Index
If left untreated, it can block part of the intestine or cut off the blood supply to other organs and tissues. This condition can be life threatening.
A Spiegel hernia (or lateral ventral hernia) is a hernia through the Spiegel fascia , which is the aponeurotic layer between the rectus abdominis muscle medially, and the lunate line laterally.
These are generally interparietal hernias, which means that they are not located under the subcutaneous fat but rather penetrate between the muscles of the abdominal wall; therefore, there is often no noticeable swelling.
Spiegel hernias are generally small and therefore the risk of strangulation is high. Most occur on the right side. (4th -7th decade of life). Compared to other types of hernias, they are rare.
A Spiegel’s hernia is a hernia through the Spiegel’s fascia or layer of tissue that separates two groups of abdominal muscles. The muscles are called the rectus and lateral oblique muscles.
This type of hernia is sometimes also called a lateral ventral hernia. Unlike most hernias, Spiegel’s hernias typically do not develop under the layers of fat, but rather between the muscles and the fascia, the tissue that connects them.
Symptoms of spiegel’s hernia
Patients usually present with an intermittent mass, localized pain, or signs of intestinal obstruction.
Ultrasound or CT scan can establish the diagnosis, although CT scan provides the highest sensitivity and specificity.
Symptoms of a Spiegel hernia can be similar to other hernias in the abdomen. This means that it is impossible to diagnose a Spiegel’s hernia on the symptoms alone.
Due to their location between the muscle layers, Spiegel’s hernias tend not to cause noticeable swelling. However, very thin people with visible abdominal muscles may notice some bloating.
Most people with a spigel hernia experience abdominal pain or vague discomfort, especially when the abdominal muscles are strained, such as when standing up or straining to have a bowel movement.
Some symptoms to look out for include:
Pain in the abdomen that seems unrelated to food, illness, or other common sources. Sudden changes in bowel function, such as constipation or a change in stool or bleeding.
Abdominal pain when standing up, coughing or defecating. A mild, unexplained swelling in the abdomen.
Most people do not feel swelling, and there does not need to be noticeable swelling for a spigel hernia to occur.
A spigel hernia can occur on either side of the abdomen, but most people feel pain in the lower abdomen.
A spigel hernia can block the intestine or other vital organs. When this occurs, it is a life-threatening complication that requires immediate medical attention.
Symptoms of a blockage include:
Severe, excruciating abdominal pain that may come on suddenly or appear after a long period of less severe pain.
Nausea and vomiting accompanied by severe pain, particularly when apparently not related to food or a virus.
Not having a bowel movement for several days, especially if this is accompanied by severe stomach pain. The appearance of blood in the stool.
Causes of spiegel’s hernia
Spiegel’s hernias develop within a weakened area in the muscles of the abdominal wall.
The weakened area can be something a person is born with, or it can develop over time. If it develops over time, it may be due to injury or increased pressure within the abdominal cavity.
This weakened area allows tissues and organs to pass through Spiegel’s fascia. Risk factors for a Spiegel hernia include:
A chronic cough, as with the lung condition “Chronic Obstructive Pulmonary Disease.” You often strain to have a bowel movement.
Trauma to the abdomen, such as during surgery or due to a serious injury. You often strain to lift heavy objects.
Fluid in the abdomen from conditions such as liver problems. Being overweight. Be pregnant.
Where do spiegel’s hernias manifest?
Spiegel hernias occur through slit-shaped defects in the anterior abdominal wall adjacent to the lunate line extending from the tip of the ninth costal cartilage to the pubic spine at the lateral border of the rectus muscle inferiorly.
Most Spiegel hernias occur in the lower abdomen where the back covering is poor. Also called “spontaneous lateral ventral hernia” or “lunate line hernia.”
Diagnosis of spiegel’s hernia
Diagnosing a Spiegel’s hernia can be difficult, so it is important to report symptoms to your doctor.
The hernia ring is a well-defined defect in the transverse fascia. The hernia may be interparietal with no obvious mass on inspection or palpation.
An ultrasound or CT scan of the abdomen can help with a diagnosis.
It may also be helpful to consult a general surgeon, as these specialists have extensive knowledge of hernias, including Spiegel’s hernias.
A Spiegel’s hernia can also be discovered during surgery or procedures done for other reasons, including:
- A bowel obstruction or blockage.
- Exploratory surgery.
- Surgery for another type of hernia.
- Gynecological surgery.
- Colonoscopy for colon cancer screening.
To diagnose a spigel hernia, a doctor will take a complete medical history and perform an exam to rule out other medical problems.
An ultrasound can detect most cases. Doctors also sometimes use CT or CT scans. Both are safe and non-invasive diagnostic tests that allow the doctor to visualize the muscles, intestines, and abdominal wall.
However, if the diagnosis is unclear, a doctor may suspect a hernia without knowing what type. They may decide to perform exploratory surgery to locate and repair the hernia.
Spiegel hernia treatment
A spigel hernia requires surgery to repair it. These hernias must be repaired due to the high risk of strangulation; surgery is straightforward, with larger defects requiring a mesh prosthesis.
