Giant Spigelian hernias

Abstract

We read with interest the recent report by Topal et al. 2007 on a giant Spigelian hernia (SH) that may have been due to abdominal wall injury (Hernia 11:67–69). The study reports a hernia defect in the internal oblique and transversus abdominis muscles occurring 45 days after blunt abdominal trauma. An open onlay repair with polyWlamented mesh was performed leading to a sound repair at 18 months. Topal et al. did not specify the clinical size of the hernia, but termed it “giant” because the muscular defect measured 10 cm in diameter. Unfortunately, the group provided no literature review on very large SHs and thus did not help the reader to put their Wnding in perspective. A 1992 French series from Gabon reported much larger SHs than the one in the Topal study [1]. We are skeptical about the suggestion by Topal et al. that SHs can be post-traumatic. Spigelian hernia is deWned as spontaneous ventral hernia. Recent MEDLINE and PUBMED searches on SH and handlebar hernia reveal many patients whose hernias were located at or near the junction of the semilunar and semicircular lines, the typical SH site; the designations “Spigelian hernia” and “traumatic hernia” are used interchangeably in many of these reports. The occurrence of a traumatic hernia at the typical SH site follows a random injury, and has been similarly described in other anatomic regions. Traumatic hernias, which are by deWnition post-traumatic rather than spontaneous, should therefore be excluded from SH statistics, even when they occur at sites often associated with SH. Conversely, some of these so-called traumatic hernias may actually be preexisting hernias which only come to light when closer attention is paid to the now-traumatized area. Unfortunately, Topal et al. did not discuss what inXuenced their choice of prosthetic mesh (polyWlamented vs. monoWlamented), and also why the prosthetic screen was placed on top of the external oblique aponeurosis. A large number of clinical studies demonstrate that multiWlamented meshes show the highest infection percentages, which constitutes a signiWcant risk factor for hernia recurrence [2]. When mesh is placed as an onlay (i.e., over the external oblique aponeurosis or the rectus sheath) it can be displaced outward by intraabdominal pressure; intermuscular or retromuscular mesh placement works better in this respect [3]. In a study comparing tissue reactions to polypropylene mesh, the best healing occurred when mesh was placed between muscles, rather than under the skin or on the peritoneum [4]. Topal et al. are to be commended for their conclusions regarding a high index of suspicion, early diagnosis, and mandatory treatment, and their suggestion of using prosthetic mesh is an excellent alternative to primary repair. A recent prospective, randomized controlled trial suggests that extraperitoneal laparoscopy oVers the best results in the elective treatment of this condition, with lower morbidity rates and shorter hospital stays [5], although Topal et al. used an open approach based upon their patient’s preference.