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Lateral abdominal wall hernias refer to structural weaknesses in the muscles and fascia along the side of the abdomen. These defects are relatively rare and can be challenging to diagnose due to their location and often subtle presentation. Patients may experience localized pain or discomfort.
The aim of this presentation is to describe a case of a patient with a lateral Spigelian hernia and to demonstrate a minimally invasive technique for its correction.
1. Patient Positioning and Preparation
The patient is positioned supine on the operating table. The surgeon was positioned on the patient’s left side, with the first assistant on the surgeon’s left side.
2. Trocar Placement
A 10mm umbilical trocar is inserted using the open technique. Additional trocars were placed under direct visualization, a 12 mm trocar was placed at a slightly lower level in line with the first trocar and a third trocar of 5 mm was placed at the epigastric region completing the triangulation.
3. Diagnostic Laparoscopy
The laparoscope is introduced through the umbilical trocar to assess the entire abdominal cavity, ensuring no other hernias are present.
4. Identification of the Hernia Defect
The hernia defect in the Spiegel's region is identified. This involves locating the peritoneal defect in the area between the lateral edge of the rectus abdominis muscle and the linea semilunaris, near the arcuate line.
5. Peritoneal Incision
A peritoneal incision is made over the hernia defect to create a peritoneal flap, extending laterally to allow for adequate visualization and access to the preperitoneal space. The incision is made carefully to avoid injury to adjacent structures.
6. Dissection of Preperitoneal Space
The preperitoneal space is carefully dissected using laparoscopic instruments. The peritoneum is gently retrated to expose the hernia sac and surrounding tissues. Hemostasis is achieved as necessary during dissection.
7. Hernia Reduction and Sac Management
The hernia sac is identified and gently reduced into the abdominal cavity.
8. Defect closure
The defect was closure using a barbed suture.
9. Mesh Placement
A prosthetic mesh is selected to cover the defect, after its measure. The mesh is introduced into the preperitoneal space and positioned to cover the hernia defect with a sufficient overlap to prevent recurrence.
10. Fixation of the Mesh
The mesh is fixed in place using cyanoacrylate glue
11. Closure of Peritoneum
The peritoneum is closed using an absorbable barbed suture, ensuring that the mesh remains covered and the integrity of the peritoneal cavity is restored.
Abdominal Hernia
1. Inability to Tolerate General Anesthesia
2. Incarcerated or Strangulated Hernia with Bowel Ischemia
3. Peritonitis or Active Intra-Abdominal Infection
4. Massive Intra-Abdominal Adhesions (from Previous Surgeries)
The surgeon was positioned on the patient’s left side, with the first assistant on the surgeon’s left side. The surgery started with the placement of a 12 mm trocar with direct optical entry at the left para-umbilical region to accommodate a 30-degree camera. One more 12 mm trocar was placed at a slightly lower level in line with the first trocar and a third trocar of 5 mm was placed at the epigastric region completing the triangulation. The upper and lower ports were used as working ports by the surgeon.
The CT scan is essential for surgery planning
1. Semilunar line
2. Arcuate line
3. Inferior Epigastric Vessels
4. Rectus Abdominis Muscle
5. Transversalis Fascia
Advantages of TAPP for Spigelian Hernia:
- Offers a clear view of the anatomy and the defect.
- Provides a tension-free repair with mesh, reducing the risk of recurrence.
- Minimally invasive, leading to less postoperative pain and faster recovery.
Disadvantages:
- More Technically Demanding: The TAPP approach requires advanced laparoscopic skills, especially when handling delicate structures, suturing the peritoneum, or working in a confined space.
- Longer Surgery Duration
1. Intra-Abdominal Access
2 . Potential for Organ Injury
3. Adhesion Formation
4. Bowel Obstruction
None
Drª. Zara Caetano
Muysoms FE, Miserez M, Berrevoet F, et al. Classification of primary and incisional abdominal wall hernias. Hernia. 2009;13(4):407-414. doi:10.1007/s10029-009-0518-x
Review Transabdominal preperitoneal (TAPP) spigelian hernia repair.