Spigelian hernia in the right upper abdominal wall: a case report | BMC Surgery

• Case report
• Open Access
• Published: 27 November 2018

• Zhou Ye^1 na1,
• Mo-Jin Wang^2 na1,
• Li-Fen Bai²,
• Han-Xiang Zhuang² &
• …
• Wen Zhuang 
  ORCID: orcid.org/0000-0003-3553-6465² 

BMC Surgery
volume 18, Article number: 109 (2018)
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Abstract

Background

Spigelian hernia (SH) is rare and constitutes less than 2% of all hernias. It is reported that more than 90% of SHs lie in the “Spigelian belt”, but SH in the upper abdominal wall is extremely uncommon. Here, we report a case of SH in the right upper quadrant of abdomen.

Case presentation

A 38-year-old female was admitted to hospital with complaints of abdominal pain and right upper quadrant mass for 10 days. Contrast-enhanced computed tomography (CECT) of abdomen revealed the dilated small intestine between the swelling ventral muscles in the right upper abdominal wall which suggested a ventral hernia. The surgeons considered it was a spontaneous hernia because there was no history of surgery or trauma in the upper abdomen. About two hours later, the patient underwent emergency surgery. According to laparotomy, a diagnosis of SH with ileum herniation in the right upper abdominal wall was confirmed. The necrotic ileum segment was resected. Meanwhile the abdominal wall defect was repaired by suturing the internal oblique and transverse muscles to the rectus sheath. The patient had a favorable outcome for 1 year without recurrence.

Conclusion

A mass and pain in the upper abdominal wall may suggest an atypical SH. SH occurring in the upper abdominal wall is a rare condition with possibility of dire outcome if not managed early.

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Background

Spigelian hernia (SH) is named after Adriaan van Spieghel, who depicted the semilunar line in 1645 [1]. The semilunar line is defined as the transition of the transversus abdominis muscle to its aponeurotic tendon [2]. Spigelian fascia is located between the semilunar line and the lateral edge of the rectus abdominis muscle. SH is a spontaneous abdominal hernia caused by a defect in the Spigelian fascia [3]. The hernia is rare and constitutes less than 2% of all hernias [4]. SH occurs anywhere on the Spigelian fascia, but it is reported that more than 90% of these hernias are located in the “Spigelian belt”, which is a transverse 6-cm-wide zone in the lower abdominal wall (Fig.  1) [5]. However, SH occurring in the upper abdominal wall is extremely rare. We present a case of SH in the right upper quadrant.

Fig. 1

The location of Spigelian fascia and “Spigelian belt”

(The image in Fig. 1 was drawn by Zhou Ye)

Full size image

Case presentation

A 38-year-old female patient presented with abdominal pain and right upper quadrant mass for 10 days. She had a history of pregnancy and caesarean section in the lower abdominal region 10 years before, but there was no history of trauma and upper abdominal surgery. Clinical examination showed a huge mass about 15 × 10 cm over right upper abdomen. There was moderate tenderness in the area of the mass, and the abdominal skin was intact and smooth except the lower abdominal surgical scar. Abdominal wall ultrasonography showed mixed echo-mass under the muscle layer of right upper abdominal wall. Contrast-enhanced computed tomography (CECT) of abdomen was performed. The images revealed the dilated small intestine between the swelling ventral muscles in the right upper abdominal wall which suggested a ventral hernia in the right upper abdominal wall (Fig. 2). There was no history of right upper abdominal surgery or trauma, therefore the surgeons considered it was a spontaneous hernia. The patient had much more severe abdominal pain and began to present hematochezia during her hospitalization. Two hours later, she underwent emergency surgery. The intraoperative finding was an atypical ventral hernia, and the ileum loop was incarcerated with necrosis. The hernia sac was located between the semilunar line and the edge of the rectus abdominis muscles in the right upper abdominal wall (Fig. 3), which confirmed it was a Spigelian hernia. The defect size was 2.0 × 1.5 cm. The necrotic ileum segment was resected and end-to-end anastomosis was performed. Considering the small defect and the necrotic ileum, a simple herniorrhaphy was made by suturing the internal oblique and transverse muscles to the rectus sheath. The postoperative course was uneventful, the patient recovered well and was discharged after 1 week of hospitalization. The patient had a favorable outcome for 1 year without recurrence.

