Laparoscopic transabdominal preperitoneal repair of Spigelian hernia a case series and literature review

Laparoscopic transabdominal preperitoneal repair of Spigelian hernia a case series and literature review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Laparoscopic transabdominal preperitoneal repair of Spigelian hernia a case series and literature review Ramiro A. Vargas Aignasse, Alejandro M. Doniquian, German R. Viscido This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7603646/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract INTRODUCTION: Spigelian hernia (SpH) is an uncommon abdominal wall defect characterized by protrusion of preperitoneal fat or a peritoneal sac through Spigelian’s aponeurosis. Most cases occur within the “Spigelian hernial belt,” between the umbilicus and the interspinal line. Diagnosis is challenging, often requiring imaging, and surgical repair remains the treatment of choice. PATIENTS AND METHODS: We conducted a retrospective review of four patients with SpH who underwent laparoscopic transabdominal preperitoneal (TAPP) repair between June 2023 and March 2025. Clinical presentation, operative details, and postoperative outcomes were analyzed. All diagnoses were confirmed by computed tomography (CT), with a mean hernial ring diameter of 2.1 cm. Repair involved reduction of the hernial contents, selective defect closure, and placement of a polypropylene mesh. DISCUSSION The TAPP approach provided optimal anatomical exposure, facilitated thorough assessment of the hernia sac, and enabled safe repair. Its use in both elective and emergency cases demonstrated favorable outcomes in terms of pain control, recovery time, and complication rates. CONCLUSION Laparoscopic TAPP repair for SpH is a safe, effective, and reproducible technique, even in emergency settings. Advantages include short operative time, prompt postoperative recovery, and a low risk of complications when performed by surgeons experienced in laparoscopic surgery. general surgery laparoscopic surgery Spigelian hernia case series Figures Figure 1 Figure 2 INTRODUCTION Spigelian hernia (SpH) is a rare primary ventral hernia, characterized by protrusion of preperitoneal fat or a peritoneal sac through a congenital or acquired defect in Spiegel's aponeurosis [ 1 ]. This aponeurosis is formed by the sheaths of the transverse muscle (TM) and the internal oblique (IO), and its limits are defined medially by the rectus muscle and laterally by the semilunar line [ 2 ]. Although SpH can occur anywhere along the abdominal wall, it is most frequently found within the “Spigelian hernia belt,” situated between the umbilicus and the interspinal line [ 3 , 4 ]. SpH accounts for only 0.1%–2% of all ventral hernias, typically presenting between the fifth and sixth decades of life, with no significant sex predilection [ 1 , 2 ]. Their clinical diagnosis is difficult and confirmation is necessary by abdominal wall ultrasound (US) or computed tomography (CT) [ 1 , 5 ]. The recommended treatment is always surgical due to the high percentage of acute complications that can reach 24% of cases [ 2 ]. Surgery can be performed through a conventional or laparoscopic approach, and techniques with and without prosthetic mesh have been reported [ 6 ]. Nowadays, the type of approach is debated. We present a series of 4 patients diagnosed with SpH who were treated laparoscopically with a transabdominal preperitoneal technique (TAPP). PATIENTS AND METHODS Between June 2023 and March 2025, four patients with SpH underwent laparoscopic repair using the TAPP approach at our institution. The cohort included two males and two females, with a mean age of 36.5 years (range: 35–64 years) and an average BMI of 26.6 kg/m² (range: 26–27.3 kg/m²). All hernias were left-sided. One case involved a low-positioned SpH, clinically mimicking an inguinal hernia, and was approached accordingly (Fig. 1A-D). Another patient presented with a concomitant umbilical hernia, which was repaired during the same procedure. The most common presenting symptoms were lower abdominal pain and a palpable mass (75%, 3 patients). One patient required emergency surgery due to bowel obstruction caused by an incarcerated SpH, while another case was diagnosed incidentally during evaluation for colonic diverticulitis. All patients were diagnosed via CT Scan, revealing an average hernia ring diameter of 2.1 cm (range: 1–3.3 cm). The hernia contents included omentum in three cases and small bowel in one case, without signs of ischemia. Surgical technique All patients were operated with the TAPP technique without intraoperative incidents. In 75% of the cases (3 patients), three trocars were used: a 12 mm trocar at umbilical level, a 10 mm trocar in the right flank and a 5 mm trocar in the right hypochondrium. In one case, in which the SpH was located close to the left inguinal region, an approach similar to that used for the repair of this pathology was chosen, using a 12 mm trocar in the umbilicus and two 5 mm trocars in both flanks. Access to the pneumoperitoneum was performed using a semi-closed technique in three patients. In the case operated in the context of intestinal obstruction, an open access was chosen in order to optimize the safety of the procedure. Technically, the preperitoneal space was accessed, incising the peritoneum 5 cm from the defect. The hernial content was reduced in all cases. The hernial ring, with an average size of 2.1 cm (range: 1-3.3 cm), was closed with a Stratafix® 2 − 0 barbed suture in two of the cases. In the remaining two cases, closure was not performed due to the proximity of the epigastric vessels and the small size of the hernial ring (1 cm), and was considered unnecessary. In all patients a 12 x 12 cm polypropylene prosthesis