Various Spiegel hernia mesh repair techniques have been described, although evidence suggests that laparoscopy produces less morbidity and shorter hospital stay compared to open procedures.
Laparoscopic suture repair without mesh is feasible and safe.
This new hassle-free approach to small Spiegel hernias combines the benefits of laparoscopic localization, reduction, and closure without the morbidity and cost associated with foreign material.
A minimally invasive surgery called laparoscopic hernia repair uses a small incision to guide a tube and camera into the abdomen. With the help of the camera, doctors locate the hernia and then use a mesh patch or stitches to repair the weakened abdominal wall.
A more invasive alternative involves a larger incision in the stomach. This surgery allows the doctor to see the hernia directly and then repair the damaged tissue.
A 2002 study compared laparoscopic and more conventional invasive surgery to repair Spiegel’s hernias in two groups of 11 people. Laparoscopic surgery produced fewer complications.
This suggests that it may be a preferred option for most people without complex hernias.
When a spigel hernia traps a portion of the intestine, surgery may need to be done right away.
Surgery can also take longer and be more complex, depending on how extensively the intestine and other tissues and organs are affected.
Spiegel’s hernia has been repaired by conventional and laparoscopic approaches. Most of the time, when laparoscopy has been used as a treatment modality for Spiegel’s hernia, it has been performed by the transabdominal approach.
Total extraperitoneal repair (TEP) of Spiegel’s hernia has also been reported in the literature.
The advantage of the total extraperitoneal repair approach is that it eliminates the complications associated with violating the peritoneal layer to reach the preperitoneal space.
Clinical presentation
Symptoms can range from abdominal pain, a lump in the anterior abdominal wall, or the patient may have a history of incarceration with or without intestinal obstruction.
Pain varies in type, severity, and location, and depends on the content of the hernia. Pain can often be provoked or aggravated by maneuvers that increase intra-abdominal pressure and is relieved with rest.
If the patient has a palpable lump along Spiegel’s fascia, the diagnosis is obvious. The same applies if the hernia appears when the patient is upright and disappears spontaneously when lying down.
The clinical diagnosis of hernia is complicated by the fact that the defect continues to expand laterally and caudally between two oblique muscles. Some patients have abdominal pain but do not have lumps.
For these patients, radiological investigations are required for diagnosis. If after radiological investigation the diagnosis is uncertain, a diagnostic laparoscopy can be performed.
Operational Techniques
Conventional approach
A transverse incision is located over the protrusion. The external oblique aponeurosis is performed in the direction of its fibers to expose the peritoneal sac.
The most common sac content is the omentum, but cases of the intestine, appendix, gallbladder, stomach, or ovary have been reported.
Most surgeons simply invert the sac on its own. The hernial orifice can be closed with sutures or a prosthetic patch placed in the preperitoneal space or above the fascia.
Endoscopic approaches
Intraperitoneal Onlay Mesh Repair (IPOM), intraperitoneal access is performed with the Veress needle or open technique.
Once abdominal access is obtained, the site of the hernial orifice is easily identified and the ports are placed at least 10 cm from the hernial defect in the form of an arc of a circle with the center of the hernial defect.
The content is reduced from the sac and adhesiolysis is performed if necessary to obtain a 5 cm overlap around the defect for a synthetic mesh. The mesh is fixed using a combination of transabdominal sutures and studs.
Transabdominal preperitoneal repair
Once the contents of the hernial sac are reduced, a peritoneal flap is lifted as in the trans abdominal preperitoneal approach (TAPP) and an attempt is made to reduce the hernial sac completely.
After dissecting the peritoneal flap for approximately 5 cm around the hernial defect, Prolene mesh is placed in the dissected extraperitoneal space and tacked. The peritoneal flap is closed with tacks or with a running suture.
Total extraperitoneal repair
Total extraperitoneal repair is performed using 3 midline ports. The extraperitoneal space is created by open access and a balloon.
The Siberian hernial sac is identified around the arcuate line and is completely reduced. The peritoneum is dissected above the arcuate line to have a 5 cm margin around the hernial defect for mesh overlap.
A Prolene mesh is used to cover the hernial defect. The mesh is attached to the anterior abdominal wall with spiral tacks.
Eponym
Adriaan van den Spiegel, a Brussels-born surgeon anatomist, described this hernia. The first publication was in 1645, twenty years after Spiegel’s death.
Raveenthiran syndrome
The Dr. Raveenthiran , described a new syndrome in which Spiegel hernia and cryptorchidism (undescended testis) occur together.
The recovery period for laparoscopic splegic hernia surgery tends to be relatively short, lasting 1 to 2 weeks. People who have more extensive surgery often have a longer recovery period.
People who experience complications, such as a bowel obstruction or infection, may also require longer recovery times.
A person should report any new symptoms to a doctor. Fever, severe pain, or unexplained bleeding may mean there are complications with recovery.
Most people can resume normal activities within 4 to 6 weeks, and light activities, such as walking and driving, can begin 1 to 2 weeks after surgery.
