there is a weakness in the spigelian fascia that gives rise to a spigelian hernia , and this may be either congenital or acquired .
spigelian hernias were named after the flemish anatomist , adrian van den spiegel , who was the first to describe the semilunar line .
however , it was josef klinkosch who was credited for recognizing a clinical entity associated with the spigelian area in 1764 .
spigelian hernias are rare , representing only 12% of abdominal wall hernias , with a slightly higher incidence in women .
here we discuss a case of a spigelian hernia discovered through diagnostic laparoscopy , in the absence of pertinent physical exam or imaging findings .
we present the case of a 75-year old , obese female who presented to our facility for evaluation of left lower quadrant abdominal pain that radiated to the lower back , daily , after a transvaginal bladder suspension surgery performed last year .
the pain was described as an intense , intermittent pain , exacerbated by abdominal flexion and partially alleviated by evacuations and sometimes spontaneously . in review of systems the patient denied changes in bowel functions , hematuria or vaginal discharge .
patient s past medical history reveals hypertension , dyslipidemia , gerd , diabetes mellitus , osteoporosis , arthritis , recurrent utis , and thyroid disease .
her surgical history revealed a prior lumbar laminectomy , appendectomy , abdominoplasty , hysterectomy and lysis of adhesions .
she had been seen multiple times by multiple specialists for this pain without any success in reaching a proper diagnosis .
the abdominal computerized tomography ( ct ) showed no evidence of acute abdominopelvic disease but reported findings consistent with constipation . due to the persistence and severity of the patient s symptoms , and the lack of definitive evidence from ct and ultrasound , the decision was made to take the patient in for a diagnostic laparoscopy .
after adequate preparation , a 5  mm camera was inserted at the level of the umbilicus . upon entry into the abdominal cavity no evidence of bleeding or injury to internal organs
was noted , multiple adhesions were visible in the area of the left lower quadrant and right lower quadrant , and were subsequently lysed using the harmonic scalpel . upon removal of these adhesions ,
a spigelian hernia was visible in the left lower quadrant , containing a segment of omentum ( fig .
1 ) . there was no relationship between the previous laparotomy incision site and the location of the spigelian hernia found .
two additional 5  mm ports were placed , one at the left midclavicular line in the left upper quadrant and another at the right midclavicular line in the right upper quadrant .
the segment of omentum trapped inside the spigelian hernia was reduced and resected using a harmonic scalpel , which permitted visualization of the defect in the spigelian fascia ( fig .
3a ) and then secondarily reinforced using a 4    6  inch proceed mesh secured with sutures at the 3 and 9 oclock position and then anchored to the abdominal wall using the securestrap fixation device ( fig .
postoperatively , the patient made an uneventful recovery and was discharged on the first postoperative day .
spigelian hernias are ventral hernias that occur at the linea semilunaris ; most often where it crosses douglas line 
spigelian hernias occur through the spigelian fascia which is composed of the aponeurotic layer between the rectus muscles medially , and the semilunar line laterally .  .
the spigelian fascia is the space between the lateral border of the rectus abdominis and the semilunar line , also called the spigelian line .
spigelian hernias are also referred to as hernias of the semilunar line , hernias through the conjoint tendon , or as spontaneous lateral ventral hernias .
as previously mentioned , they are a rare form of hernia , representing less than 2% of all abdominal hernias .
spigelian hernias may occur secondary to increased intraabdominal pressure due to obesity , pregnancy , chronic cough and prostate disease .
additionally , a history of previous abdominal surgeries may predispose patients to the development of spigelian hernias due to the resultant weakening of the semilunar line .
they tend to develop during the fourth to seventh decade of life , with a higher prevalence in females .
it is believed that they develop as a result of weakness in the fascia created by perforating vessels .
these hernias have a very narrow neck , increasing the risk of incarceration and strangulation , .
studies suggest that the risk of incarceration could be as high as 20% at the time of diagnosis .
