Introduction

Spigelian hernia is a lateral ventral hernia observed to be protruding out of the spigelian aponeurosis [1]. Spigelian aponeurosis is the aponeurosis of the transverse abdominis muscle limited laterally by Linea semilunaris and medially by lateral border of rectus abdominis. The major etiological factor is defects in the aponeurosis of transverse abdominis muscle [2]. This hernia arises due to a weakness in the spigelian aponeurosis which might be congenital, iatrogenic, traumatic or due to increased intraabdominal pressure. Spigelian hernia is a rare entity constituting 0.12% of abdominal wall hernias [3]. The occurrence of such a hernia post-surgery is rarer.

Case presentation

A 59-year-old man who is a farmer by occupation presented with complaints of swelling in the right flank and pain abdomen for 2 months. Patient was apparently well 2 months ago when he developed a swelling that was insidious in onset, gradually progressive in the right lumbar region initially small but progressed to present size (6 x 7 cm), aggravated on straining and standing and reduced on lying down. He also complains of pain in the right lumbar region of the abdomen which was insidious in onset, gradually progressive, mild in intensity, of dull aching nature, aggravated on doing activity and straining and relieved on taking rest. He had a past history of robotic pyeloplasty on his right kidney 1 year ago and chronic bronchitis. He has been smoking cigarettes for the past 10 years. He has a BMI of 22.7 kg/m² which is within the normal range. Abdominal examination revealed an ovoid swelling of size 6.5 x 7 cm located in the right lumbar region (Figure 1) which was reducible with an expansile cough impulse. Bowel sounds were heard with no signs of bowel obstruction.

Investigations done include CECT Abdomen, USG abdomen. CECT abdomen revealed a right sided ventral hernia containing bowel loops (Figures 2,3).

Discussion

Patient has a classical presentation of a rare disease including complaints of swelling and pain abdomen without symptoms of intestinal obstruction. The possible risk factors in this particular case include history of lifting heavy weights by the man who is a farmer by occupation, past history of robotic pyeloplasty 1 year ago and history of smoking for the past 10 years. Investigations revealed a ventral hernia on the right side with bowel loops as its content. Surgical intervention was done 5 days after admission. Patient was kept in the post operative room for 2 days and then shifted to the ward. Literature review showed that Spigelian hernia may also occur following laparoscopy [6]. Weakness of the abdominal wall following robotic pyeloplasty due to placement of lateral ports could be a major contributing factor in the development of Spigelian hernia. Possible methods to prevent the occurrence of Spigelian hernia at the lateral port sites would be to ensure suturing of deep fascial layers if the spigelian fascia has been pierced [7]. This highlights the importance of considering the possibility of Spigelian hernia following surgical intervention.

References

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3. Mittal T, Kumar V, Khullar R, Sharma A, Soni V, et al. Diagnosis and management of Spigelian hernia: A review of literature and our experience. J Minim Access Surg. 2008.
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6. Bassi A, Tulandi T. Small bowel herniation through a spigelian defect within 48 hours after laparoscopy. J Minim Invasive Gynecol. 2013.
7. Morrison CP, Wemyss-Holden SA, Iswariah H, Maddern GJ. Lateral laparoscopic port sites should all be closed: The incisional spigelian hernia. Surg Endosc. 2002.