Total laparoscopic repair of Spigelian hernia with undescended testis.

Spigelian hernia is very rare in the paediatric age group. We present the case of an 11-month-old male child who presented with left Spigelian hernia with the left undescended testis in its sac. Hernia repair with orchidopexy was done using total laparoscopic approach. It is the first reported case of total laparoscopic repair of Spigelian hernia with undescended testis in the paediatric age group.

INTRODUCTION

A Spigelian hernia is a ventral interstitial hernia through a defect in the Spigelian fascia; an undescended testis is sometimes associated with this clinical entity in male newborns. Spigelian hernia was first described in 1764, and the typical patient profile is of an overweight 50-year-old with associated respiratory disease. Its occurrence as a congenital hernia was first described in 1935. Since then, 54 cases have been reported in infants and children. However, Spigelian hernia associated with undescended testis is extremely rare in the literature and has been reported only in thirty cases in the literature (1, 3 and 5).

CASE REPORT

We present a case of an 11-month-old male child who presented to us with left lower abdominal swelling with empty ipsilateral hemiscrotum. On physical examination, it revealed Spigelian hernia with left nonpalpable testis. The patient was posted for laparoscopy. Diagnostic laparoscopy which was performed through umbilicus revealed Spigelian hernia with left testis inside hernial sac [Figure 1]. Two 5 mm ports were inserted parallel to the umbilical port on either side and testis was mobilised and brought down in the scrotum and orchidopexy was done [Figure 2]; Spigelian hernia was repaired with non-absorbable suture [Figure 3].

Figure 1

Vas and vessels seen entering the hernial sac

Figure 2

Mobilised testis in scrotum

Figure 3

Follow-up of the patient with healed scars

DISCUSSION

Spigelian hernia is a ventral interstitial hernia which occurs due to weakness of aponeurosis between semilunar line and lateral edge of rectus abdominis muscle.[123456] External oblique muscle and its aponeurosis are usually strong, whereas as comparied to those muscles internal oblique muscle and transversalis fascia are weak. Undescended testis with Spigelian hernia is a congenital condition. There has been considerable speculation and controversy regarding the possible mechanism of cryptorchidism in Spigelian hernia. According to the general viewpoint, Spigelian hernia is the primary defect and the undescended testis takes the path of least resistance to descend into the hernial sac and for its association.[678] Raveenthiran speculated that ectopic location of the testis is the primary abnormality, and it leads to the formation of Spigelian hernia by dragging a peritoneal sac along with it.[9] Rushfeldt et al. believed that failure of development of gubernaculum as contributing factor;[2] thus, inguinal canal could not develop, and the testis remains in their intra-abdominal position.[210]

Ultrasonography helps in assessing the size of the defect and contents of the hernia sac. The management of this anomaly includes repair of the hernia and scrotal placement of the undescended testis. While undertaking surgical repair of Spigelian hernia, one should look for an undescended testis and expect it to be in the hernia sac. Furthermore, since an inguinal canal may not be found, one should be prepared to perform an orchidopexy either through a subcutaneous route or a new internal ring may be created through the abdominal wall medial to the inferior epigastric vessels and just lateral to the pubic tubercle.[4] However, one should be careful in orchidopexy by creating neointernal ring as testicular atrophy has been reported in one patient.[4] The possible reported explanations for such an outcome include vascular damage, tension and compression of the cord and scrotal infection.

Declaration of patient consent

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.