Spigelian hernia mimicking appendicular mass

Abstract

Case report A 44-year-old woman with a virgin abdomen presented to the Emergency Department with a 2-day history of nausea, constipation and right iliac fossa abdominal pain. Physical examination revealed tenderness maximum at McBurney’s point associated with an ill defined palpable intra-abdominal mass. The patient’s haemoglobin and white blood cell count were within normal limits. Abdominal plain film radiograph (PFR) showed faecal loading of the colon, but no other cause for the patient’s symptoms (Fig. 1). Given the equivocal blood tests and PFR results, computed tomography (CT scan) of the abdomen and pelvis was performed. The CT scan revealed an incarcerated loop of small bowel within a right sided Spigelian hernia, dilated proximal small bowel loops, and a radiologically normal retro-caecal appendix (Figs. 2, 3). Because of the presence of small bowel obstruction and possible need for bowel resection, the patient underwent open surgery through a right iliac fossa incision where a knuckle of dusky but viable terminal ileum was reduced, and the defect closed with non-absorbable sutures. Incidental appendicectomy was not performed as this would have required extension of the incision and mobilisation of the caecum, and because the appendix was not responsible for the patient’s symptoms. The patient recovered uneventfully, and was discharged on the fourth post-operative day. Discussion