fixed by means of 4 resorbable straps was placed in the proximity of the defect. Subsequently, the peritoneum was closed with a continuous suture of Stratafix® 2 − 0 to cover the mesh and restore anatomical continuity (Fig. 2: A-F). The average operative time was 75 minutes (range: 65–80 minutes). No intraoperative accidents occurred. Patients were discharged on average 12 hours after surgery (range: 6–14 hours). Postoperative follow-up was performed at 7 and 14 days, and then at 1, 3 months and 1 year, with no complications or recurrences during this period. DISCUSSION Written informed consent was obtained from all patients for the publication of their clinical data and accompanying images. SpHs owe their name to the French anatomist Adriaan van Spieghel, who first described the crescentic line in 1645. However, it was Josef Klinkosch who recognized this entity as a clinical condition in 1764 [ 7 , 8 ]. They represent an uncommon type of primary ventral hernia, with an incidence of up to 2% of all abdominal wall hernias [ 1 ]. In 85–90% of cases, they develop in Spigelian hernial belt or Spangen's area [ 3 , 4 ] located between the umbilicus and the interspinous line. They are also known as “interstitial” or “interparietal” hernias, as the sac is usually located between the aponeuroses of the OI and MT, below the aponeurosis of the external oblique (EO) muscle, without compromising it [ 1 , 9 ]. Low SpH represent an even rarer subtype, in which the hernial tumor is located below the interspinal line, simulating direct inguinal hernias [ 3 , 10 ]. In our series, one patient presented a low SpH which was confirmed at laparoscopy and was approached as if it were an inguinal hernioplasty due to its proximity to this region. The clinical diagnosis of this entity represents a significant challenge, as they are usually small hernias, with a hernial ring usually measuring between 1 and 2 cm [ 9 , 10 ]. In addition, symptoms are nonspecific, predominantly diffuse abdominal pain that intensifies with physical exertion, while physical examination findings are usually subtle or inconclusive. In our retrospective series, we identified three different clinical presentations that illustrate the variability of this disease. The first case was referred to with an erroneous ultrasound diagnosis of abdominal wall lipoma; the second presented as an intestinal obstruction; and the third was an incidental CT finding during evaluation for colonic diverticulitis. These presentations underscore the diagnostic difficulty of this condition and suggest that its actual frequency may be underestimated. Being a pathology that requires a high index of suspicion, diagnostic imaging methods are imposed as part of the diagnostic algorithm. US is recommended as the first option due to its availability, low cost and because it is a safe method, with a sensitivity rate close to 86% [ 11 ]. However, CT with Valsalva maneuver is the standard due to its sensitivity close to 100% and its ability to provide detailed information on the size, location and content of the hernia sac [ 11 , 12 ] Finally, diagnostic exploratory laparoscopy is reserved for patients with persistent symptoms and ambiguous findings after imaging methods [ 10 , 12 ]. Surgical treatment is indicated in all cases of SpH because of the high risk of complications, which can be as high as 24%, a significantly higher percentage compared to other abdominal wall hernias. This higher incidence of complications is attributed to the particular characteristics of the hernial ring, which is usually small and rigid. These hernias frequently go unnoticed until they cause symptoms such as abdominal pain or severe complications, such as strangulation or intestinal obstruction [ 2 , 4 , 13 ]. The open approach has been the mainstay of treatment for these hernias. Several techniques with and without prosthetic mesh have been reported. These include simple closure and the use of onlay prostheses in the retrorectal or preperitoneal space [ 2 ]. The recurrence rate evaluated in series of more than 70 patients with 8-year follow-up is acceptable and close to 4% [ 14 ]. Currently, the laparoscopic approach to the abdominal wall is a widely accepted practice with excellent results. Laparoscopic repair of SpH was first described by Carter in 1992 [ 15 ]. Today, they can be repaired by intraperitoneal technique (IPOM), TAPP or with a totally extraperitoneal access (TEP), each showing specific advantages and disadvantages [ 4 , 5 , 16 ]. According to the Barnes review, the IPOM approach is the most commonly used in 43% of cases [ 5 ]. Technically it is the least demanding with a shorter learning curve. It does not require the creation of a peritoneal flap and offers ample space for mesh placement [ 17 , 18 ]. Its main advantage lies in the possibility of performing concomitant procedures, such as cholecystectomy or treatment of other parietal pathologies, in the finding of incidental lesions and in its safe application in emergency situations. They are of choice in high localization SpH, bilateral, larger than 3 cm in diameter and with irreducible content. However, their disadvantages include higher cost due to the use of visceral contact prostheses, the risk of adhesions between these and the intestinal loops, and possible visceral and/or vascular lesions [ 13 ]. Fernández-Moreno has reported excellent results in 15 patients with this technique, with an average surgical time of 43 minutes, no intraoperative complications, short hospitalization time and no recurrence or complications associated with the prosthesis at 4 years of follow-up [ 19 ]. It was even suggested by Moreno-Egea as the standard technique for the treatment of SpH [ 20 ]. The totally extraperitoneal approach (TEP), described