Fig. 2

CECT investigation revealed the presence of air between ventral muscles in the right upper abdominal wall

Full size image

Fig. 3

The hernia sac (arrow) was located between the semilunar line and the edge of the rectus abdominis muscles

Full size image

Discussion

Spigelian hernia (SH), also known as spontaneous lateral ventral hernia, usually occurs when abdominal pressure increases. SHs in most cases have explicit predisposed causes, such as chronic coughing, obesity, peritoneal dialysis [6,7,8,9,10,11,12]. The site of the hernia is a significant indicator to identify SH. The Spigelian fascia is wider beneath the umbilical region, so it is weaker than that in the upper abdomen. However, superior to umbilical region, the transverses abdominis muscle and internal oblique muscle often extend into the posterior rectus sheath which makes the Spigelian fascia stronger [3]. Anatomically, SH occurring in the upper abdomen is uncommon. Furthermore, in the upper abdominal wall, the Spigelian fascia is posterior to the rectus muscle, making it difficult even for the experienced surgeon to locate a fascial defect during the physical examination.

Ultrasound is recommended as first line imaging investigation, and CT scanning should be added in challenging cases [13,14,15]. Other studies show that the CT scanning is better than ultrasound, because ultrasound is dependent by the operator [11, 16]. Still, it is reported that only 50% of cases are correctly diagnosed preoperatively [17].

SH is dangerous and the risk of incarceration is higher than other hernias because the defect can be small. It is reported that the risk of incarceration is up to 21%, and thus patients should be offered prompt surgical repair [18]. Surgical procedures are generally classified as open and laparoscopic procedures. The laparoscopic approach should be applied in uncomplicated cases [19, 20]. If the defect is extensive(usually more than 5 cm) and the abdominal wall is obviously destructive, open surgery should be performed [3]. Repairing the defect of SH contains fascial closure or fascial suturing reinforced with synthetic mesh in the cases of large defects [21, 22]. Small hernia defects could be repaired by laparoscopic herniorrhaphy alone [23].

In conclusion, a mass and pain in the upper abdominal wall may suggest an atypical SH. In addition, the risk of strangulation of SH is higher than other hernias. SH occurring in the upper abdominal wall is a rare condition with possibility of dire outcome if not managed early.

Abbreviations

CECT:

Contrast-enhanced computed tomography

CT:

Computed tomography

SH:

Spigelian hernia

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Author notes

1. Zhou Ye and Mo-Jin Wang contributed equally to this work.

Authors and Affiliations

1. Department of Digestive Diseases, The Third Affiliated Hospital of Chongqing Medical University (Gener Hospital), Chongqing, China

   Zhou Ye

2. Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China

   Mo-Jin Wang, Li-Fen Bai, Han-Xiang Zhuang & Wen Zhuang

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Contributions

ZY and MJW designed the study and drafted the manuscript. MJW, WZ, HXZ and LFB contributed case information and participated in data analysis. All authors approved the final version of the manuscript.

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Wen Zhuang.

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Additional files

Additional file 1:

CT 1. CECT investigation revealed the ventral hernia (transverse section 1). (TIF 73 kb)

Additional file 2:

CT 2. CECT investigation revealed the ventral hernia (transverse section 2). (TIF 73 kb)

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About this article

The Different Types of Hernias Explained

A hernia is a common medical condition that happens when your internal organs and tissues protrude through the tough muscle wall of your abdomen. But did you know there are six different types of hernias?

A soft, mushy bulge on the surface of your skin is a tell-tale symptom of a hernia. Small hernias may not be painful, but they can get more serious without medical intervention. An untreated hernia may get larger and block internal organs or blood vessels, triggering a medical emergency.

Identifying and treating your hernia early is the best way to protect your health, and you don’t need invasive surgery to fix it. Hernia repair at the Center for Minimally Invasive and Robotic Surgery is safe and effective.

Rachel Alt, MD, Brian Prebil, DO, and our surgical team regularly perform minimally invasive hernia repair for all the most common types of hernias. Read on to learn more about the different types of hernias, from the rib cage down to the groin.

