A spigelian hernia is an uncommon entity [2]. Several authors have suggested that this hernia, however, is largely unrecognised and therefore underreported [6]. The diagnosis of this surgical curiosity often is difficult and intraoperative location troublesome because the defect frequently is hidden behind one or more muscle layers of the abdominal wall. Laparoscopy is an excellent method for locating these hernias, and facilitates accurate repair. We present a case in which the repair of a small but symptomatic Spigelian hernia was facilitated by direct visualisation of the defect at laparoscopy.

Case report

A 42-year-old man presented with a painful bulge lateral to the rectus sheath just below the line of the umbilicus on the left side and an inguinal hernia. He proceeded to inguinal hernia repair and surgical exploration of the suspected spigelian hernia. However, this suspected spigelian hernia could not be identified immediately preoperatively, and despite exploration of the site in question, the hernia could not be demonstrated. He presented again 2 months later with a painful bulge in the same area. Again, on the day of surgery, exact location of the hernia preoperatively was impossible. However, after insertion of a laparoscope via a periumbilical port, a small defect was found at a site 2 cm superior to the site of tenderness. This was repaired under laparoscopic visualization, and an onlay mesh was used to reinforce the repair. Recovery was uneventful, and the patient was discharged the next day.

Discussion

Spigelian hernias can pose a diagnostic dilemma. First described by Klinkosch in 1764, these hernias are readily and easily diagnosed when they are large and easily palpable, but difficult to detect when small. In addition to this, the presenting symptom may be only persistent tenderness rather than a mass, especially if the external oblique aponeurosis remains intact [5].

Various authors have reported the accuracy of ultrasound [7] and computed tomography scan [4] in the diagnosis of spigelian hernia. Spangen [5] recommended preperitoneal dissection through a vertical incision for hernias that cannot be palpated preoperatively. Laparoscopy would seem to be an excellent diagnostic aid to the repair of spigelian hernias [3], preventing the need for a large incision. It allows accurate location of the defect, a precise incision, and repair under laparoscopic visualization. Additionally, the pneumoperitoneum renders tiny defects more obvious. Laparoscopic repair has been reported by a number of authors [1, 3]. The vast majority of hernias, however, still are repaired by the open method. Open repair in conjunction with laparoscopic visualization of the hernial orifice is an excellent approach with minimal morbidity, allowing accurate closure of the defect under direct vision.