Rare Spigelian Hernias Repaired With Laparoscopic Technique in Small Case Series

In a retrospective single-center case series published in Discover Medicine, a team at Clínica Universitaria Reina Fabiola in Córdoba describes four patients who underwent laparoscopic transabdominal preperitoneal repair of Spigelian hernia between June 2023 and March 2025, with no intraoperative complications, no postoperative complications and no recurrences observed during follow-up.

Spigelian hernia, abbreviated SpH, is a rare primary ventral hernia in which preperitoneal fat or a peritoneal sac pushes through a congenital or acquired defect in the Spigelian aponeurosis, the fibrous layer formed by the sheaths of the internal oblique and transversus abdominis muscles. The aponeurosis is bounded medially by the rectus abdominis muscle and laterally by the semilunar line. Although such hernias can occur anywhere along the abdominal wall, they most frequently develop within the so-called Spigelian hernia belt, a zone between the umbilicus and the interspinous line. According to the literature cited in the study, these hernias account for approximately 0.1 to 2 percent of all ventral hernias and typically present between the fifth and sixth decades of life, with no clear sex predilection.

Part of what makes the condition notorious among surgeons is its tendency to hide. Because the hernia is interparietal, meaning the sac usually sits between the aponeuroses of the internal oblique and transversus abdominis muscles beneath the external oblique aponeurosis, it is often not palpable on physical examination. The hernial ring is typically small, usually measuring between 1 and 2 centimeters, and symptoms are nonspecific, often consisting of diffuse abdominal pain that worsens with physical exertion. The authors of the new series note that this combination of features means the condition is frequently misdiagnosed and may be underestimated in frequency. Surgical treatment is recommended in all cases because the risk of acute complications, which can reach up to 24 percent, is higher than that observed in other primary ventral hernias, a fact attributed to the small, rigid character of the hernial ring, which allows the hernia to go unnoticed until it causes pain, strangulation or intestinal obstruction.

Imaging is therefore central to diagnosis. Ultrasound is recommended as the first option because it is widely available, inexpensive and safe, with a sensitivity close to 86 percent. Computed tomography, particularly when combined with the Valsalva maneuver, is considered the standard, with a sensitivity close to 100 percent and the added ability to detail the size, location and content of the hernial sac. Diagnostic exploratory laparoscopy is reserved for patients with persistent symptoms and ambiguous findings after imaging. In the Córdoba series, all four diagnoses were confirmed by CT, and the mean hernial ring diameter was 2.1 centimeters, with a range of 1 to 3.3 centimeters.

The four patients included two men and two women, with a mean age of 36.5 years and a range of 35 to 64 years, and a mean body mass index of 26.6 kilograms per square meter. All hernias were located on the left side, and no relevant medical or surgical history was recorded. Lower abdominal pain and a palpable mass were the most frequent presenting symptoms, observed in three of the four patients, or 75 percent. One patient required emergency surgery because of intestinal obstruction caused by an incarcerated Spigelian hernia, while another case was diagnosed incidentally during imaging performed for colonic diverticulitis. One patient also had an associated umbilical hernia, which was repaired during the same procedure. The hernial contents consisted of omentum in three cases and small bowel in one, without signs of ischemia.

The operative technique followed the standard principles of transabdominal preperitoneal repair, commonly abbreviated TAPP. All procedures were performed by surgeons experienced in laparoscopic abdominal wall surgery using a three-trocar configuration. In three cases, this consisted of a 12 millimeter trocar at the umbilical level, a 5 millimeter trocar on the right flank and a 5 millimeter trocar in the right hypochondrium. In one patient with a low Spigelian hernia near the left inguinal region, the arrangement was modified to resemble that used for inguinal hernia repair, with a 12 millimeter umbilical trocar and two 5 millimeter trocars in both flanks. Pneumoperitoneum was established with a closed Veress needle technique in three patients, while the case operated on in the context of intestinal obstruction used an open access technique to optimize safety.

Once inside the abdomen, the surgeons accessed the preperitoneal space through an incision in the peritoneum approximately 5 centimeters from the hernial defect. The hernial contents were reduced in all cases, and selective closure of the defect was performed with a 2-0 barbed suture when deemed appropriate; in two cases closure was omitted because the defect was smaller than 1 centimeter and close to the epigastric vessels. A 12 by 12 centimeter polypropylene mesh was then placed in the preperitoneal space and secured with four absorbable staples placed peripherally to the hernia defect, with care taken to ensure adequate mesh overlap and to avoid fixation near the epigastric vessels and other vascular structures. Finally, the peritoneum was closed with a continuous barbed suture to cover the mesh completely and restore anatomical continuity, isolating the prosthesis from the abdominal cavity.