by Moreno-Egea in 1992, is the least used. Its main advantage is that, since it does not require access to the abdominal cavity, it theoretically eliminates the risk of intestinal lesions related to contact with the prosthesis. Another positive point is that it makes it possible to repair concomitant homolateral inguinal hernia defects. On the other hand, it is a more technically demanding technique, with a long learning curve and longer operative times. The reduced operative field can cause discomfort during the procedure, and extensive dissection is required for correct mesh placement. In addition, accidental introduction of the pneumoperitoneum can compromise visibility, and the associated costs are higher due to the use of specific material. In general, it is proposed in low, reducible and small SpH. It is not recommended for irreducible hernias, obese patients or patients with multiple abdominal surgeries [ 8 , 9 , 12 , 21 , 22 ]. On the other hand, the TAPP approach has the advantages of both techniques, since on the one hand it allows visualization of the abdominal cavity, the contents of the sac, its viability and also allows placement of a polypropylene mesh isolated from the intestine, reducing the risk of adhesions and lowering costs. Its best application is in obese patients, hernias of low location, with a large ring or recurrent hernias through the anterior approach. However, among its main disadvantages are the potential vascular and/or intestinal lesions already mentioned and the “relative” prolongation of the operative time determined by the opening and subsequent closure of the peritoneal flap [ 5 , 22 ]. In our experience we found it to be a practical and comfortable approach for this pathology, with an acceptable operative time, early institutional discharge and adequate pain management. Probably in high hernias, where the peritoneum is thinner, it may be more laborious. Patle, in his series of 6 cases with this technique, reported satisfactory results, with an average operative time of 60–90 minutes and no recurrences at 2 years of follow-up [ 23 ]. In the series with the largest number of patients reported, Barnes reported an average operative time of 45 minutes, with no associated immediate complications or recurrences during a 12-month follow-up [ 24 ]. In summary, SpHs represent a diagnostic and therapeutic challenge, given their low prevalence, nonspecific symptomatology, and potential for serious complications. Our institutional experience, together with the available evidence in the literature, supports the laparoscopic TAPP approach as a safe, effective and adaptable technique for different clinical settings, including emergency situations. CONCLUSION Laparoscopic SpH repair by TAPP technique is a safe, reproducible and effective technique even in emergency. The short operative time in trained surgeons, rapid recovery, adequate exposure of the abdominal cavity, vision of the contents of the herniated sac and the possibility of using polypropylene prostheses covered by the peritoneum avoiding visceral contact are outstanding advantages of this approach. Abbreviations SpH, Spigelian hernia; US, ultrasonography; CT, computed tomography; TAPP, transabdominal preperitoneal approach; TEP, totally extraperitoneal approach; IPOM, intraperitoneal onlay mesh Declarations Ethical approval Ethical approval was waived by the Ethics Committee of Clínica Universitaria Reina Fabiola, Universidad Católica de Córdoba, Argentina, as this study is a retrospective case series. It involved no direct patient intervention or manipulation of variables and was therefore classified as minimal risk research. In accordance with national and institutional regulations, informed consent to participate was not required. The research was conducted in accordance with institutional guidelines and the Declaration of Helsinki. Consent to participate As this study was a retrospective case series classified as minimal risk research, informed consent to participate was not required according to institutional and national regulations. Consent to publish Written informed consent was obtained from all patients for the publication of their clinical data and accompanying images. Data availability statement The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request. References Polistina FA, Garbo G, Trevisan P, Frego M (2015) Twelve years of experience treating Spigelian hernia. Surgery 157:547–550. https://doi.org/10.1016/j.surg.2014.09.027 Webber V, Low C, Skipworth RJE, Kumar S, de Beaux AC, Tulloh B (2017) Contemporary thoughts on the management of Spigelian hernia. Hernia 21:355–361. https://doi.org/10.1007/s10029-017-1579-x Skandalakis PN, Zoras O, Skandalakis JE, Mirilas P (2006) Spigelian hernia: surgical anatomy, embryology, and technique of repair. 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J Laparoendosc Adv Surg Tech A 24:66–71. https://doi.org/10.1089/lap.2013.0407 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 20 Jan, 2026 Reviews received at journal 01 Dec, 2025 Reviewers agreed at journal 01 Dec, 2025 Reviews received at journal 13 Nov, 2025 Reviewers agreed at journal 04 Nov, 2025 Reviews received at journal 23 Oct, 2025 Reviews received at journal 20 Oct, 2025 Reviewers agreed at journal 18 Oct, 2025 Reviewers agreed at journal 15 Oct, 2025 Reviewers invited by journal 15 Oct, 2025 Editor invited by journal 14 Oct, 2025 Editor assigned by journal 10 Oct, 2025 Submission checks completed at journal 08 Oct, 2025 First submitted to journal 08 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7603646","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":534882706,"identity":"554a5555-163d-4a41-a9a6-ba1e4185fbf5","order_by":0,"name":"Ramiro A. 