Hiatal hernia

Your diaphragm is a large muscle in your chest that separates your lungs from your abdomen. If you have a hiatal hernia, part of your stomach pushes through a weak spot in your diaphragm and enters your rib cage.

Hiatal hernias, also called upper stomach hernias, are some of the most common hernias among older adults. Many other types of hernias create a visible bulge in the skin, but a hiatal hernia isn’t easy to see. The most common symptom of a hiatal hernia is acid reflux (heartburn).

Epigastric hernia

The epigastric area of your abdomen is between your rib cage and your belly button. Epigastric hernias form when organs in your upper abdomen (like your stomach) push through the muscle wall.

Epigastric hernias are often small, but they can cause pain and tenderness in the affected area. Pain might be more noticeable with activity that puts pressure on your abdomen, like coughing, sneezing, or laughing.

Incisional hernia

Incisional hernias are a complication of abdominal surgery. Stomach surgery, like gastric bypass, Cesarean sections, and many more necessitate incisions in the abdomen. But sometimes, those incisions don’t fully heal.

If an incisional hernia develops, internal organs push through a weak spot in your abdominal wall near the surgical incision. These hernias can develop anywhere you have an abdominal surgical scar.

Umbilical hernia

Umbilical hernias form in your belly button area. Fat or part of your intestines may push through a weak spot in the muscles around your belly button, creating a visible bulge. Like epigastric hernias, umbilical hernias may be more painful when you strain.

Inguinal hernia

Inguinal hernias are the most common type of hernia. About 27% of men and 3% of women develop an inguinal hernia in their lifetimes. These hernias develop when intestines or fat tissue push through your lower abdominal wall into your groin area.

If you have an inguinal hernia, you might notice a soft lump in your groin (or scrotum, in men). Inguinal hernias can happen on the right or left side of your body, but they’re more common on the right.

Femoral hernia

Femoral hernias develop when tissue pushes through the muscles in your groin or inner thigh. These hernias are small- to medium-sized, and they are more common in women than men.

Femoral hernias are found in the groin, like with inguinal hernias, but they’re located closer to the femoral blood vessels that feed your leg. Femoral hernias may increase your risk of circulation problems because the large lump could block the blood supply to your leg.

What to do about a hernia

Not all hernias cause noticeable symptoms, but a soft bulge in your abdomen or groin should never be ignored. Hernias don’t heal on their own, and you might need surgery to repair the hernia and prevent complications.

Dr. Alt and Dr. Prebil perform highly specialized hernia repair with the da Vinci® robotic surgery system. It’s a minimally invasive technique that combines our surgical expertise with robotic precision. People who choose minimally invasive hernia repair can enjoy shorter recovery times and better outcomes.

Don’t wait to get your hernia examined. Call the office to schedule an appointment at our office in Peoria, Arizona, or request more information online now.

Pain in the right hypochondrium behind: causes and treatment, pain in the right hypochondrium under the ribs

Articles

Reading time 10 minutes e y neurologist and therapist. Sometimes it occurs once, but in some cases it becomes permanent. It is equally common in both men and women. There are a large number of reasons that cause this symptom, from simple to dangerous. If there is pain in the hypochondrium, see a doctor as soon as possible to diagnose.

This article is advisory in nature. Treatment is prescribed by a specialist after consultation.

Causes

The most common causes of pain on the right under the ribs from the back are listed below: Deformation of the spinal column develops due to:

• malformations of intrauterine development;
• back injuries;
• obesity;
• back muscle weakness;
• frequent carrying of weights on one shoulder – bag, backpack;
• improper organization of the workplace – when they sit in one position for a long time with an uneven back.

Varieties

Depending on the nature of the pain on the right back from the back under the ribs is:

• pulling;

• aching;

• piercing;

• blunt;

• shooting.

Depending on the location, pain may occur: in the lumbar region or lower ribs. Painful sensations sometimes spread to the side, shoulder blade, chest, abdomen, lower limbs.

Pain syndrome also occurs by duration:

This is a sudden and severe pain that can persist for hours or even days. The pain intensifies during physical activity and even deep breathing. Indicates an acute pathology or exacerbation of an existing disease. Often in this case, patients prefer to lie on the healthy side and not move. Sometimes the pain syndrome is accompanied by fever, headache, shortness of breath, cough, nausea, and impaired urination.

