min [Figure 6], [Figure 7], [Figure 8].
Figure 6: The hernia live in surgery

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Figure 7: Case resolution

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Figure 8: Closed peritoneum

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The patient did well and left the hospital 48 h after surgery having resumed complete oral intake, with a mild discomfort on his side that responded well to an oral nonsteroidal anti-inflammatory drug. Postoperative visits at weeks 1, 4, and 12 proved uneventful, and he was asymptomatic on his 6-month follow-up.

In our three-patient case series, we had two females (66%) and one male (33%) with a mean age range of 73 ± 13 years, one done under emergency circumstances, two electives of which one had a coexisting inguinal hernia that was repaired in the same procedure. The mean size defect was 3.3 cm, and the surgical technique used in all the cases was TAPP with variations of the suture used for defect closure, variations in the type of mesh, and variations in the use of penetrating fixation depending on the available materials and given circumstances.

An Embase–Medline search of the published literature was conducted finding 181 articles, of which 167 were excluded due to the following reasons: for describing non-SHs, those including case reports, and those describing open treatment of ventral hernias, leaving a total of 14 case series articles of laparoscopic treatment of SH for review. All the procedures reported were by laparoscopic means and included TAPP repairs, totally extraperitoneal (TEP), and intraperitoneal onlay mesh (IPOM). The total number of surgeries was 234, with IPOM being the most popular with 104 repairs (44%) followed by TAPP with 72 repairs (31%) and TEP with 58 repairs (25%). The mean age of the patients was 62 years (range 32–88); 59% were women and 41% were men, with left-sided hernias being more common. The complications that were most often reported were hematomas, and there were only three reoccurrences reported (1.2%) [Figure 9].
Figure 9: Surgeries reported

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It is worth mentioning that the mean operative time observed was 45–180 min, with TEP procedure on an average being the longest to perform among the ones cited; in terms of complications, IPOM was associated more frequently with postoperative pain, and it was thought to be in relation to the double-crown technique of penetrating fixation, whereas TEP and TAPP were associated more often with hematomas because of the extent of dissection required. The defect size ranged from 1 to 10 cm and mesh size despite not being reported on every procedure, it was mentioned that surgeons followed the 5 cm overlap rule. The three reoccurrences reported were on SHs larger than 8 cm operated with an IPOM bridged technique.

A literature review of laparoscopic repair of SH is shown in [Table 1].
Table 1: Results of the Literature Review

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  Discussion Top

SHs occur when a defect is located in the lateral edge of the rectus muscle in its junction to the lateral muscle complex in the transversus abdominis muscle fascia, and it can happen anywhere along the linea semilunaris.[1] It may be misdiagnosed clinically passing as a lipoma for those not familiar with it, especially because a small hernia sometimes cannot be palpable as it does not pass through all the layers of the abdominal wall; therefore, the preferred method of diagnosis is CT scan.[5] The only accepted treatment for SHs is surgery and this should happen as soon as the preoperative workup can be done due to the high rate of incarceration (25%) and that of strangulation (7%).[5] At present, the method of choice by surgeons to repair this kind of hernias is laparoscopic surgery. There are several approaches, of which the more popular are TEP, TAPP,[6],[7] and IPOM, with IPOM also being suggested as the gold standard of care when combined with a lightweight titanium-coated mesh.[8],[9]

Nevertheless, other groups of surgeons, despite having IPOM as their preferred method of repair, raise questions on the efficiency of this approach given its association with complications of intraperitoneal coated mesh placement.[10] In another large case series, among a total of 40 patients, 25 had IPOM repair and 15 had an extraperitoneal repair, of which two in the extraperitoneal group developed hematoma that needed drainage and two in the IPOM had atrial fibrillation and ileus.[11] No conclusions were made about the superiority of either approach as both procedures were considered safe and provided similar outcomes. Other types of approaches claim providing a less invasive, single-incision laparoscopic outpatient repair with no complications or recurrence after a 2-month follow-up.[12] Bittner et al. have questioned the paradigm of mesh placement and described two cases of primary suture closure of small, <2 cm in diameter, SH with a 12-month follow-up, with no complications or recurrence noted.[13] However, in a three-case series, where SH was incidentally found during a surgery for a different reason, two patients were treated with IPOM and one had a primary closure with no mesh.[14] They concluded that whenever mesh is available the surgical technique should include its placement.

