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 Table of Contents     
Year : 2019  |  Volume : 15  |  Issue : 3  |  Page : 253-255

A new hybrid mini-laparoscopic technique for Spigelian hernia

1 Department of General Surgery, Faculty of Medical Sciences, University of Pernambuco; Member of UNIPECLIN (Clinical Research Group of the University of Pernambuco), University of Pernambuco; Videolaparoscopic Surgery Clinic Gustavo Carvalho, Recife, Brazil
2 Department of General Surgery, Faculty of Medical Sciences, University of Pernambuco, Recife, Brazil
3 Department of General Surgery, Pernambuco Health College, Recife, Brazil
4 Department of General Surgery, State Servers Hospital, Recife, Brazil

Date of Submission08-Jul-2018
Date of Acceptance27-Jul-2018
Date of Web Publication4-Jun-2019

Correspondence Address:
Gustavo Lopes Carvalho
Avenida Boa Viagem 5526b Ap. 1902, PE CEP: 51030-000, Recife
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.JMAS_179_18

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 ¤ Abstract 

We describe the original technique used for the treatment of a patient who presented with pain and bulging in the abdomen, who was diagnosed with Spigelian hernia (SH) using ultrasound. In this case, the hernia occurred in the anterolateral abdominal wall with herniation of the distal ileum and mesentery, in addition to a large right inguinal hernia. A mini-laparoscopic approach was proposed; due to Child-A hepatic cirrhosis, it was done by a hybrid technique, using a harmonic scalpel. The primary closure of the hernia defects was performed, followed by the placement of a polypropylene mesh in the preperitoneal space. The mesh was fixed. In this case, the inguinal hernia was homolateral to the SH. Following the surgery, the patient had no further complications, being discharged the day after the procedure.

Keywords: Hernia repair, hybrid approach, mini-laparoscopy, minimally invasive surgery, Spigelian hernia

How to cite this article:
Carvalho GL, Góes GH, Cordeiro RN, Lima DL, Amorim LL, Furtado RH. A new hybrid mini-laparoscopic technique for Spigelian hernia. J Min Access Surg 2019;15:253-5

How to cite this URL:
Carvalho GL, Góes GH, Cordeiro RN, Lima DL, Amorim LL, Furtado RH. A new hybrid mini-laparoscopic technique for Spigelian hernia. J Min Access Surg [serial online] 2019 [cited 2020 Jul 5];15:253-5. Available from:

 ¤ Introduction Top

Spigelian hernia (SH) is an uncommon type of hernia characterised by a protrusion of the preperitoneal fat or abdominal contents, through a congenital defect or weakness in the Spigelian fascia.[1],[2] The objective of the present study is to report the successful surgical treatment of a patient with SH by an original hybrid mini-laparoscopic approach.

 ¤ Case Report Top

A 71-year-old male patient presented with severe pain in the hypogastric region. Ultrasonography revealed anteroposterior abdominal wall defect (3.5 cm) with herniation of loops of the distal ileum and mesentery (SH compatible). A large right inguinal hernia (2.8 cm) was also diagnosed. A minimally invasive combined approach was performed.

Surgical case description

A transumbilical incision was performed in the umbilical scar, and an 11 mm trocar was inserted under direct vision. The pneumoperitoneum was created using the open technique, with the visualization of the peritoneal cavity. A 3.5 mm trocar was introduced in the right periumbilical hypogastric region, and dissection of the preperitoneal space was performed with the CO2 and the dissector. The 11 mm trocar was removed and reintroduced into the newly created preperitoneal space. The laparoscopic view confirmed two defects on the right side: one in the inguinal region and the other lateral to the rectus abdominal muscle [Figure 1]. A mini-laparoscopic (3.5 mm) trocar was inserted to the left of the lower umbilical midline into the preperitoneal space under direct vision. Through the Luer-lock of this trocar, CO2 under pressure was injected, and a preperitoneal workspace was created. A 5 mm trocar was inserted in the right flank, also inside the newly created preperitoneal space, for the use of harmonic scalpel. Next, an 11 mm trocar was inserted blindly into the preperitoneal space through the same umbilical incision but through a subcutaneous tunnel in the aponeurotic region that was 2–3 cm below the umbilical orifice. A 3 mm trocar was used on the left flank for the mini grasping forceps. A harmonic scalpel was chosen in this surgery due to the underlying liver disease, cirrhotic (Child-A) patient. We chose to close the two herniary orifices to reduce the risk of recurrence, and the formation of seroma. Besides, we used a fish scale suture to close the defects [Figure 1], with totally extraperitoneal (TEP) technique. As the two hernias were homolateral, a single mesh (28 cm × 16 cm) was used, which facilitates and reduces the cost of the procedure [Figure 2]. We used haemostatic tissue in the bladder region to decrease bleeding after dissection [Figure 2]. In addition to the use of tackers, a transfascial suture was used to fix the mesh. The 11 mm trocar was removed and reintroduced into the peritoneal cavity to evaluate the position of the mesh. The procedure was uneventful, with a total duration of 125 min. The patient had no further complications, being discharged in the 1st post-operatory day.
Figure 1: (a) Observation of two defects on the right side: one in the inguinal region and the other lateral to the rectus abdominal. (b) Blunt dissection for the creation of the preperitoneal space. (c and c') Hernia defect closure with fish scale suture