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12:37:50","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":685687,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFIGURE2.png","url":"https://assets-eu.researchsquare.com/files/rs-7603646/v1/0e4538ce310cc8944ca4a939.png"},{"id":94666900,"identity":"2ccd2ef4-2b49-453b-a377-8f42adb9a489","added_by":"auto","created_at":"2025-10-29 12:37:50","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":61504,"visible":true,"origin":"","legend":"","description":"","filename":"da1dd278883746ac9b9d91d8b070c5711structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7603646/v1/dcaa44ba127fd93f370f5b4c.xml"},{"id":94666902,"identity":"5dca5955-efe4-42dc-ba8b-fe2b9d358430","added_by":"auto","created_at":"2025-10-29 12:37:50","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":70267,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7603646/v1/2274cf7154041e790e7a406e.html"},{"id":94666892,"identity":"5760963f-7cd4-457b-8742-3bd7f7fd26f4","added_by":"auto","created_at":"2025-10-29 12:37:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":511262,"visible":true,"origin":"","legend":"\u003cp\u003eComputed tomography (CT) (A.) axial projection and (B.) sagittal projection showing a 3.3 cm low parietal defect between the rectus muscle and the left internal oblique, through which the hernial sac with omental contents protrudes, compatible with a low Spiegelian hernia. Arrangement of the trocars for the low SpH approach, using two 5 mm trocars in both flanks and a 10 mm trocar at supraumbilical level (C). Reduction of the lipoma through Spiegel's defect (dotted circle), noting that it is lateral to the epigastric vessels (black arrow). Elements of the spermatic cord without hernia present (blue arrow) (D). SpH: Spigelian Hernia.\u003c/p\u003e","description":"","filename":"FIGURE1.png","url":"https://assets-eu.researchsquare.com/files/rs-7603646/v1/c777d2d8550c2e245c016d48.png"},{"id":94666894,"identity":"6f39da31-8057-4af1-a1da-a62e303c4a91","added_by":"auto","created_at":"2025-10-29 12:37:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1279139,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Opening of the peritoneum and access to the preperitoneal space. (B) Reduction of the hernia sac lipoma and exposure of the abdominal wall defect. (C) Identification of the SpH ring after reduction. (D) Closure of the defect using a continuous barbed suture. (E) Placement of polypropylene mesh in the preperitoneal space and fixation with a device. (F) Closure of the peritoneum with a continuous barbed suture, isolating the mesh from the abdominal cavity. \u003cstrong\u003eSpH\u003c/strong\u003e: Spigelian Hernia.\u003c/p\u003e","description":"","filename":"FIGURE2.png","url":"https://assets-eu.researchsquare.com/files/rs-7603646/v1/a05ea45075a4d6a19b8c878f.png"},{"id":94674096,"identity":"e15d885c-2f77-4615-80e4-b8e99def5563","added_by":"auto","created_at":"2025-10-29 13:42:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2150315,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7603646/v1/bad2bcb9-ddff-4474-8a2a-56ae61f2fd5f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Laparoscopic transabdominal preperitoneal repair of Spigelian hernia a case series and literature review","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eSpigelian hernia (SpH) is a rare primary ventral hernia, characterized by protrusion of preperitoneal fat or a peritoneal sac through a congenital or acquired defect in Spiegel's aponeurosis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This aponeurosis is formed by the sheaths of the transverse muscle (TM) and the internal oblique (IO), and its limits are defined medially by the rectus muscle and laterally by the semilunar line [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough SpH can occur anywhere along the abdominal wall, it is most frequently found within the \u0026ldquo;Spigelian hernia belt,\u0026rdquo; situated between the umbilicus and the interspinal line [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. SpH accounts for only 0.1%\u0026ndash;2% of all ventral hernias, typically presenting between the fifth and sixth decades of life, with no significant sex predilection [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTheir clinical diagnosis is difficult and confirmation is necessary by abdominal wall ultrasound (US) or computed tomography (CT) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe recommended treatment is always surgical due to the high percentage of acute complications that can reach 24% of cases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Surgery can be performed through a conventional or laparoscopic approach, and techniques with and without prosthetic mesh have been reported [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Nowadays, the type of approach is debated.\u003c/p\u003e\u003cp\u003eWe present a series of 4 patients diagnosed with SpH who were treated laparoscopically with a transabdominal preperitoneal technique (TAPP).\u003c/p\u003e"},{"header":"PATIENTS AND METHODS","content":"\u003cp\u003eBetween June 2023 and March 2025, four patients with SpH underwent laparoscopic repair using the TAPP approach at our institution. The cohort included two males and two females, with a mean age of 36.5 years (range: 35\u0026ndash;64 years) and an average BMI of 26.6 kg/m\u0026sup2; (range: 26\u0026ndash;27.3 kg/m\u0026sup2;). All hernias were left-sided. One case involved a low-positioned SpH, clinically mimicking an inguinal hernia, and was approached accordingly (Fig.\u0026nbsp;1A-D). Another patient presented with a concomitant umbilical hernia, which was repaired during the same procedure.