In a largest case series of 77 patients comparing TEP and TAPP mesh repairs for SHs, there was no significant difference in morbidity or recurrence rate between the two groups, with the TEP approach being significantly more costly in terms of consumables.[15]

Larger hernias with significant distortion of the abdominal wall are recommended for open repair due to the possible need for adjuvancy, component separation techniques, and a sounder abdominal wall reconstruction.

  Conclusion Top

In this 3 patient case series we found comparable data to what is currently being published in the Literature. In our experience we found that the TAPP approach for Spiegel hernias is safe, effective and reproducible when the foundations of the technique are executed properly following the principles of reduction of the hernia sac, defect closure and mesh reinforcement with a sufficient overlap covered by a wide peritoneal flap. We also found that within the accepted methods, each minimally invasive approach has its own advantages, therefore every surgeon should choose a repair in which he/she has more expertise, in order to provide a positive predictable outcome in his/her patients. SHs seem to be more susceptible to incarcerate or strangulate, therefore we advise surgical treatment not be delayed for long after diagnosis and due preoperative protocol takes place.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Huttinger R, Sugumar K, Baltazar-Ford KS. Spigelian hernia. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538290. [Last accessed on 2019 Jun 10].  Back to cited text no. 1
Cinar H, Polat AK, Caglayan K, Ozbalci GS, Topgül HK, Polat C. Spigelian hernia: Our experience and review of the literature. Ann Ital Chir 2013;84:649-53.  Back to cited text no. 2
Webber V, Low C, Skipworth RJ, Kumar S, De Beaux AC, Tulloh B. Contemporary thoughts on the management of Spigelian hernia. Hernia 2017;21:355-61.  Back to cited text no. 3
Carter JE, Mizes C. Laparoscopic diagnosis and repair of Spigelian hernia: Report of a case and technique. Am J Obstet Gynecol 1992;167:77-8.  Back to cited text no. 4
Barnes TG, McWhinnie DL. Laparoscopic Spigelian hernia repair: A systematic review. Surg Laparosc Endosc Percutan Tech 2016;26:265-70.  Back to cited text no. 5
Law TT, Ng KK, Ng L, Wong KY. Elective laparoscopic totally extraperitoneal repair for Spigelian hernia: A case series of four patients. Asian J Endosc Surg 2018;11:244-7.  Back to cited text no. 6
Patterson AL, Thomas B, Franklin A, Connor C, Pullatt R. Transabdominal preperitoneal repair of Spigelian hernia. Am Surg 2016;82:E18-9.  Back to cited text no. 7
Moreno-Egea A, Campillo-Soto Á, Morales-Cuenca G. Which should be the gold standard laparoscopic technique for handling Spigelian hernias? Surg Endosc 2015;29:856-62.  Back to cited text no. 8
Fernández-Moreno MC, Martí-Cuñat E, Pou G, Ortega J. Intraperitoneal onlay mesh technique for Spigelian hernia in an outpatient and short-stay surgery unit: What's new in intraperitoneal meshes? J Laparoendosc Adv Surg Tech A 2018;28:700-4.  Back to cited text no. 9
Nagarsheth KH, Nickloes T, Mancini G, Solla JA. Laparoscopic repair of incidentally found Spigelian hernia. JSLS 2011;15:81-5.  Back to cited text no. 10
Kelly ME, Courtney D, McDermott FD, Heeney A, Maguire D, Geoghegan JG, et al. Laparoscopic hernia repair: A series of 40 patients. Surg Laparosc Endosc Percutan Tech 2015;25:e86-9.  Back to cited text no. 11
Peterko AC, Kirac I, Cugura JF, Bekavac-Beslin M. Single incision laparoscopic Spigelian hernia repair – An approach with standard instrumentarium. Acta Clin Croat 2013;52:383-6.  Back to cited text no. 12
Bittner JG 4th, Edwards MA, Shah MB, MacFadyen BV Jr., Mellinger JD. Mesh-free laparoscopic Spigelian hernia repair. Am Surg 2008;74:713-20.  Back to cited text no. 13
Barnes TG, McFaul C, Abdelrazeq AS. Laparoscopic transabdominal preperitoneal repair of Spigelian hernia-closure of the fascial defect is not necessary. J Laparoendosc Adv Surg Tech A 2014;24:66-71.  Back to cited text no. 14
Kara D, Merritt D, Kristine K, Joann C, Michael U, John L, et al. (2020). Laparoscopic totally extraperitoneal and transabdominal preperitoneal approaches are equally effective for spigelian hernia repair. Surgical Endoscopy. 10.1007/s00464-020-07582-9.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]

  [Table 1]


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