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Figure 2: (a) Ending the closure of the hernia defect. (b) Mesh placement (28 cm × 16 cm) for inguinal and Spigelian hernias, reducing the cost of the procedure. (c) Use of haemostatic tissue in the bladder area to stop bleeding. (d) Spigelian hernia being closed at the edges of the transverse abdomen

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 ¤ Discussion Top

Although nonspecific and variable, the clinical presentation of SH consists of abdominal pain that is poorly localizedor referred to the area of the hernia, especially in cases where the orifice is small, exacerbated by physical activity or coughing and relieved in the decubitus position.[1] The gold-standard imaging examination is ultrasonography. However, when the diagnostic doubt persists, a computed tomography scan is used.[3]

The SH has always a surgical indication, and the technique by the anterior route begins with the dissection and reduction of the hernia content followed by the closure of the orifice; another alternative is the placement of a synthetic mesh in the preperitoneal region (posterior to the transverse muscle) or the pre-muscular region (between the external and internal oblique muscles) to strengthen the abdominal wall.[2]

The endoscopic approach may be intra-abdominal, preperitoneal or TEP. In these approaches, the mesh should overlap 4–5 cm of the margins of the hernia defect, being eventually fixed to avoid its displacement.[2]

A combined transabdominal preperitoneal (TAPP) TEP technique was previously described for the treatment of inguinal hernias. The combination of mini-laparoscopy (MINI)-TEP-TAPP with the use of MINI instruments is simple, safe and versatile. Mini-laparoscopic preperitoneal dissection also allows faster and easier formation of the preperitoneal space, reducing the learning curve.[4]

The mini-laparoscopic approach, compared with conventional laparoscopy, causes less post-operative pain due to less trauma to the abdominal wall, provides better visualization of the operative field and dexterity of movements, and it is associated with a shorter hospital stay. In more precise and complex procedures, the low friction of the 3 mm instruments shows better results.[5],[6],[7],[8]

 ¤ Conclusion Top

We described the successful treatment of one patient with Spigelian hernia by the minimally invasive combined approach: TAPP and TEP. MINI for hernia reduction showed to be a safe and effective method, with faster post-operative recovery and early hospital discharge.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 ¤ References Top

Spangen L. Spigelian hernia. World J Surg 1989;13:573-80.  Back to cited text no. 1
Filip S, Dragomirescu C, Copăescu C. Laparoscopic treatment of spiegel hernia by total extraperitoneal (TEP) approach. Chirurgia (Bucur) 2014;109:325-9.  Back to cited text no. 2
Akpo G, Deme H, Badji N, Niang F, Toure M, Niang I, et al. Diagnosis of strangulated Spiegel hernia based on CT scan: About a case. Pan Afr Med J 2016;25:222.  Back to cited text no. 3
Malcher F, Cavazzola LT, Carvalho GL, Araujo GD, Silva JA, Rao P, et al. Minilaparoscopy for inguinal hernia repair. JSLS 2016;20: e2016.00066. DOI: 10.4293/JSLS.2016.00066.  Back to cited text no. 4
Firme WA, Carvalho GL, Lima DL, Lopes VG, Montandon ID, Santos Filho F, et al. Low-friction minilaparoscopy outperforms regular 5-mm and 3-mm instruments for precise tasks. JSLS 2015;19. pii: e2015.00067.  Back to cited text no. 5
Carvalho GL, Silva FW, Silva JS, de Albuquerque PP, Coelho Rde M, Vilaça TG, et al. Needlescopic clipless cholecystectomy as an efficient, safe, and cost-effective alternative with diminutive scars: The first 1000 cases. Surg Laparosc Endosc Percutan Tech 2009;19:368-72.  Back to cited text no. 6
Carvalho GL, Loureiro MP, Bonin EA, Claus CP, Silva FW, Cury AM, et al. Minilaparoscopic technique for inguinal hernia repair combining transabdominal pre-peritoneal and totally extraperitoneal approaches. JSLS 2012;16:569-75.  Back to cited text no. 7
Carvalho GL, Silva de Abreu GF, Lima DL, Góes GH. Type IV mirizzi syndrome treated by hepaticoduodenostomy by minilaparoscopy. CRSLS e2016.00057. DOI: 10.4293/CRSLS.2016.00057.  Back to cited text no. 8


  [Figure 1], [Figure 2]


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