Rare clinical scenario and surgical approach for traumatic obstructed Spigelian hernia with penetrating scrotal injury: A case report

Abstract

Introduction and importance

Traumatic Spigelian hernias, an unusual subtype of traumatic abdominal wall hernias (TAWH). This case highlights the individualized surgical management of Spigelian hernia depending on the presentation, history, and existence of concurrent intra-abdominal injuries. This case report, presented in line with the SCARE criteria, highlights a case of obstructed Spigelian hernia.

Case presentation

We present a 37-year-old male patient involved in a free fall from a coconut tree while harvesting fruits. A sharp branch injured the scrotum before he landed on the ground. Then he started presenting with abdominal pain, failure to pass stool, abdominal distention, and later on vomiting. Abdominopelvic CT-scan showed ventral hernia concealed at the right lower quadrant of the abdomen with proximal intestinal dilatation. Exploratory laparotomy was done along with Spigelian hernia repair.

Clinical discussion

This case was atypical, lacking evidence-based guidelines on surgical treatment. Considering the emergency aspect of the case, we performed an exploratory laparotomy along with hernia repair. The scrotal wound was cleaned and left open. The postoperative follow-up was conclusive, as the patient recovered with the hernia tract having healed by fibrosis.

Conclusion

Spigelian hernia can be caused by trauma and may be difficult to diagnose at first glance. The attention should be paid to a thorough clinical examination and adequate workup. The surgical intervention may depend on intraoperative findings if done on an emergency basis.

Highlights

• •Spigelian hernia
• •Intestinal obstruction
• •Laparotomy
• •Hernia repair
• •Case report

1. Introduction

An injury that occurs often, blunt abdominal trauma, has a range of complications that closely correspond to the mode of injury [1]. Traumatic abdominal wall hernia (TAWH) is an uncommon hernia [2,3,4] occurring in <0.12–2.4 % of blunt abdominal trauma [5,6] first described by Selby in 1906 [7]. Spigelian hernia is a subtype of traumatic abdominal wall hernia (TAWH) occurring at the level of arcuate line [8].

Traumatic Spigelian hernias are uncommon clinical entities that appear differently clinically. Early diagnosis and effective treatment depend on having a high index of suspicion. If the diagnosis is delayed, the bowel loops may become imprisoned or strangulated, which can cause morbidity [9]. While surgical repair is still the primary course of treatment, radiological evaluation can be a helpful adjunct in determining the proper diagnosis. Each patient has a unique set of circumstances that determine whether to undergo immediate or delayed repair with or without mesh, based on the appearance, history, and existence of concurrent intra-abdominal injuries [10].

This is a report of an isolated traumatic Spigelian hernia in a middle-aged male following a free fall from a tree with a penetrating scrotal injury communicating with the intraperitoneal cavity. This case report is presented in line with the SCARE criteria [11].

2. Case presentation

2.1. History of the presenting illness

A 37-year-old male patient presented to the emergency department with chief complaints of abdominal pain for 5 days, failure to pass flatus or stool, abdominal distention for 3 days, and episodes of vomiting for 1 day.

The patient was apparently well until he got involved in a free fall from a coconut tree while harvesting fruits, and then a sharp tree branch penetrated his right scrotum. According to him, the sharp branch injured him before his landing on the ground in a standing position. After falling down, the patient did not experience severe pain, only what he could term a trivial injury on his right scrotum—no bleeding but minimal abdominal pain. But as the days passed, the patient started developing abdominal distention and constipation, which were increasing gradually. On the 4th day, he vomited greenish material mixed with food ingested. He decided then to report to the hospital for further management.

The patient denied any history of fever, headache, blurry vision, tingling, backache, convulsions, loss of consciousness, fatigability, awareness of heartbeat, shortness of breath, chest pain, hematemesis, blood in urine, or inability to use the lower limbs. The patient had no known comorbidities or known allergies to food or medication, no history of previous surgery, and no history of cigarette smoking or alcohol consumption.

2.2. Physical examination

On examination, he was fully conscious, not pale, afebrile, jaundiced, or dyspneic, with no palpable peripheral lymph nodes and no lower limb edema, and his vital signs were within the physiological range. The abdomen was grossly distended, moving with respiration, inverted umbilicus, and no visible marks of previous surgery or traditional therapeutic scar, tender on deep palpation, not palpable mass or organs. There was a tympanic note on percussion, and bowel sounds increased. The rectum was full of stools. Per genitalia, two bruises of about 3 cm were noted at the right scrotum and right groin, respectively.

The provisional diagnosis of fecal impaction was thought to rule out Ogilvie's syndrome.

2.3. Workups

The relevant laboratory workups were done and showed no dysruption.

The thoracoabdominal x-ray was done and showed features of dilated bowels, but it was not conclusive to make the diagnosis (Fig. 1).

Fig. 1.

Thoracoabdominal X-ray of the patient.

