Bilateral spigelian hernias: diagnosis and treatment in a regional hospital.

In recent times, the viability and future of rural hospitals has been questioned by governments eager to balance health budgets. Regional hospitals can be highly efficient in certain clinical scenarios, which if translated into the metropolitan environment would require interhospital transfers and cause potential logistical problems. Port Augusta is a regional centre in South Australia, approximately 300 km from Adelaide. The immediate population is in the vicinity of 15 000, with a further 15 000 in the surrounding regions. The hospital has resident anaesthetic, paediatric and obstetric services and a surgical service staffed by surgeons from the University of Adelaide, Department of Surgery, with each surgeon rostered on for a week at a time. The following case summary illustrates the ease with which potentially complicated clinical scenarios can be effectively dealt with at the level of the regional hospital, in this instance, Port Augusta. A 21-year-old female presented with severe lower abdominal pain and frequent bilious vomiting. The patient had recently undergone a caesarean section for twin pregnancy. There were no significant co-morbidities. General examination revealed signs of mild dehydration with abdominal distension. There was tenderness in the paraumbilical region without any overt signs of peritonitis. The caesarean section scar appeared healthy with no evidence of infection. Obstetrics review did not reveal any clinically evident complications related to pregnancy. Blood tests were normal. Response to analgesia and conservative therapy was unsatisfactory. A surgical opinion was sought. Computed tomography (CT) scan of the abdomen was undertaken to aid the diagnosis and surprisingly revealed bilateral spigelian hernias with signs suggestive of incarceration (Fig. 1). A laparoscopic assisted repair was undertaken. At laparoscopy, both hernias were evident with incarcerated but viable omentum (Fig. 2). These were reduced laparoscopically. The defects were repaired via open incisions with non-absorbable sutures. Symptomatic improvement was apparent immediately, and the patient made excellent recovery to be discharged on the second postoperative day and continues to do well on follow-up. Spigelian hernias are an uncommon variety of spontaneous ventral hernias appearing at the lateral edge of the rectus sheath. Bilateral spigelian hernias are