Case of incarcerated appendix within a Spigelian hernia
An obese 74 year-old female patient presented to the emergency room with severe right lower abdominal pain for the past day. She also reported a one month history of abdominal cramps during activity. Physical exam demonstrated abdominal guarding. Labs were significant for leukocytosis. Coronal computed tomography (CT) images showed a spigelian hernia in the right lower quadrant containing an incarcerated appendix. The appendix itself was dilated, the appendiceal wall was thickened, and fat stranding was noted both within the hernia and at the adjacent cecum. Review of prior CT images demonstrates a normal appendix within the hernia. Spigelian hernias involve the aponeurosis between the semilunar line and lateral edge of the rectus abdominis muscle; while uncommon overall, they are the most common type of spontaneous lateral ventral hernia. Clinical diagnosis is often complicated due to their intramural position below the external oblique aponeurosis and abdominal fat. There are less than ten reported cases of incarcerated appendix within these hernias, primarily in surgical journals; this case specifically is unique in that we can document the appendix by coronal CT images both before and after incarceration.