\u003c/p\u003e\u003cp\u003eThe most common presenting symptoms were lower abdominal pain and a palpable mass (75%, 3 patients). One patient required emergency surgery due to bowel obstruction caused by an incarcerated SpH, while another case was diagnosed incidentally during evaluation for colonic diverticulitis. All patients were diagnosed via CT Scan, revealing an average hernia ring diameter of 2.1 cm (range: 1\u0026ndash;3.3 cm). The hernia contents included omentum in three cases and small bowel in one case, without signs of ischemia.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSurgical technique\u003c/h2\u003e\u003cp\u003eAll patients were operated with the TAPP technique without intraoperative incidents. In 75% of the cases (3 patients), three trocars were used: a 12 mm trocar at umbilical level, a 10 mm trocar in the right flank and a 5 mm trocar in the right hypochondrium. In one case, in which the SpH was located close to the left inguinal region, an approach similar to that used for the repair of this pathology was chosen, using a 12 mm trocar in the umbilicus and two 5 mm trocars in both flanks. Access to the pneumoperitoneum was performed using a semi-closed technique in three patients. In the case operated in the context of intestinal obstruction, an open access was chosen in order to optimize the safety of the procedure.\u003c/p\u003e\u003cp\u003eTechnically, the preperitoneal space was accessed, incising the peritoneum 5 cm from the defect. The hernial content was reduced in all cases. The hernial ring, with an average size of 2.1 cm (range: 1-3.3 cm), was closed with a Stratafix\u0026reg; 2\u0026thinsp;\u0026minus;\u0026thinsp;0 barbed suture in two of the cases. In the remaining two cases, closure was not performed due to the proximity of the epigastric vessels and the small size of the hernial ring (1 cm), and was considered unnecessary.\u003c/p\u003e\u003cp\u003eIn all patients a 12 x 12 cm polypropylene prosthesis fixed by means of 4 resorbable straps was placed in the proximity of the defect. Subsequently, the peritoneum was closed with a continuous suture of Stratafix\u0026reg; 2\u0026thinsp;\u0026minus;\u0026thinsp;0 to cover the mesh and restore anatomical continuity (Fig.\u0026nbsp;2: A-F).\u003c/p\u003e\u003cp\u003eThe average operative time was 75 minutes (range: 65\u0026ndash;80 minutes). No intraoperative accidents occurred.\u003c/p\u003e\u003cp\u003ePatients were discharged on average 12 hours after surgery (range: 6\u0026ndash;14 hours). Postoperative follow-up was performed at 7 and 14 days, and then at 1, 3 months and 1 year, with no complications or recurrences during this period.\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e Written informed consent was obtained from all patients for the publication of their clinical data and accompanying images.\u003c/p\u003e\u003cp\u003eSpHs owe their name to the French anatomist Adriaan van Spieghel, who first described the crescentic line in 1645. However, it was Josef Klinkosch who recognized this entity as a clinical condition in 1764 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. They represent an uncommon type of primary ventral hernia, with an incidence of up to 2% of all abdominal wall hernias [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In 85\u0026ndash;90% of cases, they develop in Spigelian hernial belt or Spangen's area [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] located between the umbilicus and the interspinous line. They are also known as \u0026ldquo;interstitial\u0026rdquo; or \u0026ldquo;interparietal\u0026rdquo; hernias, as the sac is usually located between the aponeuroses of the OI and MT, below the aponeurosis of the external oblique (EO) muscle, without compromising it [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Low SpH represent an even rarer subtype, in which the hernial tumor is located below the interspinal line, simulating direct inguinal hernias [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In our series, one patient presented a low SpH which was confirmed at laparoscopy and was approached as if it were an inguinal hernioplasty due to its proximity to this region.\u003c/p\u003e\u003cp\u003eThe clinical diagnosis of this entity represents a significant challenge, as they are usually small hernias, with a hernial ring usually measuring between 1 and 2 cm [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In addition, symptoms are nonspecific, predominantly diffuse abdominal pain that intensifies with physical exertion, while physical examination findings are usually subtle or inconclusive. In our retrospective series, we identified three different clinical presentations that illustrate the variability of this disease. The first case was referred to with an erroneous ultrasound diagnosis of abdominal wall lipoma; the second presented as an intestinal obstruction; and the third was an incidental CT finding during evaluation for colonic diverticulitis. These presentations underscore the diagnostic difficulty of this condition and suggest that its actual frequency may be underestimated.