Spigelian hernia in children: low versus classical Mamta Sengar a, ⁎, Anup Mohta a , Sujoy Neogi b , Alisha Gupta c , Vivek Viswanathan a a Department of Pediatric Surgery, Chacha Nehru BalChikitsalaya, Geeta Colony, Delhi 110031, India b Department of Pediatric Surgery, Maulana Azad Medical College, Delhi 110031, India c Department of Pediatric Surgery, Chacha Nehru Bal Chikitsalaya, Delhi 110031, India abstract article info Article history: Received 15 February 2018 Received in revised form 24 May 2018 Accepted 13 June 2018 Key words: Spigelian hernia Low Pediatric Cryptorchidism Purpose: Pediatric spigelian hernias are very rare. They are often missed or misdiagnosed. A series of cases with spigelian hernia, presented to a tertiary care center are presented here with emphasis on different anatomy of spigelian hernias with cryptorchidism and those without associated cryptorchidism. Materials and Methods: Over a period of seven years, nine cases of spigelian hernia presented to our tertiary care center. Male:female ratio was 3:1.There was a preponderance of right sided hernias. Three patients had associated cryptorchidism. One patient had associated lumbar hernia. All three patients with cryptorchidism had low spigelian hernia while others had classical spigelian hernia. Conclusion: There is a likelihood of anatomical variation in SH associated with UDT and those without UDT. Understanding this anatomy may help in correct scrotal placement of testis. Type of Study: Prospective Observational. Level of Evidence: 4. © 2018 Elsevier Inc. All rights reserved. Spigelian hernia (SH) is a rare entity in children. In a recently pub- lished extensive review, only 71 cases were identified [1]. Many of the cases of SH are either missed at presentation or misdiagnosed as lumbar or inguinal hernias [2, 3]. This could probably be caused by variation in location, size, shape, variable symptoms of presentation and anatomical proximity to other abdominal hernias [2–5]. Recently many authors have highlighted the association of cryptorchidism and SH. In the pres- ent series, 4 out of 10 cases (40%) had associated ipsilateral cryptorchi- dism. There were marked differences noted between clinical and peroperative findings in cases associated with cryptorchidism and those without it. This publication is aimed to highlight these differences. Understanding these differences might help in further understanding of the entity. 1. Materials and methods All children up to 12 years of age, presenting to a single tertiary care center over eight years (2010–2017), diagnosed as having SH were prospectively included. Age of presentation, presenting complaint, ex- amination findings and associated anomalies including cryptorchidism were noted in all the cases. Intraoperative findings, anatomy of sac and its contents were also recorded. 2. Results Ten cases of SH were included. Median age at presentation was 26 months (range 6 days–12 years). There were 7 males and 3 females (male:female ratio 2.3:1). Right-sided hernias were more common than left with a ratio of 1.6:1. Two patients (20%) had bilateral SH. Of 7 male patients, 4 (57.1%) had associated ipsilateral cryptorchidism while 3 (42.9%) had scrotal testes. The clinical presentations were variable, with pain at hernia site in 3 (30%), empty scrotum in 2 (20%), transient hernia bulge on excessive crying in 1 (10%), reducible swelling in iliac fossa in 3 (30%) and irreduc- ible swelling at spigelian belt at lateral edge of rectus in 1 (10%) case. The diagnoses made at initial presentation were SH (n = 5), unde- scended testis (n = 1), direct inguinal hernia (n = 1), lumbar hernia (n = 2) and nonspecific abdominal pain (n = 1). The associated anom- alies, apart from undescended testis, were lumbar hernia in 1 case and coronal hypospadias in another. None of these patients had history of trauma or any illness leading to raised intraabdominal pressure. Three patients had undergone ultrasound abdomen and 1 patient computed tomogram of abdomen prior to presentation to our hospital, but none of the radiological investigations helped in making a diagnosis. Longest duration for which the entity remained undiagnosed was 2 years in a 12-year-old girl with transient bulge. The clinical details of these cases have been tabulated in Table 1. All patients were managed surgically by open technique. There were significant differences in peroperative findings in cases with and without associated ipsilateral cryptorchidism. Sac in cases associated Journal of Pediatric Surgery 53 (2018) 2346–2348 Abbreviations: SH, spigelian hernia; UDT, undescended testis. ⁎ Corresponding author. Tel.: +91 9811883968. E-mail address: mamtasengar@gmail.com (M. Sengar). https://doi.org/10.1016/j.jpedsurg.2018.06.016 0022-3468/© 2018 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg