although accounting for 1% of all hernias they account for up to 5.8% of all bowel obstructions and as such are of significant clinical importance . congenital internal hernias can be classified as either paraduodenal ( 5055% ) , pericecal ( 1015% ) , foramen of winslow ( 610% ) , transmesenteric and transmesocolic ( 810% ) , paravesical ( < 4% ) and intersigmoid ( 48% ) according to their anatomical location . other causes of internal hernias include trauma either due to previous surgery or penetrating trauma and chronic inflammation such as cholecystitis . hernias occurring through the falciform ligament are a particularly rare cause of internal hernia with only 37 cases reported in the international literature . these hernias are increasing in frequency due to the number of iatrogenic injuries to the falciform ligament and possibly increased prevalence of cholecystitis . spigelian hernias ( or ventral hernias ) are a rare abdominal wall hernia that account for 0.122% of all abdominal wall hernias . in adults they are considered acquired and result when abdominal fat protrudes between a separation of internal oblique muscle and transversus muscle fibres . this may occur secondary to pregnancy , chronic cough , straining and morbid obesity due to a raised intra - abdominal pressure or abdominal operations . we present a case of a 67-year - old lady who was seen in rural surgical clinic and booked for repair of a symptomatic spigelian hernia . she reported pain in her right lower quadrant over a three - year period and had an accompanying ct scan which demonstrated the hernia containing omentum and preperitoneal fat . she had no previous surgery and nothing else to preclude laparoscopic repair and was booked for a laparoscopic mesh repair . optical entry in the left upper quadrant was used to instil laparoscopy and two 5  mm ports where inserted on the left abdomen to allow dissection and mesh placement . at laparoscopy the falciform ligament was divided and a concurrent defect that continued onto anterior wall was covered with a piece of bard ventralex mesh secured with a double crown of absorbable tacks . the spigelian hernia was repaired with a similar piece of bard ventralex mesh and secured in a similar fashion . she made an uneventful post operative recovery and was discharged on the second post operative day . follow up ct imaging performed at a three month follow up showed the mesh remaining in situ with no evidence of recurrent hernia . falciform ligament hernias like all internal abdominal hernias present most commonly as bowel obstructions with 50% requiring a bowel resection . the largest review on falciform ligament hernias by egle et al . illustrates perfectly the difficulty in clinically diagnosing these hernias with only five of 37 cases having a diagnosis pre - operatively . computer topography imaging ( ct ) has a sensitivity of 35.7% when identifying falciform ligament hernias when performed pre - operatively . spigelian hernias present as either a lateral abdominal wall mass that is reducible and has a cough impulse or if incarcerated may present as visceral abdominal pain . palpation of a lump can be unreliable due to coverage of the hernia by the external oblique muscle . a high index of clinical suspicion must be maintained as 9 out of 17 cases in a series by artioukh and walker were not suspected pre - operatively . ct imaging of a spigelian hernia is by far the most accurate diagnostic method of demonstrating a hernia defect passing through the muscular layers   though ultrasound scanning can demonstrate hernia defects in the abdominal wall and bowel contained within them in the right hands . in the case of our patient the diagnosis of the falciform ligament hernia was made intra operatively and this was allowed by the laparoscopic approach , which then allowed the repair of both hernias fig . 2 . falciform ligament hernias are more likely to be encountered intra - operatively when operating on a patient with a small bowel obstruction rather than a known diagnosis pre - operatively and as such many differing surgical approaches have been made . in the review published by egle et al . the majority of surgeons elected to divide the falciform ligament and ligament of teres following assessment of the herniated bowel and possible resection . unfortunately information regarding the nature of these operations ( laparoscopic verses open ) is not available for comparison . the likely aetiology of the falciform ligament hernia in the case of our patient remains unknown though congenital is the most likely as there was no known iatrogenic cause . spigelian hernias necessitate surgical repair due to their high rates of strangulation , incarceration and intestinal obstruction . recently laparoscopic repair preperitoneal of these hernias has been shown to reduce hospital stays morbidity . the advantage of a trans abdominal laparoscopic repair , such as the one performed in our case , is that it allows for examination of the abdominal organs and as such surgical repair of incarcerated and strangulated hernias . ct imaging has increased the diagnosis pre - operatively of rare abdominal wall and internal abdominal hernias . despite this fact laparoscopic examination of all possible herniation sites and examination of the abdominal organs is a valuable surgical tool when available if there is a diagnostic dilemma and the patient not critically obstructed . this case demonstrates the difficulty in diagnosing internal hernias , when suspicion is low , by ct imaging . although laparoscopy in this case was able to diagnose and repair this internal hernia intraoperative , it remains unclear if this hernia was contributing to the presenting symptomatology . while exceedingly rare , this case demonstrates that modern imaging and surgical techniques , while essential , need to be balanced with clinical acumen and a high degree of suspicion for uncommon pathologies . the authors of this study declare no conflicts of interest and received no monetary benefits , or otherwise for this manuscript . patients informed , written consent for use of de - identified data and photos has been obtained . i , aaron griffin , guarantee this manuscript as the primary , and corresponding author .
highlightswe present a case of a concurrent spigelian hernia and internal hernia through the falciform ligament.we discuss the clinical presentation and management of this case.we suggest methods to decrease mortality from internal hernias such as a raised awareness and a laparoscopic approach for adequate internal examination of the abdominal contents .