Spigelean hernia

spigelean hernia repair, definition
anatomy
pathophysiologie
different technique

1. Spigelean hernia Georges KHALIFEH FFI GHPSO Chirurgie digestive et visceral

2. Enonym Adriaan van den Spiegel , born in  Brussels , was an anatomist  at the  University of Padua  during the 17th century. In 1619 he became a professor of surgery.  Spiegel  was the first to described this rare hernia in 1627 .  The history of the Spigelian hernia became acknowledged in 1645, twenty years after Spiegel's death. In 1764, almost a century later, the  Flemish  anatomist, Josef Klinkosch was acknowledged for recognizing and describing a hernia located in the Spigelian   fascia , and coined the term Spigelian hernia.

3. They are rare and account for ~1% (range 0.1-2%) of ventral hernias.

4. Epidemiology Review of the literature (876 patients) Female-to-male ratio was 1.4:1 Right-to-left-side ratio was 1.18:1. Twenty-nine instances of bilateral hernias were reported. In 6 patients, there was more than 1 hernia on the same side. 29 of the hernias were located above the umbilicus. Most spigelian hernias have been diagnosed in patients between 40 and 70 years of age. Twenty eight children , 17 boys and 11 girls, younger than 16 years of age were operated on for spigelian hernia. Incarceration at the time of operation was seen in t01 of 419 reported hernias (24.1 %).

5. ANATOMY L inea semilunaris ( Spigelii ): This is the line forming and marking the transition from muscle to aponeurosis in the transversus abdominis muscle The part of the aponeurosis that lies lateral to the rectus abdominis muscle is usually called the spigelian fascia .

6. Spigelian hernia belt A hernia may occur throughout the length of the spigelian aponeurosis . The term spigelian hernia usually refers to hernias located above the inferior epigastric vessels. About 9 of 10 of these hernias occur within a transverse belt lying 0-6 cm cranial to the interspinal plane

7. A bove the umbilicus 29\876 A bove the umbilicus the fibers of the transversus abdominis and internal oblique muscles cross one another at angles , making herniation more unlikely than if the fibers were to run parallel, as they do below N the umbilicus .

8. low spigelian hernias caudal and medial to the inferior epigastric artery within the Hesselbach triangle

9. POSSIBLE LOCATION OF THE HERNIA SAC A hernial sac can easily expand in this space and, therefore , adopts a typical T- or mushroom-shaped appearance. The space is largest laterally , so large spigelian hernias can be palpated laterally to the spigelian aponeurosis . That the hernia is palpated more laterally than the location of the hernia orifice often makes it more difficult to diagnose. The external aponeurosis is so thick that it is rarely penetrated by the hernia. This explains why only 15 of 876 patients have been reported to have a subcutaneously located hernial sac.

10. POSSIBLE LOCATION OF THE HERNIA SAC Most spigelian hernias are interstitial , that is, the sac penetrates through the transversus aponeurosis and internal oblique muscle but dissects under the external oblique. The hernia sac consists of peritoneum and occasionally bands from the transversalis fascia and is often preceded by preperitoneal fat.

11. The defect is usually small, with rigid edges All sizes have been reported, but most necks vary from 0.5 to 2.0 cm, although some have been described as large as 4.0 to 6.0 cm

12. MORBIDITY They usually contain small intestine or omentum but may include any viscus or organ. Richter’s hernia and sliding hernias have been associated with spigelian hernia Up to one third of reported cases have been incarcerated at the time of operation .

13. Pathology congenital or acquired Defects in the aponeurosis of transverse abdominal muscle (mainly under the arcuate line and more often in obese individuals) have been considered as the principal etiologic factor.

14. Pathology congenital or acquired Pediatric cases, especially neonates and infants, are mostly congenital A Spigelian hernia is associated with ipsilateral   cryptorchidism  among 75% male infants  . Two hypotheses have been proposed to explain the association, but the exact mechanism is still in debate Spigelian -cryptorchidism syndrome  (failure in the development of a gubernaculum)  Raveenthiran syndrome  (ectopic testis from a potential hernia sac)

15. Raveenthiran syndrome Dr. Raveenthiran of SRM Hospital, Kattankulathur described a new syndrome in which Spigelian hernia and  cryptorchidism  (undescended testis) occur together. Some common complications of this distinct syndrome   cryptorchidism  are  testicular torsion , and its link to testicular cancer

16. Spigelian -cryptorchidism syndrome a  The Spigelian hernia sac after dissection,  b  the Spigelian hernia sac containing a normal testis without gubernaculum and a loop of small intestine with compromised circulation

17. Location The hernial orifice of a Spigelian hernia is located in the Spigelian fascia , that is, between the lateral border of the rectus abdominis muscle and the  semilunar line , through the transversus abdominis aponeurosis , close to the level of the  arcuate line . The majority of Spigelian hernias are found in a transverse band lying 0-6 cm cranial to a line running between both anterior superior iliac spines referred to as the Spigelian hernia belt . Most Spigelian hernias occur in the lower abdomen where the posterior sheath is deficient

18. DIAGNOSIS The diagnosis of a Spigelian hernia at times presents greater challenge than its treatment. The clinical presentation varies, depending on the contents of the hernial sac and the degree and type of herniation . The pain , which is the most common symptom, varies, and there is no pain typical to a Spigelian hernia. Findings to facilitate diagnosis are a palpable hernia and a palpable hernial orifice . It should be stressed, though, that since the hernia lies deep to a muscle, it commonly does not cause a noticeable bulge in the abdominal wall.

19. Radiographic features Ultrasound Ultrasound can be recommended for verification of the diagnosis in both palpable and nonpalpable Spigelian hernia . CT The hernial orifice and sac can be well demonstrated by computed tomography, which gives more detailed information on the contents of the sac than does ultrasound scanning.

20. Treatment Anterior herniorraphy + mech Laparoscopic: Primary closure TEP totally extraperitoneal TAPP transabdominal preperitoneal IPOM intra abdominal ONLAY mesh

21. Herniorraphy par abord direct

22. Hernioplastie prosthetique par abord direct

23. Suture sous celioscopie

24. IPOM

25. 2002

26. Conclusion Laparoscopic technique : morbidity , hospital stay ,As outpatient Non complicated SH we recommend TEP If associated hernia TAP Anterior hernioplasty for complications or emergency

27. How to best handle with recurrence Which mesh and how should it be fixed?

28. TAPP and IPOM Easy Precise location of the defect Access to hernia contents Concomitant treatment of any other pathology( hernia ) Efficient and safe in emergencies

29. Which mesh and how should it be fixed? Standard polypropylene mesh (TEP preserved peritoneum TAPP)) Composite mesh

30. How to best handle with recurrence? Recurrence rate 5-14% Larson (70 patients): repaired using simple suture (recurrence rate 4.3 %) Bames (26 patients): zero recurrences after laparoscopic surgery (F/U 4 year) Some authors mesh for defect >2 cm or weak local tissue Open and laparoscopic both safe similar results Patient settings (SH is unique ) Intra abdominal laparoscopic approach is most advisable for recurrent cases

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