PMC4582484_01
Ultrasound image of Spigelian hernia. Defect is shown (A) without (B) with Valsalva maneuver.
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F1
During Valsalva manoeuvre a protrusion of a peritoneal sac, but no organs could be demonstrated (Figure 1 (Fig. 1)). 
Spigelian hernia defect without any contents, after creation of peritoneal flap
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F2
A peritoneal flap was created (Figure 2 (Fig. 2)) and the sac was dissected circumferentially.
Defect reinforced with a lightweight multifilament polypropylene/polyglacin mesh. Fixation with fibrin sealant.
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F3
The mesh was then fixed with 2 ml of a fibrin sealant (Tissuecol Baxter, Unterschleissheim, Germany) (Figure 3 (Fig. 3)).
Ultrasound image 8 months after the operation during Valsalva maneuver. No recurrence. Mesh is shown (indicated by arrow).
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F4
In the follow-up after 3 weeks and again after 8 months, no recurrence was detectable and adequate tissue integration could be observed (Figure 4 (Fig. 4)).