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Answer: Combined Spigelian and Richter Hernias
Figure 1shows an anterior abdominal wall defect at the junction of the semilunar line and lateral border of the left rectus sheath with a loop of incarcerated bowel. A laparoscopic repair was planned. Insufflation of the abdomen caused spontaneous reduction of the combined spigelian and Richter hernias. The bowel was examined and the wall did not appear ischemic. The abdominal wall defect was easily appreciated (Figure 2). A large peritoneal flap was created, including the hernia sac, to expose the musculoaponeurotic walls of the defect. A large piece of polypropylene mesh was used to cover the defect and create a tension-free repair. The peritoneum was then rolled over the mesh and tacked in place to avoid direct contact between the mesh and the viscera. The patient was discharged from the hospital after 18 hours. He has since been seen in follow-up and all bowel symptoms have resolved and he is doing well.
Computed tomographic scan showing bowel incarcerated within a hernia sac at the junction of the lateral border of the left rectus sheath and semilunar line.
Intraoperative photograph of the abdominal wall defect.
Combined spigelian and Richter hernias are extremely rare, with only 3 case reports in the English-language literature.1-3Although complete or partial bowel obstruction is not classically associated with Richter hernias, ischemia of a portion of the bowel wall is a common finding and the serosa always needs to be examined. This is because a portion of the bowel wall is trapped within the hernia and the neck of the hernia sac can compress the venous outflow. The succus entericus can still pass through and patients rarely present with obstruction. However, a partial bowel resection may be necessary to resect the ischemic segment.
Since this can be accomplished laparoscopically, minimally invasive techniques are gradually replacing open repair for the treatment of spigelian, ventral, epigastric, and incisional hernias when visceral incarceration may be present. In addition, laparoscopy allows easier identification of the margins of the hernia defect, a larger field of vision, examination of the entire abdominal cavity, and the performance of any additional procedures, if necessary. In this case, the patient was also found to have a recurrent left inguinal hernia that was repaired by the transabdominal preperitoneal technique without the need for a second incision.
Another option would have been to perform an open repair directly over the defect through a small incision. This could be done with local anesthesia only and would spare the patient a general anesthetic, with its associated risks in an elderly patient such as the one described.
In conclusion, spigelian hernia should be considered in the differential diagnosis of patients with focal, unilateral abdominal pain. Computed tomography is an excellent tool to aid in the diagnosis since this type of hernia can be difficult to detect on physical examination.
Correspondence:John Alfred Carr, MD, FCCP, Passavant Surgical Associates, Passavant Area Hospital, 1600 West Walnut St, Jacksonville, IL 62650 (email@example.com).
Accepted for Publication:August 17, 2006.
Financial Disclosure:None reported.
Image of the Month—Diagnosis. Arch Surg. 2007;142(8):800. doi:10.1001/archsurg.142.8.800
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