Diagnosis

Girdle pain behind or in front under the ribs is a non-specific symptom that occurs with a large number of diseases. To find the cause of the pain, the patient is prescribed a detailed examination:

• Poll . The doctor studies complaints, their nature and features of occurrence. It also necessarily specifies past diseases, injuries, operations and other factors that could provoke pain.
• Inspection . The specialist carefully examines and palpates the painful area.
• Radiography . With the help of an x-ray image, the condition of the bones, joint spaces is assessed, and neoplasms are also visualized.
• CT scan is more informative than x-ray examination of bone tissue, as well as some internal organs.
• MRI is prescribed for visualization of soft tissues, internal organs.
• Ultrasound of the abdominal organs. The examination helps to assess the condition of the kidneys, pancreas, liver, gallbladder. Ultrasound of the pelvic organs is also widely used to visualize the female reproductive system.
• Endoscopy . Depending on the characteristics of the clinical case, the patient may be prescribed FGDS and colonoscopy.
• ECG . Assign to exclude pathologies of the cardiovascular system.
  
• Laboratory tests: complete and biochemical blood tests, ESR, rheumatoid factor, etc.

Which doctor to contact

Pain in the right hypochondrium when turning the torso or at rest, at least once in a lifetime, every person has experienced. Most people do not pay attention to this symptom and go to the doctor only when they begin to pull, stab or shoot hard on the back of the back. One of the reasons for the late appeal is banal ignorance. Not everyone knows which specialist to contact in such a situation.

Diagnosis and treatment of soreness on the right and behind from the back are carried out by different specialists, depending on the cause of the symptom. If you are injured, first make an appointment with an orthopedic traumatologist. If the pain occurs during a sharp turn and limits the mobility of the spine, then a neurologist, vertebrologist will help here. This will eliminate the pathology of the musculoskeletal system. In some cases, when the pain is accompanied by other symptoms, you need to consult a surgeon, gastroenterologist, urologist, gynecologist or oncologist.

Make an appointment with an orthopedic traumatologist

Appointment lasts 60 minutes, includes diagnostics, analysis of your MRI and preparation of a treatment plan, takes place both in person and online.

Treatment

The tactics of treating back pain on the right side of the back depends on the etiology of the symptom, it is chosen individually for each patient. Therapy is aimed at:

• pain relief;
• normalization of muscle tone;
• increased mobility of the spinal column and joints;
• prevention of complications;
• improving the quality of everyday life.

In most cases, treatment is conservative. It includes:

• Taking medications

  The doctor determines the type of medication, its dosage, frequency and duration of administration individually. Depending on the characteristics of the clinical case, appoint:

  • non-steroidal anti-inflammatory drugs that reduce pain, relieve inflammation and swelling;
  • muscle relaxants aimed at relaxing muscles;
  • antispasmodics, relaxing the smooth muscles of the internal organs;
  • glucocorticosteroids – relieve inflammation, swelling and redness in the joint area.

• Therapeutic exercise

  Properly selected exercise therapy increases body mobility, eliminates pain and strengthens the muscular frame. Exercises must be performed regularly and with a metered load, without sharp bends, heavy lifting and exercising to exhaustion.

• Physiotherapy

  The following physiotherapy treatments are most effective:

  • laser therapy reduces pain, swelling and improves tissue repair;
  • magnetic therapy is aimed at relieving pain and inflammation;
  • shock wave therapy improves spinal and joint mobility;
  • acupuncture helps to relax muscles and reduce pain.

• Massage

  Therapeutic massage has a beneficial effect on the musculoskeletal system and the muscular frame, and improves overall well-being.

Surgical treatment is used in rare cases, if conservative therapy is not effective for a long time, with absolute indications for surgery, as well as late visits to the doctor. The surgeon decides on the operation individually, after a preliminary diagnosis and an assessment of the balance of benefits and risks.

Treatment depends on the etiology of the pain. Therefore, before drawing up a treatment plan, a comprehensive examination of the patient is carried out.

