A mass in the left flank

A 76-year-old male patient was admitted to the Emergency Department complaining of recurrent diffuse colicky abdominal pain and vomiting. His past medical history revealed previous appendectomy and right inguinal hernia repair. The physical examination revealed a firm painful palpable mass in the left lower quadrant without clinical signs of peritonitis. Laboratory studies revealed an elevated C-reactive protein (2.63 mg/dL, normal < 0.5) with normal white blood cell count. The patient was treated with intravenous (i.v.) fluids and pain medications, and a surgical consultation was requested. To rule out acute diverticulitis complicated by paracolic abscess, an i.v. contrast-enhanced computed tomography (CT) scan of the abdomen was performed. The CT scan revealed a herniated bowel loop with a thickened wall and perifocal fluid in the left lower quadrant. The lesion was located inferior to the umbilicus and lateral to the rectus abdominis muscle. The diagnosis of incarcerated spigelian hernia was made and the patient underwent emergency surgical intervention. Intraoperative findings confirmed the diagnosis. The hernia sac contained a viable sigmoid loop not requiring resection. The defect in the abdominal wall, measuring about 4 cm, was closed up as successive anatomical layers and a polypropylene mesh was set into the lateral aspect of the rectus sheath. The postoperative course was uneventful and the patient was discharged on the fourth postoperative day