The reported outcomes were favorable across the small cohort. All patients underwent laparoscopic TAPP repair without intraoperative complications, with a mean operative time of 75 minutes and a range of 65 to 80 minutes. Postoperative recovery was uneventful in all patients, and the mean hospital stay was 12 hours, ranging from 6 to 14 hours. Follow-up was performed at 7 and 14 days, subsequently at 1 and 3 months, and at 1 year, and no postoperative complications or hernia recurrences were observed during that period. The authors conclude that laparoscopic TAPP repair is a safe, effective and reproducible technique for Spigelian hernia, including in emergency settings, offering a short operative time, prompt postoperative recovery and a low risk of complications when performed by surgeons experienced in laparoscopic surgery.

The discussion in the paper places these results within a broader and still unsettled debate about the optimal surgical approach. The open approach has long been the mainstay of treatment, with techniques including simple closure and onlay prostheses in the retrorectal or preperitoneal space; the recurrence rate in series of more than 70 patients with 8-year follow-up is reported as acceptable and close to 4 percent. Laparoscopic repair of Spigelian hernia was first described by Carter in 1992, and today three laparoscopic options exist: intraperitoneal onlay mesh, or IPOM; totally extraperitoneal repair, or TEP; and TAPP. According to a review by Barnes and colleagues cited in the paper, IPOM is the most commonly used technique, accounting for approximately 43 percent of reported cases, and is technically the least demanding, though it carries higher costs related to intraperitoneal meshes and potential risks of adhesions to bowel loops and of visceral or vascular injuries. Fernández-Moreno has reported excellent results in 15 patients with that technique, with an average operative time of 43 minutes and no recurrence or prosthesis-related complications at 4 years of follow-up, and Moreno-Egea has suggested it as the standard technique. TEP, described by Moreno-Egea, is the least used; it theoretically eliminates the risk of intestinal lesions related to contact with the prosthesis but is more technically demanding, with a long learning curve and longer operative times, and is generally proposed for low, reducible and small hernias.

The authors argue that TAPP combines the advantages of both alternatives, since it allows visualization of the abdominal cavity and the viability of the sac contents while permitting placement of a polypropylene mesh isolated from the intestine, reducing the risk of adhesions and lowering costs. Its best applications, they write, are in obese patients, low-lying hernias, hernias with a large ring, and recurrent hernias after anterior approach repairs, though the creation of the peritoneal flap can be technically demanding in high hernias where the peritoneum is thinner. Previous TAPP series cited in the paper include one by Patle and colleagues, who reported satisfactory results in six cases with average operative times of 60 to 90 minutes and no recurrences at 2 years, and the largest reported series by Barnes, with an average operative time of 45 minutes, no immediate complications and no recurrences during 12-month follow-up. The new report adds a small but contemporary institutional experience to that literature, including one low Spigelian hernia confirmed at laparoscopy and approached as an inguinal hernioplasty because of its proximity to the groin. As the authors themselves emphasize, the evidence base remains limited by the low incidence of the condition and the scarcity of comparative studies, and the present findings come from a retrospective series of only four patients at a single center, so the reported absence of complications and recurrences should be interpreted within that narrow scope and short follow-up.

Subject of Research: Laparoscopic transabdominal preperitoneal repair of Spigelian hernia

Article Title: Laparoscopic transabdominal preperitoneal repair of Spigelian hernia in a single-center case series

Article References: Vargas Aignasse, R. A., Doniquian, A. M., & Viscido, G. R. (2026). Laparoscopic transabdominal preperitoneal repair of Spigelian hernia in a single-center case series. Discover Medicine, 3(1), Article 161. https://doi.org/10.1007/s44337-026-00730-5

Image Credits: AI Generated

DOI: 10.1007/s44337-026-00730-5

Keywords: Spigelian hernia, laparoscopic surgery, TAPP repair, abdominal wall hernia, hernia repair, case series, mesh repair, computed tomography, emergency surgery, surgical outcomes, retrospective study, general surgery