Consequences

Pain in the right hypochondrium behind can signal a serious pathological process in the body. If this symptom is ignored, complications are possible:

• reduced mobility of the spine and joints;
• spinal deformity;
• paresis and paralysis of limbs;
• chronic pain syndrome with periodic exacerbations;
• spread of the infectious process through internal organs and tissues;
• myocardial infarction;
• peritonitis;
• ankylosis – fusion of bones.

Many of these complications can lead to disability, self-care, and even disability, so don’t wait too long to see a doctor when a symptom occurs.

Prevention

Pain in the back of the right hypochondrium can be prevented by:

• an active lifestyle;

• refusal from activities and sports, accompanied by a high risk of injury;

• proper and rational nutrition;

• maintain water balance – drink at least 2 liters of water per day;

• giving up bad habits;

• weight loss and weight control;

• maintaining correct posture;

• gymnastics – during prolonged work or sitting;

• timely treatment of any pathological processes;

• periodic preventive medical examinations.

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What diseases can cause pain in the right side?

Diseases of the liver and gallbladder

Biliary colic rightfully bears the title of one of the most severe types of pain associated with diseases of the internal organs. It occurs with cholelithiasis, when the stone causes blockage and spasm of the bile ducts.

In chronic cholecystitis, the pain under the right rib, under the pit of the stomach, may radiate under the right shoulder blade. By nature, it is dull, some patients are constantly worried, while others occur in the form of rare attacks. Usually worsening of the condition is provoked by errors in the diet.

Also pain under the right rib can be a manifestation of hepatitis, cirrhosis, liver cancer.

Our expert in this area:

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Deputy chief physician for medical work. Oncologist, surgeon, chemotherapist, Ph.D.

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Acute appendicitis

In acute inflammation of the vermiform appendix – the appendix – the pain first occurs in the entire abdomen or around the navel, and then shifts to the right iliac region. Other possible manifestations: nausea and vomiting, constipation, diarrhea, fever.
If acute appendicitis is suspected, an ambulance should be called immediately. You cannot self-medicate. Laxatives and enemas can lead to rupture of the appendix, and painkillers blur the clinical picture and prevent the doctor from correctly assessing the patient’s condition and symptoms.

Sometimes intestinal colic is hidden under the symptoms of acute appendicitis – this is not a dangerous condition. This is especially common in children. In this case, it is still better to send the patient to a surgical hospital – the doctor will observe him for a while, and if everything is in order, he will let him go home.

Diseases of the urinary system

In terms of strength and pain, renal colic can compete with biliary colic. It is caused by the same reasons – the stone blocks the lumen of the ureter and causes spasm of its wall. Often, an attack is provoked by abundant food and alcohol – often patients are taken to the emergency department of the clinic directly from the feast.

Dull, aching pain in the lower back on the right side may be caused by pyelonephritis, an inflammatory disease of the kidneys. Other possible manifestations: fever, frequent urination, impurities of pus and blood in the urine, weakness.

Problems with the spine

If we talk about back pain on the right, first of all, the “most popular diagnosis” comes to mind – osteochondrosis of the lumbar spine. The pain is usually aching, occurs on one, less often on both sides, intensifies during physical exertion, a long stay in a monotonous position.

Another common cause is a herniated disc, which most often occurs in the lumbar spine, due to the rather high mobility and high loads that the lower back has to experience. Pain occurs, as a rule, on one side, spreads to the buttock, down the back of the leg.

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Gynecological diseases in women

In women, the cause of pain in the lower abdomen on the right is often inflammatory processes in the uterine appendages (adnexitis), ovarian cysts. The intensity of pain is different, they can spread to the groin, leg.

There may be more serious conditions requiring immediate medical attention. For example, a tubal pregnancy, in which the fertilized egg is fixed not in the uterus, but in the fallopian tube. Worried about aching, cutting or cramping pain on the side where the embryo is fixed, prolonged scanty uterine bleeding. A tubal pregnancy threatens to rupture the fallopian tube – a life-threatening condition.

Pain in the right half of the chest

Pain in the chest on the right can be associated with thoracic osteochondrosis, intercostal neuralgia, pneumonia (inflammation of the lung), pleurisy (inflammation of the pleura – a thin film of connective tissue that covers the lungs), diseases of the heart, organs abdominal cavity (gall bladder, liver, pancreas).