A person must strictly follow the recommendations and advice of their surgeon to obtain the best possible results during recovery.
People who have had a hernia before are more likely to have another hernia.
However, a 2002 study followed up with 76 people who had undergone Spiegel hernia surgery an average of 8 years later. He found that only three had experienced another hernia.
The results suggest that most people who receive surgery for a spigel hernia are unlikely to have another hernia in the following years. Your risk, however, is still higher than that of people without a history of hernias.
History and discussion of Spiegel’s hernia
Spiegel’s hernia is named after Adriaan van Spieghel, who described the lunate line. However, the hernia was first described by Klinkosch in 1764. The hernia appears to reach its peak in the fourth to seventh decades.
The ratio of males to females is 1: 1.18. Spiegel hernias are very rare, constituting only 0.12% of all abdominal wall hernias.
Spiegel’s hernia can be congenital or acquired. The perforating vessels can weaken the area in the Spiegel’s fascia and a small lipoma or fat enters here which gradually leads to the formation of hernias.
Spiegel’s hernia may be related to stretching in the abdominal wall caused by obesity, multiple pregnancies, previous surgery, or scarring.
Spiegel’s hernia has been described as a complication of chronic ambulatory peritoneal dialysis (CAPD).
The Spiegela aponeurosis is broader 0–6 cm cranial to the interspinous plane and 85–90% of hernias are within this “Spiegela hernia” belt.
The hernial ring is a well-defined defect in the aponeurosis.
The hernial sac, surrounded by extraperitoneal fat, is often interparietal that passes through the transverse and internal oblique aponeurosis and then extends below the intact external oblique aponeurosis, or extends into the rectus sheath along the muscle right.
The diagnosis of a Spiegel hernia is difficult; Few surgeons suspect it, it has no characteristic symptoms, and the hernia may be interparietal with no obvious mass on inspection or palpation.
Only 50% of cases are diagnosed preoperatively. It can present as a swelling adjacent to the iliac crest. The patient may have a classic lump when standing up.
The lump is painful if the patient stretches and disappears when lying down. Sometimes local discomfort can be mistaken for peptic ulceration.
Rarely the hernia can enter the rectus sheath and can be confused with spontaneous rupture of the rectus muscle or with a hematoma in the rectum sheath.
Ultrasound is recommended as a first-line imaging investigation. With this help, the correct diagnosis was obtained in 19 of the 24 cases studied.
Ultrasonic examination of the semilumar line should be performed in all patients with obscure abdominal pain associated with protrusion of the abdominal wall in the standing patient.
The advantages of real-time ultrasonography is the ability to perform examinations both in the supine and upright positions and while the patient is performing a Valsalva maneuver.
Now, the CT scan with thin and narrow sections is considered the most reliable technique for making the diagnosis in doubtful cases.
The use of oral contrast medium is recommended during the examination so that any intestinal content can be identified.
The increasing availability of magnetic resonance imaging (MRI) may be beneficial in the preoperative evaluation of these difficult cases.
The differential diagnosis includes appendicitis and appendicular abscess, a tumor of the abdominal wall or a spontaneous hematoma of the rectum sheath, or even acute diverticulitis.
Spiegel hernias are treacherous and have a real risk of strangulation. The risk of strangulation is greater due to a sharp fascial margin around the defect.
The Richter type of hernia has also been reported to occur with Spiegel’s hernia. For this reason, surgery should be recommended in all patients.
Surgery can be performed by open technique or laparoscopically. Carter and Mizes performed the first laparoscopic intra-abdominal Spiegel hernia repair in 1992. They used sutures to close the defect.
After that, there have been multiple reports of successful management of Spiegel’s hernia by laparoscopy. In these reports, the mesh is placed intraperitoneally or extraperitoneally after creating a peritoneal flap by the transabdominal approach.
In the only prospective randomized controlled trial comparing conventional versus laparoscopic treatment of Spiegel’s hernia (11 conventional and 11 laparoscopic), there was a significant advantage in terms of morbidity and hospital stay in the laparoscopic group.
There have also been case reports of treating Spiegel’s hernia by total extraperitoneal approach.
The advantage of extraperitoneal mesh placement is that Prolene mesh can be used, reducing the cost of the procedure.
The incidence of complications such as intestinal obstruction and fistulization of the intestine is also expected to decrease (which can occur with intraperitoneal mesh placement).
Compared to the transabdominal extraperitoneal approach, the total extraperitoneal repair approach eliminates the complications associated with violating the peritoneal layer to reach the preperitoneal space.
The need to close the peritoneal flap with tacks or sutures (in the trans abdominal pre-peritoneal approach) also increases surgical time and cost.
Conclution
It can be tempting to delay seeking treatment for sudden abdominal pain. This reaction can be especially true if the pain goes away for a while. However, Spiegel’s hernias present serious medical risks.
They are relatively easy to treat, and most people will not need surgery again. So when the signs of a Spiegel hernia appear, people should see a doctor.