therefore , the presence of a spigelian hernia is an indication for its surgical repair . once repaired , reoccurrence is uncommon , .
spigelian hernias can be repaired using an open conventional approach , or laparoscopic repair . despite the increased popularity of the laparoscopic approach
an open approach is more feasible in emergent presentations associated with viscus incarceration , as this prevents undue delays and allows for rapid reduction with possible revival of ischemic tissues , as well as reduction of the rate of iatrogenic bowel injury during trocars insertion for the laparoscopic approach  .
although direct approximation may be performed , studies have shown a distinct advantage in recurrence rates with the usage of prosthetic mesh .
a prospective randomized trial comparing outcomes in patients who underwent open repair vs. those who underwent laparoscopic repair showed an advantage regarding morbidity ( p  <  0.05 ) and hospital stay ( p  <  0.001 ) , for those who underwent laparoscopic repair .
the study took 11 patients who underwent open repair and compared their outcomes with 11 patients who underwent laparoscopic repair .
they reported an average hospital stay of five days for the open repair group vs. one day for the laparoscopic group .
this study demonstrated a clear advantage to the laparoscopic approach in terms of hospital stay and morbidity . when done laparoscopically , the trans - abdominal approach is preferred .
the advantage of tep repair is that it significantly decreases the risk of complications related to penetrating the peritoneal layer , therefore decreasing adhesions and additional complications , . in our case ,
the tep approach was not employed because the diagnosis was made only after inserting a laparoscope into the peritoneal cavity .
another consideration besides the surgical approach is the method used for fixation of the mesh .
huber and colleagues described a novel approach using a fibrin sealant in place of staples to secure the mesh .
this is believed to reduce the risk of complications such as nerve entrapment , hematomas , and post - operative chronic pain .
spigelian hernias present with localized pain at the hernia site which may or may not be palpable during the physical exam . during the physical exam , a tender spot is often palpable over the hernia defect when the abdominal muscles are tensed .
palpation of the hernia is facilitated by having the patients alternately tense and relax their abdominal muscle .
the diagnosis is unequivocal if the patient presents with a palpable mass and hernia defect along the spigelian aponeurosis .
however , palpable masses are often not well localized during physical exam , as the hernia may dissect through the layers of the abdominal wall and localize away from the semilunaris line .
this may lead to confusion during an open surgical approach since the incision is often made over the palpable mass , but the actual defect may exist away from the mass .
additionally , patients often have localized pain in the area , but no bulge , because the hernia lies beneath the external oblique aponeurosis , .
although ct and ultrasound are often useful to make the diagnosis , spigelian hernias are often not visible with either study . when the mass is not palpable during physical exam and not visible through ultrasound or ct scan , diagnostic laparoscopy may be indicated
we experienced an unusual case where the diagnosis of a spigelian hernia was especially challenging due to vague symptomatology and the lack of a palpable defect ; likely as a consequence of the patient s obesity .
we encountered a patient with chronic left lower quadrant pain whose physical examination was only positive for pain on palpation and during abdominal flexion .
the laparoscopic approach was central to this case since it permitted both diagnosis and surgical repair .
written informed consent was obtained from the patient for publication of this case report and accompanying images .
a copy of the written consent is available for review by the editor - in - chief of this journal on request .
raul mederos : attending surgeon , performed the procedure . supervised every step of the case report production and data collection .
javier alvarado : assisted in surgery , contributed to study design , data collection , and writing .
moises matos : corresponding author , contributed to study design , data collection , and writing .
 highlightsthe combination of physical exam findings and imaging is usually sufficient for the diagnosis of spigelian hernias.patient with chronic lower abdominal pain and with normal physical exam and imaging studies revealed to have a spigelian hernia.diagnostic laparoscopy of patient with chronic lower abdominal pain reveals spigelian hernia with omentum.the omentum is reduced and the hernia defect is repaired . 