ORIGINAL ARTICLE Preperitoneal mesh repair of spigelian hernias under local anesthesia: description and clinical evaluation of a new technique Received: 23 January 2003 / Accepted: 5 May 2003 / Published online: 20 September 2003 Ó Springer-Verlag 2003 Abstract We report on a new method for the repair of spigelian hernia, in which we combined the step-by-step local anesthesia and open preperitoneal mesh repair techniques. After initial infiltration of local anesthetics, we incised the attenuated fascia and slightly enlarged the fascial defect to facilitate easy return of hernial content into the abdominal cavity. We injected preperitoneally, in a radial fashion around the peritoneal sac, more saline solution, consisting of 1:200,000 epinephrine (g:g) and 1 3 bupivacain (v:v). We dissected the peritoneum away from the anterior abdominal wall to create a preperito- neal pocket of sufficient size. We spread open a 9·9-cm polypropylene mesh in the area, as if we were doing a GPRVS of Stoppa. We followed up our four patients for an average of 32 months. All four cases had an uneventful recovery and were discharged in an average of 3.5 days. They returned to normal daily activity on the 9 th day after surgery. We suggest that the preperi- toneal mesh repair of a spigelian hernia under local anesthesia is a simple and feasible technique with favorable early and late postoperative results and deserves further investigation in larger series. Keywords Spigelian hernia Æ Mesh repair Æ Preperitoneal repair Æ Local anesthesia Æ Polypropylene Introduction The spigelian hernia is a rare kind of abdominal wall de- fect that has been treated using a variety of techniques. When it is considered, the diagnosis is not as difficult as it had once been thought [1, 2]. The condition requires a surgical repair because of its high risk of complications [3, 4]. Aside from its conventional repair by direct approxi- mation of the neighboring muscular tissues, some alter- native open mesh and laparoscopic modalities of repair have been reported in recent years [5, 6, 7]. Could the concept of open posterior preperitoneal repair technique that has been successfully used in inguinal and some ventral hernias be applied to the repair of spigelian hernia defects with favorable early and late results [8, 9]? We, herewith, report on four patients in whom we repaired the spigelian hernia defects by an open preperitoneal tension- free technique under local anesthesia. A separate author who has followed up our patients for an average of 32 months determined the surgical results and patients’ compliance. Patients and methods There were two males and two females whose ages ranged from 42–67 years (Table 1). All four patients referred with pain, and three reported a lump at the site of hernia. Case #2 has had chronic renal failure and was under continuous ambulatory peritoneal dialysis (CAPD) program at the time of diagnosis. An incarcerated spigelian hernia was diagnosed in Case #3 when she was hospi- talized for an extensive aortic aneurysm that had extensions to both common iliac arteries. We found a lump at the site of spigelian hernia during initial physical examination in all four cases. We confirmed the presence of hernia by an ultrasound in three cases, and by a CT scan in two (Fig. 1). We suspected long- term elevated intra-abdominal pressure in cases #2 and #4, in whom the abdominal wall exhibited a general muscular weakness. After definite preoperative diagnosis of spigelian hernias, we accomplished an open preperitoneal mesh repair under local anesthesia in all four cases. Surgical technique We applied local anesthesia in a three-step fashion, as adapted from that of Amid et al. [10]. For this purpose, we used 65 ml (range 40–90 ml) of saline solution Hernia (2003) 7: 202–205 DOI 10.1007/s10029-003-0153-x Z. Malazgirt Æ A. Dervisog˘lu Æ C. Polat E. Guneren Æ H. Guven Æ T. Akpolat Z. Malazgirt (&) Æ A. Dervisog˘lu Æ C. Polat Æ E. Guneren H. Guven Æ T. Akpolat Departments of Surgery and Nephrology, Ondokuz Mayis University, Kurupelit, 55139 Samsun, Turkey E-mail: zaferm@superonline.com Tel.: +90 362 457 6000-2524 Fax: +90 362 457 6041 Z. Malazgirt Ondokuz Mayis University, P.O. Box 013, 55001 Samsun, Turkey