Computed tomographic evaluation of spigelian hernia

High-resolution ultrasound of spigelian and groin hernias: a closer look at fascial architecture and aponeurotic passageways

From the clinical point of view, a proper diagnosis of spigelian, inguinal and femoral hernias may be relevant for orienting the patient's management, as these conditions carry a different risk of complications and require specific approaches and treatments. Imaging may play a significant role in the diagnostic work-up of patients with suspected abdominal hernias, as the identification and categorization of these conditions is often unfeasible on clinical ground. Ultrasound imaging is particularly suited for this purpose, owing to its dynamic capabilities, high accuracy, low cost and wide availability. The main limitation of this technique consists of its intrinsic operator dependency, which tends to be higher in difficult-to-scan areas such as the groin because of its intrinsic anatomic complexity. An in-depth knowledge of the anatomy of the lower abdominal wall is, therefore, an essential prerequisite to perform a targeted ultrasound examination and discriminate among different types of regional hernias. The aim of this review is to provide a detailed analysis of the fascial architecture and aponeurotic passageways of the abdominal wall through which spigelian, inguinal and femoral hernias extrude, by means of schematic drawings, ultrasound images and video clips. A reasoned landmark-based ultrasound scanning technique is described to allow a prompt and reliable identification of these pathologic conditions.

Epiploic appendage torsed within a spigelian hernia: US and CT findings

We report the sonographic and CT findings in a patient with an epiploic appendage strangulated within a Spigelian hernia sac. The patient presented with a small, tender, palpable mass, which, at sonography, was located within the abdominal wall, lateral to the rectus abdominis muscle, and had the appearance of an inflamed epiploic appendage. The same findings were confirmed by unenhanced CT. Surgery showed an epiploic appendage of the sigmoid colon within a small Spigelian hernia; the appendage was torsed around its pedicle at the entrance into the hernia sac.

Computed tomographic diagnosis of appendicitis within a spigelian hernia

A Spigelian hernia is a rare abdominal wall hernia diagnosed with ultrasonography or computed tomography. We report the first case of acute appendicitis within a Spigelian hernia diagnosed by computed tomography.

Primary and unusual abdominal wall hernias

Primary ventral hernias can be congenital or acquired, but are not associated with a fascial scar or related to a trauma. Some ventral hernias such as Spigelian, lumbar, or obturator hernias represent a diagnostic challenge, given their relative rarity and their unusual anatomic locations. The article presents the etiology, clinical presentation, and diagnosis of these hernias, and briefly describes the various surgical approaches, including open and laparoscopic.

Congenital spigelian hernias and cryptorchidism

PURPOSE

Spigelian hernias in childhood are rare. Only 24 infants in the English literature have been identified to have spigelian hernias, and 12 of these have been associated with cryptorchidism. Spigelian hernias are more commonly seen in the adult population and are considered to be acquired because they are typically associated with trauma or other etiologies of increased intraabdominal pressure. In the infant however, the etiology remains unclear, but a congenital defect in abdominal wall development is suspected.

METHODS

We discuss the presentation and treatment of 4 additional patients with spigelian hernias (2 siblings included) associated with cryptorchidism.

RESULTS

The hernias occurred within the well-described spigelian hernia belt in the semilunar line at the level of the semicircular fold of Douglas. Of the 6 repaired spigelian hernias, 5 were closed primarily with absorbable suture similar to previously reported cases; the sixth hernia required a patch closure because of its large size. All cryptorchid testes (7) were repaired in single-stage orchiopexies.

CONCLUSIONS

Spigelian hernias are rare entities in infants. We present 4 new cases of spigelian hernias associated with cryptorchidism and, with previously reported cases, discuss the probability of a congenital origin of these hernias in infants.

Pre-operative sonographic diagnosis of incarcerated neonatal Spigelian hernia containing the testis

BACKGROUND

Spigelian hernia (SH) is a ventral hernia that occurs along the semilunar line formed by the fibrous union of the rectus sheath and the anterior abdominal wall muscles, usually containing small bowel segments, omental fat or both. Spigelian hernias are rare in adults and exceedingly rare in children. A few case reports describing SH in the paediatric population have been published and an association with cryptorchidism has been very rarely reported.

OBJECTIVE

To report three examples of SH.

RESULTS

We describe three examples of SH containing incarcerated testis in two neonates. These were diagnosed preoperatively with US. Ultrasound-guided reduction of the hernia contents was performed successfully in one case.

CONCLUSIONS

Ultrasound plays an important role in the diagnosis and management of these hernias.

Abdominal wall hernias: a cross-sectional pictorial review

The classification of abdominal wall hernias is often made difficult by confusing eponymous and anatomic nomenclature. In this article, we review the anatomy that defines the various types of hernias. The specific cross-sectional radiologic features required to correctly identify each type are then emphasized. The appropriate clinical context and the merits of the various imaging techniques available for the investigation of abdominal wall hernias are also discussed.

Demonstration of para-ileostomy herniation using computed tomography

Twenty-eight patients with end ileostomies underwent localised computed tomography (CT) of the ileostomy region. Para-ileostomy herniation was demonstrated in 10 patients. In two of these the hernia was not detectable clinically. This incidence (36%) is higher than that reported previously. Herniation was associated with a larger defect in the anterior abdominal wall at the stomal site and was more common lateral to the stoma. No association was shown between herniation and the underlying disease process, or to the site of the stoma relative to the rectus abdominis muscle. Demonstration of a hernia by clinical examination or CT was important in clinical management decisions. CT is recommended in patients with stoma-related symptoms or unexplained abdominal symptoms following ileostomy formation when a para-stomal hernia is suspected, but clinical examination is negative.

Spigelian hernia

The diagnosis of spigelian hernia presents greater difficulties 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 typical pain of spigelian hernia. Findings to facilitate diagnosis are palpable hernia and a palpable hernial orifice. Large, easily palpable spigelian hernias are not a diagnostic problem. It is small hernias and hernial orifices that are overlooked because they are masked by the subcutaneous fat and an intact external aponeurosis. In the absence of a palpable orifice or sac, persistent point tenderness in the spigelian aponeurosis with a tensed abdominal wall most strongly suggests the diagnosis. Spigelian hernia can be ruled out in patients without palpable tenderness. Ultrasonic scanning can be recommended for verification of the diagnosis in both palpable and nonpalpable spigelian hernia. The hernial orifice and sac can also be demonstrated by computed tomography, which gives more detailed information on the contents of the sac than does ultrasonic scanning. The treatment of spigelian hernia is surgical, and the risk of recurrence is small. A gridiron incision is excellent for operations for palpable hernias. If the hernia cannot be palpated preoperatively, preperitoneal dissection through a vertical incision is recommended. This gives good exposure, facilitates hernioplasty, and permits preperitoneal exploration and treatment of other abdominal wall hernias. The incision is also suitable for exploratory laparotomy, which should be performed on patients with abnormal ultrasonographic or computed tomographic findings in whom no palpable hernia can be detected preoperatively.