Presentation
Bulging left thigh mass, with varicose veins in the left lower extremity. Fall 1 year prior.
Patient Data
A large hernia sac containing contrast-filled small bowel loops and fat arises through a 4.6 cm abdominal wall defect adjacent to the left rectus abdominis muscle and the semilunar line. It extends down to the level of the mid femoral diaphysis, with no evidence of obstruction. The hernia sac compresses the left greater saphenous vein, with associated varicosities in the distal left lower extremity (not shown). The hernia sac also displaces the common femoral artery and vein as well as some inguinal lymph nodes. Skin thickening and subcutaneous fat stranding around the inferior portion of the sac.
Comminuted malunited fracture involving the left femoral neck and intertrochanteric region, with relative atrophy of the left hip and thigh muscles.
Case Discussion
Spigelian hernias, also known as spontaneous lateral ventral hernias or hernia of semilunar line, are rare. They only account for 2% of ventral hernias. They were first described by Adriann van der Spieghel in 1645. When small, they may only be apparent in the upright position, disappearing in the supine position.
The hernia sac often contains omentum and properitoneal fat, but may also contain small bowel or large colon. Incarceration rates are high for this type of hernia.
Ultrasound and CT are the modalities of choice for evaluation. CT offers excellent visualization of the abdominal wall defect and the contents of the hernia.
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