Where does it occur and why is it difficult to find?
Spigel's, or semilunar, line is the junction of the muscle fibers of the lateral abdominal muscles into the tendon plate along the outer edge of the rectus muscle. Below the level of the navel, the aponeurotic layer is weaker here, and it is in this zone, which is called the hernia belt, that a defect most often forms. The hernial sac usually does not come out, but spreads between the layers of the abdominal wall, remaining covered by the external muscle. Therefore, upon examination, the protrusion is not visible, and during palpation in obese people it is almost impossible to palpate it.
- Defect along the outer edge of the rectus abdominis muscle
- Most often below the level of the navel
- The hernial sac is located between the layers of the wall
- External protrusion is often absent
- In obese patients, palpation is uninformative
Causes and risk factors
A hernia occurs when a weak spot in the abdominal wall experiences a prolonged increase in intra-abdominal pressure. This is facilitated by excess weight, pregnancy, chronic smoker's cough, constipation, difficulty urinating due to prostate adenoma, heavy physical labor and heavy lifting. An additional factor is previous surgeries and abdominal injuries, which leave scars and areas of weakened tissue, as well as connective tissue diseases. With age, the strength of the aponeurosis decreases, so most cases are detected after forty years.
- Overweight and Obesity
- Repeated pregnancies
- Chronic cough and smoking
- Constipation and straining
- Heavy physical activity
- Past surgeries and abdominal injuries
- Age-related tissue weakening
Symptoms
The most common complaint is pain or a pulling sensation in the lower lateral abdomen, usually on one side. The pain intensifies with straining, coughing, lifting heavy objects and in a standing position, and subsides in a lying position. Sometimes a person notices a small soft protrusion that appears with tension and disappears while lying down. Due to the unclear picture, patients are examined for a long time for colitis, urolithiasis or problems with the spine. When pinched, the pain becomes sharp and constant, followed by nausea and vomiting.
- Pain in the lower lateral abdomen on one side
- Increased pain when coughing and straining
- Intermittent soft protrusion
- Relief while lying down
- Discomfort during physical activity
- If pinched - sharp pain, nausea, vomiting
Diagnostics
The examination is carried out in a standing or lying position, always with tension on the abdominal wall: the doctor asks you to strain or raise your head and legs, then the defect can sometimes be felt. The main method of confirmation is ultrasound examination of the abdominal wall, which is performed at rest and with straining: this shows the release of contents through the defect. In case of doubtful data and in obese patients, computed tomography is prescribed: it accurately shows the size of the gate, the contents of the sac and helps to plan the operation. At the same time, other causes of pain in the side are excluded.
- Examination by a surgeon standing and lying down with straining
- Ultrasound of the abdominal wall at rest and during tension
- Computed tomography of the abdomen
- Exclusion of urolithiasis and intestinal pathology
- Assessing the size of the hernial orifice before surgery
Treatment
There is no conservative treatment: bandages and gymnastics do not close the defect, but only mask the complaints. Given the narrow gate and the high risk of entrapment, elective surgery is recommended immediately after confirmation of the diagnosis. Laparoscopic intervention is more often performed: the defect is closed with a mesh implant from the inside, which provides minimal trauma and quick recovery. For large hernias and adhesions, open access is used. Recovery takes several weeks, during which heavy lifting is limited and bowel movements are normalized to avoid straining.
- Planned surgery after diagnosis confirmation
- Laparoscopic plastic surgery with mesh implant
- Open surgery for large defects
- Emergency surgery for strangulation
- Limiting loads during the recovery period
- Weight loss and treatment of constipation to prevent relapse