The patient was kept nil per oral with three Mayo's lines inserted. The enema was done successfully. The patient passed stool upon enema. The generalized abdominal distention decreased, leaving a localized distention in the right lower quadrant of the abdomen with right-sided abdominal tenderness and a tympanic note on percussion.

The abdominopelvic CT scan was requested and showed features suggestive of Spigelian hernia with marked bowel dilatation (Fig. 2A, Fig. 2B).

Fig. 2A.

CT-scan of the abdomen showing obstructed bowel loop within the anterior abdominal wall.

Fig. 2B.

CT-scan of the abdomen showing the passage of bowels through the anterior abdominal wall.

2.4. Surgery

The emergent exploratory laparotomy was done through the extended midline incision.

2.5. Intraoperative findings

There were grossly dilated small intestines with collapsed terminal ileum and colon; obstructed right Spigelian hernia entrapping a loop of proximal ileum that was found to be viable (Fig. 3A, Fig. 3B); foreign bodies (including a piece of red cloth and multiple pieces of wood) with pus discharge through the internal defect of about 3 cm (Fig. 4A, Fig. 4B) in great diameter, 6 cm from midline; communication between the internal ventral defect and inguinoscrotal bruises (Fig. 5A, Fig. 5B, Fig. 5C). The overlying anterior rectus sheath was intact.

Fig. 3A.

Entrapped bowel loops released.

Fig. 3B.

The inner anterior abdominal wall defect wherein the the ileal loops herniated through.

Fig. 4A.

The red piece of cloth detached from the bowel loops. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 4B.

Foreign bodies extracted from the hernia tract (pieces of re cloth and woods).

Fig. 5A.

Scrotal opening communicating with the inner anterior abdominal wall defect.

Fig. 5B.

Cleaning and tracking the hernia the defect from the inner aspect of the anterior abdominal wall with swab on stick.

Fig. 5C.

Estimation of the length of hernia tract with the artery forceps.

2.6. Intervention done

The entrapped loop of the proximal ileum was released, and the bowel decompressed by pushing the content from the dilated bowel to the distal intestines, followed by peritoneal lavage. The pus was taken for culture. Exploration and lavage of the hernia tract were done. The internal defect was repaired with five separate Vicryl 0 sutures. The inguinoscrotal bruises were cleaned and left open. The extended midline incision was then closed in layers, and no drain was left in situ.

2.7. Postoperative follow up

The patient was kept on intraveinous fluids (sodium dextrose/ringer lactate, 3 L per 24 h for two days), broad-spectrum antibiotics (ceftriaxone+sulbactam 1.5 g two times a day and metronidazole 500 mg three times a day), and paracetamol 1 g four times a day. He resumed bowel movement on the second day post-operation and was discharged home on the fifth day post-operation after being counseled on a modification of lifestyle. He was seen nine days later, i.e., two weeks post-operation, as an outpatient for clinical assessment and suture removal. The patient was assessed again one month later, i.e., 6 weeks post hernia repair, at surgical clinics; he was clinically fine. The postoperative follow up was conclusive, as the patient recovered with the hernia tract having healed by fibrosis.

3. Discussion

3.1. Hernia site

The linea semilunaris, also known as the semilunar line, is where the Spigelian fascia is situated lateral to the rectus abdominis muscle. Aponeuroses that are situated between the semilunar line laterally and the rectus abdominis medially make up this layer. The semilunar line is named after the Flemish anatomist and surgeon Adrian van der Spiegel (1578–1625), who was the first to explain the anatomical and surgical significance of the well-known linea semilunaris. The semilunar line was originally called “linea semilunaris spigelii” (the line of Spiegel). He described it as the line that separates the transversus abdominis muscle's aponeurosis from the muscle, running from the ninth costal cartilage to the pubic tubercle. Its lateral convexity can occasionally be mistaken for the rectus sheath's lateral boundary [12].

Usually, the Spigelian hernia is characterized by a herniation at or below the arcuate line, or linea arcuata. It happens as a result of a distinct fissure in the Spiegel fascia that is next to the semilunar line. It may be acquired or congenital. Most famously, the arcuate line is recognized for serving as a junction where the anterior and posterior rectus sheaths layer together. Since the rectus muscles are only posteriorly bound by transversalis fascia, this line marks the termination of the posterior layer of the rectus sheath containing transversus abdominis aponeurosis. Because the posterior rectus sheath is absent at the intersection of the semilunar line and arcuate line, there is an intriguing physiologic weakness that permits herniation lateral to the rectus. Furthermore, the weakening is caused by the reduction of transversus [13,14,15,16].

3.2. Diagnosis

An underlying condition that raises intra-abdominal pressures, abdominal wall trauma, or the deterioration of the abdominal wall's aponeurotic layers—which can occur with aging or problems involving the manufacture of collagen—are the usual causes of a Spigelian hernia. This hernia may also be idiopathic in other situations [8,17]. We have hereby reported a case of traumatic Spigelian hernia.

