Elective transabdominal preperitoneal repair of an incidentally detected spigelian hernia with massive sigmoid colon protrusion through a small fascial defect: a case report.

Introduction and importance: Spigelian hernia is a rare type of ventral hernia. The hernia orifice is generally narrow, and incarceration of the contents - usually omentum or small bowel - is a common problem. Case presentation: A 79-year-old man underwent laparoscopic cholecystectomy for acute cholecystitis. Preoperative computed tomography (CT) incidentally revealed a left Spigelian hernia with protrusion of the sigmoid colon through a small fascial defect. Considering the potential risk of future incarceration, elective hernia repair was planned, and laparoscopic transabdominal preperitoneal (TAPP) repair was selected as the first-line approach. Intraoperatively, the incarcerated sigmoid colon was carefully reduced into the abdominal cavity. The preperitoneal space was widely dissected, and the fascial defect was closed with a continuous non-absorbable barbed suture; a polyester mesh was placed in the preperitoneal space and fixed with absorbable tacks, followed by complete peritoneal closure with absorbable sutures. The postoperative course was uneventful; pain was minimal, and the patient was discharged on postoperative day 4. No recurrence was observed at 6-month follow-up. Discussion: Colon-containing Spigelian hernias are uncommon, and reported cases almost always present with abdominal pain or bowel obstruction. This case is unique in that a large segment of sigmoid colon protruded through a small fascial defect but remained entirely asymptomatic and was discovered incidentally on CT. Conclusion: Even small Spigelian defects may harbor a substantial amount of colon without symptoms. Elective TAPP repair with fascial defect closure and mesh reinforcement is a safe and effective option for Spigelian hernias.