\u003c/p\u003e\u003cp\u003eBeing a pathology that requires a high index of suspicion, diagnostic imaging methods are imposed as part of the diagnostic algorithm. US is recommended as the first option due to its availability, low cost and because it is a safe method, with a sensitivity rate close to 86% [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, CT with Valsalva maneuver is the standard due to its sensitivity close to 100% and its ability to provide detailed information on the size, location and content of the hernia sac [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Finally, diagnostic exploratory laparoscopy is reserved for patients with persistent symptoms and ambiguous findings after imaging methods [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSurgical treatment is indicated in all cases of SpH because of the high risk of complications, which can be as high as 24%, a significantly higher percentage compared to other abdominal wall hernias. This higher incidence of complications is attributed to the particular characteristics of the hernial ring, which is usually small and rigid. These hernias frequently go unnoticed until they cause symptoms such as abdominal pain or severe complications, such as strangulation or intestinal obstruction [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe open approach has been the mainstay of treatment for these hernias. Several techniques with and without prosthetic mesh have been reported. These include simple closure and the use of onlay prostheses in the retrorectal or preperitoneal space [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The recurrence rate evaluated in series of more than 70 patients with 8-year follow-up is acceptable and close to 4% [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCurrently, the laparoscopic approach to the abdominal wall is a widely accepted practice with excellent results. Laparoscopic repair of SpH was first described by Carter in 1992 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Today, they can be repaired by intraperitoneal technique (IPOM), TAPP or with a totally extraperitoneal access (TEP), each showing specific advantages and disadvantages [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAccording to the Barnes review, the IPOM approach is the most commonly used in 43% of cases [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Technically it is the least demanding with a shorter learning curve. It does not require the creation of a peritoneal flap and offers ample space for mesh placement [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Its main advantage lies in the possibility of performing concomitant procedures, such as cholecystectomy or treatment of other parietal pathologies, in the finding of incidental lesions and in its safe application in emergency situations. They are of choice in high localization SpH, bilateral, larger than 3 cm in diameter and with irreducible content. However, their disadvantages include higher cost due to the use of visceral contact prostheses, the risk of adhesions between these and the intestinal loops, and possible visceral and/or vascular lesions [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Fern\u0026aacute;ndez-Moreno has reported excellent results in 15 patients with this technique, with an average surgical time of 43 minutes, no intraoperative complications, short hospitalization time and no recurrence or complications associated with the prosthesis at 4 years of follow-up [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. It was even suggested by Moreno-Egea as the standard technique for the treatment of SpH [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe totally extraperitoneal approach (TEP), described by Moreno-Egea in 1992, is the least used. Its main advantage is that, since it does not require access to the abdominal cavity, it theoretically eliminates the risk of intestinal lesions related to contact with the prosthesis. Another positive point is that it makes it possible to repair concomitant homolateral inguinal hernia defects. On the other hand, it is a more technically demanding technique, with a long learning curve and longer operative times. The reduced operative field can cause discomfort during the procedure, and extensive dissection is required for correct mesh placement. In addition, accidental introduction of the pneumoperitoneum can compromise visibility, and the associated costs are higher due to the use of specific material. In general, it is proposed in low, reducible and small SpH. It is not recommended for irreducible hernias, obese patients or patients with multiple abdominal surgeries [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOn the other hand, the TAPP approach has the advantages of both techniques, since on the one hand it allows visualization of the abdominal cavity, the contents of the sac, its viability and also allows placement of a polypropylene mesh isolated from the intestine, reducing the risk of adhesions and lowering costs. Its best application is in obese patients, hernias of low location, with a large ring or recurrent hernias through the anterior approach. However, among its main disadvantages are the potential vascular and/or intestinal lesions already mentioned and the \u0026ldquo;relative\u0026rdquo; prolongation of the operative time determined by the opening and subsequent closure of the peritoneal flap [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In our experience we found it to be a practical and comfortable approach for this pathology, with an acceptable operative time, early institutional discharge and adequate pain management. Probably in high hernias, where the peritoneum is thinner, it may be more laborious. Patle, in his series of 6 cases with this technique, reported satisfactory results, with an average operative time of 60\u0026ndash;90 minutes and no recurrences at 2 years of follow-up [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In the series with the largest number of patients reported, Barnes reported an average operative time of 45 minutes, with no associated immediate complications or recurrences during a 12-month follow-up [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In summary, SpHs represent a diagnostic and therapeutic challenge, given their low prevalence, nonspecific symptomatology, and potential for serious complications. Our institutional experience, together with the available evidence in the literature, supports the laparoscopic TAPP approach as a safe, effective and adaptable technique for different clinical settings, including emergency situations.