According to Damschen et al., TAWH is a hernia that develops through the muscle and fascial layers following a forceful trauma while the skin on top is still intact [10,18]. Wood et al. divided TAWH into three categories according to the defect's magnitude and mechanism of injury. Type I abdominal wall defects resulted from high-energy injuries such as car accidents or falls, while type II flaws were caused by low-energy traumas such as bicycle handlebar injuries. The least prevalent type, type III, is characterized by abnormalities with intra-abdominal herniation of bowel loops after deceleration injuries [9,10,19]. The case reported here is a type III.

When combined with a clinical examination, a dynamic CT scan can be helpful in the diagnosis of Spigelian hernias. Often, until surgical investigation is done, the preoperative diagnosis may remain unclear. According to a Weiss et al. study, about 50 % of cases are detected during investigation [16,20].

3.3. Management

Three clinical stages that are universal for the therapy of the disorder and represent its natural history have been described by Webber et al. (Table 1) [14].

Table 1.

Clinical stages of Spigelian hernia.

Stages	Anatomy	Clinical features	Treatment
I	Defect: <2 cm Content: interstitial fat only with no peritoneal component	Intermittent, well-localized pain but no palpable swelling	Open surgery: they are not visible laparoscopically
II	Defect: 2–5 cm Content: peritoneal component present	Palpable swelling	Laparoscopy/Open repair
III	Defect: >5 cm	Large hernia with distortion the of abdominal wall	Open repair

As per the latest guidelines from the EHS, it is recommended that Spigelian hernias be corrected (if desired) using mesh. Depending on the surgeon's experience, either an open or laparoscopic procedure may be used [21]. The Intraperitoneal Onlay Mesh (IPOM) technique, which accounts for 35 % of all laparoscopic repairs, is followed by the Total Extraperitoneal Patch (TEP) approach (30 %), the Transabdominal Preperitoneal (TAPP) approach (22 %), and laparoscopic suturing approaches [16,22,23]. Considering the emergency aspect of the case, we performed an exploratory laparotomy along with hernia repair using a Vicryl 0 suture. We went through the midline to explore the abdomen. The loops of ileum that were obstructed within the anterior abdominal wall were released, and the hernia defect was repaired from the inner aspect of the abdominal wall. The scrotal wound was cleaned and left open to allow any drainage from the hernia tract. The postoperative follow up was conclusive as the patient recovered with the hernia tract having healed by fibrosis.

4. Conclusion

Although rare, Spigelian hernia can be caused by trauma and maybe difficult to diagnose at glance. The attention should be paid to thorough clinical examination and adequate workup of the patient. The surgical intervention may depend on intraoperative findings if done on emergency basis.

Abbreviations

BID

Twice daily

OD

Every day

TAWH

Traumatic abdominal wall hernia

TDS

Three times daily

Consent for publication

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.

Ethical approval

Since this is a case report, the Institutional Review Board of Muhimbili University of Health and Allied Sciences waived the requirement for ethical approval as per current regulations.

Funding

The authors are thankful to Dr. Jerry Massawe who helped in acquisition of the intraoperative images. Hervé Tshikomba Mbuyamba is grateful to Else Kroner Frenesius Sttiftung and all the BEBUC Panel for their substantial support to his studies. He is thankful to the leading committee of Université Officielle de Mbujimayi for the opportunity given to him to pursue his studies at Muhimbili University of Health and Allied Sciences.

Author contribution

Hervé Tshikomba Mbuyamba was involved in the management of the patient, obtained the informed consent from the patient, summarized the case, prepared the photos and wrote the manuscript. John Bosco Ngendahayo was involved in the management of the patient, supervised the case and reviewed the case report. Ally Hamis Mwanga revised the manuscript and contributed to literature review. All the authors reviewed the manuscript and agreed on its contents.

Guarantor

All of the authors mentioned in this manuscript are the guarantors of this case reports. For access to data reported in this paper, John Bosco Ngendahayo should be contacted.

Research registration number

• 1.Name of the registry: Medical Records of Muhimbili National Hospital.
• 2.Unique identifying number or registration ID: M76-84-52.
• 3.Hyperlink to your specific registration (must be publicly accessible and will be checked): https://www.mnh.or.tz/index.php/directories/information-and-communication-technology/medical-records-department.

Conflict of interest statement

Hervé Tshikomba Mbuyamba reports financial support from Else Kröner-Fresenius Foundation through BEBUC Schorlarship Program to sponsor his master of medicine in General Surgery at Muhimbili University of Health and Allied Sciences. However, the authors declare that there is not competing interest.

Data availability

All the relevant data concerning the case report are published in this paper. The medical file, laboratory investigations and imaging results are available on reasonable request to the Guarantor. The pictures of the case are available on reasonable request to the corresponding author.