Spigelian Hernia Following Laparoscopic Hysterectomy: Case Report and Review of the Literature

TL;DR

A rare case of Spigelian hernia following laparoscopic hysterectomy is reported, highlighting its diagnostic challenges and severe complications.

Contribution

This case report adds to the understanding of iatrogenic Spigelian hernias after gynecologic laparoscopy and emphasizes the importance of early detection.

Findings

A 70-year-old patient developed a Spigelian hernia with bowel rupture after laparoscopic hysterectomy.

Spigelian hernias can occur despite proper trocar site closure, especially in older patients.

Early recognition and treatment are crucial to prevent severe complications like peritonitis.

Abstract

Spigelian hernia (SH) is a rare type of lateral ventral hernia occurring through the Spigelian fascia, accounting for only 0.1-2% of all ventral hernias. Though commonly considered spontaneous, an increasing number of iatrogenic cases have been reported following laparoscopic surgery, particularly when 10-mm trocar ports are used. Due to the anatomical location between the rectus abdominis and semilunar line, SH can be challenging to detect clinically, often presenting with nonspecific symptoms. This is especially true in gynaecologic laparoscopy, where SH remains an underrecognized complication.

We present the case of a 70-year-old woman who underwent laparoscopic total hysterectomy with bilateral salpingo-oophorectomy for a benign adnexal mass. Two days postoperatively, the patient developed a tender swelling at the trocar site after straining during defecation. CT imaging revealed a loop of small bowel herniated between abdominal wall muscles, with the fascial stitch still visible. During emergency laparoscopy, as we mobilized the small bowel out of the hernia defect, a bowel rupture was identified in the involved segment, leading to fecal peritonitis and necessitating conversion to open surgery. The patient's postoperative course was complicated by severe aspiration pneumonia requiring ICU admission and prolonged mechanical ventilation, as well as a surgical site infection requiring debridement.

This case highlights the diagnostic difficulty and potentially severe complications of trocar-site Spigelian hernias. Even with proper fascial closure, factors such as early postoperative straining, advanced age, and predisposing anatomical defects may contribute to hernia formation. Surgeons should maintain a high level of suspicion in any postoperative patient presenting with localized pain or swelling near trocar sites, particularly lateral to the rectus muscle. Recognizing this uncommon yet potentially serious complication early can ensure early diagnosis and treatment, reducing the risk of morbidity.

This report underscores the need for vigilance in gynaecologic laparoscopic practice and serves as a reminder that even well-closed trocar sites can lead to Spiegel hernia and thus culminate in severe complications.

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