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eLaparoscopic SpH repair by TAPP technique is a safe, reproducible and effective technique even in emergency. The short operative time in trained surgeons, rapid recovery, adequate exposure of the abdominal cavity, vision of the contents of the herniated sac and the possibility of using polypropylene prostheses covered by the peritoneum avoiding visceral contact are outstanding advantages of this approach.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSpH, Spigelian hernia; US, ultrasonography; CT, computed tomography; TAPP, transabdominal preperitoneal approach; TEP, totally extraperitoneal approach; IPOM, intraperitoneal onlay mesh\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was waived by the Ethics Committee of Cl\u0026iacute;nica Universitaria Reina Fabiola, Universidad Cat\u0026oacute;lica de C\u0026oacute;rdoba, Argentina, as this study is a retrospective case series. It involved no direct patient intervention or manipulation of variables and was therefore classified as minimal risk research. In accordance with national and institutional regulations, informed consent to participate was not required. The research was conducted in accordance with institutional guidelines and the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs this study was a retrospective case series classified as minimal risk research, informed consent to participate was not required according to institutional and national regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all patients for the publication of their clinical data and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePolistina FA, Garbo G, Trevisan P, Frego M (2015) Twelve years of experience treating Spigelian hernia. Surgery 157:547\u0026ndash;550. https://doi.org/10.1016/j.surg.2014.09.027\u003c/li\u003e\n\u003cli\u003eWebber V, Low C, Skipworth RJE, Kumar S, de Beaux AC, Tulloh B (2017) Contemporary thoughts on the management of Spigelian hernia. Hernia 21:355\u0026ndash;361. https://doi.org/10.1007/s10029-017-1579-x\u003c/li\u003e\n\u003cli\u003eSkandalakis PN, Zoras O, Skandalakis JE, Mirilas P (2006) Spigelian hernia: surgical anatomy, embryology, and technique of repair. Am Surg 72:42\u0026ndash;48\u003c/li\u003e\n\u003cli\u003eMalazgirt Z, Topgul K, Sokmen S, Ersin S, Turkcapar AG, Gok H, et al (2006) Spigelian hernias: a prospective analysis of baseline parameters and surgical outcome of 34 consecutive patients. Hernia 10:326\u0026ndash;330. https://doi.org/10.1007/s10029-006-0103-5\u003c/li\u003e\n\u003cli\u003eBarnes TG, McWhinnie DL (2016) Laparoscopic Spigelian hernia repair: a systematic review. Surg Laparosc Endosc Percutan Tech 26:265\u0026ndash;270. https://doi.org/10.1097/SLE.0000000000000286\u003c/li\u003e\n\u003cli\u003eHuber N, Paschke S, Henne-Bruns D, Brockschmidt C (2013) Laparoscopic intraperitoneal mesh fixation with fibrin sealant of a Spigelian hernia. GMS Interdiscip Plast Reconstr Surg DGPW 2:Doc08. https://doi.org/10.3205/iprs000028\u003c/li\u003e\n\u003cli\u003eRuiz de la Hermosa A, Amunategui Prats I, Machado Liendo P, Nevarez Noboa F, Mu\u0026ntilde;oz Calero A (2010) Spigelian hernia. Personal experience and review of the literature. Rev Esp Enferm Dig 102:583\u0026ndash;586. https://doi.org/10.4321/s1130-01082010001000003\u003c/li\u003e\n\u003cli\u003eJ\u0026auml;hne J, K\u0026ouml;nigsrainer A, Ruchholtz S, Schr\u0026ouml;der W (2022) Was gibt es Neues in der Chirurgie? Jahresband 2022. ecomed, Landsberg\u003c/li\u003e\n\u003cli\u003eMittal T, Kumar V, Khullar R, Sharma A, Soni V, Baijal M, et al (2008) Diagnosis and management of Spigelian hernia: a review of literature and our experience. J Minim Access Surg 4:95\u0026ndash;98. https://doi.org/10.4103/0972-9941.45204\u003c/li\u003e\n\u003cli\u003eHanzalova I, Sch\u0026auml;fer M, Demartines N, Clerc D (2021) Spigelian hernia: current approaches to surgical treatment\u0026mdash;a review. Hernia 26:1427\u0026ndash;1433. https://doi.org/10.1007/s10029-021-02511-8\u003c/li\u003e\n\u003cli\u003eAnilir E, Buyuker F, Tosun S, Alimoglu O (2020) Incarcerated Spigelian hernia: a rare cause of abdominal wall tender mass. North Clin Istanb 7:74\u0026ndash;77. https://doi.org/10.14744/nci.2018.09582\u003c/li\u003e\n\u003cli\u003eHenriksen NA, Kaufmann R, Simons MP, Berrevoet F, East B, Fischer J, et al (2020) EHS and AHS guidelines for treatment of primary ventral hernias in rare locations or special circumstances. BJS Open 4:342\u0026ndash;353. https://doi.org/10.1002/bjs5.50252\u003c/li\u003e\n\u003cli\u003eLaw TT, Ng KK, Ng L, Wong KY (2018) Elective laparoscopic totally extraperitoneal repair for Spigelian hernia: a case series of four patients. Asian J Endosc Surg 11:244\u0026ndash;247. https://doi.org/10.1111/ases.12454\u003c/li\u003e\n\u003cli\u003eLarson DW, Farley DR (2002) Spigelian hernias: repair and outcome for 81 patients. World J Surg 26:1277\u0026ndash;1281. https://doi.org/10.1007/s00268-002-6605-0\u003c/li\u003e\n\u003cli\u003eCarter JE, Mizes C (1992) Laparoscopic diagnosis and repair of Spigelian hernia: report of a case and technique. Am J Obstet Gynecol 167:77\u0026ndash;78. https://doi.org/10.1016/s0002-9378(11)91630-5\u003c/li\u003e\n\u003cli\u003eSkouras C, Purkayastha S, Jiao L, Tekkis P, Darzi A, Zacharakis E (2011) Laparoscopic management of Spigelian hernias. Surg Laparosc Endosc Percutan Tech 21:76\u0026ndash;81. https://doi.org/10.1097/SLE.0b013e31820d66df\u003c/li\u003e\n\u003cli\u003eKadian YS, Verma A, Rattan KN, Kajal P (2017) Laparoscopic diagnosis and repair of Spigelian hernia: a case report and literature review. Int J Surg Case Rep 31:184\u0026ndash;187. https://doi.org/10.1016/j.ijscr.2017.01.043\u003c/li\u003e\n\u003cli\u003eRankin A, Kostusiak M, Sokker A (2019) Spigelian hernia: case series and review of the literature. Visc Med 35:133\u0026ndash;136. https://doi.org/10.1159/000494280\u003c/li\u003e\n\u003cli\u003eFern\u0026aacute;ndez-Moreno MC, Mart\u0026iacute;-Cu\u0026ntilde;at E, Pou G, Ortega J (2018) Intraperitoneal onlay mesh technique for Spigelian hernia in an outpatient and short-stay surgery unit: what\u0026rsquo;s new in intraperitoneal meshes? J Laparoendosc Adv Surg Tech A 28:700\u0026ndash;704. https://doi.org/10.1089/lap.2017.0319\u003c/li\u003e\n\u003cli\u003eMoreno-Egea A, Campillo-Soto \u0026Aacute;, Morales-Cuenca G (2015) Which should be the gold standard laparoscopic technique for handling Spigelian hernias? Surg Endosc 29:856\u0026ndash;862. https://doi.org/10.1007/s00464-014-3738-9\u003c/li\u003e\n\u003cli\u003eTakayama Y, Okada S, Nakatani K, Matsumoto R, Suganuma T, Rikiyama T (2021) The advantage of laparoscopic surgery in the treatment of Spigelian hernia: a report of two cases. Int J Surg Case Rep 82:105903. https://doi.org/10.1016/j.ijscr.2021.105903\u003c/li\u003e\n\u003cli\u003eDonovan K, Denham M, Kuchta K, Carbray J, Ujiki M, Linn J, et al (2021) Laparoscopic totally extraperitoneal and transabdominal preperitoneal approaches are equally effective for Spigelian hernia repair. Surg Endosc 35:1827\u0026ndash;1833. https://doi.org/10.1007/s00464-020-07582-9\u003c/li\u003e\n\u003cli\u003ePatle NM, Tantia O, Sasmal PK, Khanna S, Sen B (2010) Laparoscopic repair of Spigelian hernia: our experience. J Laparoendosc Adv Surg Tech A 20:129\u0026ndash;133. https://doi.org/10.1089/lap.2009.0314\u003c/li\u003e\n\u003cli\u003eBarnes TG, McFaul C, Abdelrazeq AS (2014) Laparoscopic transabdominal preperitoneal repair of Spigelian hernia\u0026mdash;closure of the fascial defect is not necessary. J Laparoendosc Adv Surg Tech A 24:66\u0026ndash;71. https://doi.org/10.1089/lap.2013.0407\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"general surgery, laparoscopic surgery, Spigelian hernia, case series","lastPublishedDoi":"10.21203/rs.3.rs-7603646/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7603646/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eINTRODUCTION:\u003c/h2\u003e\u003cp\u003eSpigelian hernia (SpH) is an uncommon abdominal wall defect characterized by protrusion of preperitoneal fat or a peritoneal sac through Spigelian\u0026rsquo;s aponeurosis. Most cases occur within the \u0026ldquo;Spigelian hernial belt,\u0026rdquo; between the umbilicus and the interspinal line. Diagnosis is challenging, often requiring imaging, and surgical repair remains the treatment of choice.\u003c/p\u003e\u003ch2\u003ePATIENTS AND METHODS:\u003c/h2\u003e\u003cp\u003eWe conducted a retrospective review of four patients with SpH who underwent laparoscopic transabdominal preperitoneal (TAPP) repair between June 2023 and March 2025. Clinical presentation, operative details, and postoperative outcomes were analyzed. All diagnoses were confirmed by computed tomography (CT), with a mean hernial ring diameter of 2.1 cm. Repair involved reduction of the hernial contents, selective defect closure, and placement of a polypropylene mesh.\u003c/p\u003e\u003ch2\u003eDISCUSSION\u003c/h2\u003e\u003cp\u003eThe TAPP approach provided optimal anatomical exposure, facilitated thorough assessment of the hernia sac, and enabled safe repair. Its use in both elective and emergency cases demonstrated favorable outcomes in terms of pain control, recovery time, and complication rates.\u003c/p\u003e\u003ch2\u003eCONCLUSION\u003c/h2\u003e\u003cp\u003eLaparoscopic TAPP repair for SpH is a safe, effective, and reproducible technique, even in emergency settings. Advantages include short operative time, prompt postoperative recovery, and a low risk of complications when performed by surgeons experienced in laparoscopic surgery.\u003c/p\u003e","manuscriptTitle":"Laparoscopic transabdominal preperitoneal repair of Spigelian hernia a case series and literature review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-29 12:37:46","doi":"10.21203/rs.3.rs-7603646/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-20T13:03:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-01T17:24:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"254696319315589494020014238049905878545","date":"2025-12-01T16:15:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-13T16:56:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"337290199941026797571581017078342004663","date":"2025-11-04T13:56:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-23T16:32:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-20T17:35:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"134630731108432632633024054762137131678","date":"2025-10-18T18:03:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2130094868945329296149250822408138937","date":"2025-10-16T01:06:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-15T22:51:01+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-14T12:58:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-10T11:17:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-08T20:51:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Medicine","date":"2025-10-08T20:48:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fa4f7267-8574-4641-bfb0-1cebe2f82173","owner":[],"postedDate":"October 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T22:53:14+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-29 12:37:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7603646","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7603646","identity":"rs-7603646","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}