laparoscopic living - donor nephrectomy has gained worldwide acceptance since first being described in 1995 . in experienced hands ,
the technique has been shown to be safe and to provide kidneys for transplantation that function identically to those of historic open nephrectomy controls . as with any laparoscopic procedure ,
we report a complication of laparoscopic living - donor nephrectomy in which incarceration of a spigelian hernia occurred postoperatively .
bg is a 51-year - old woman who wished to donate a kidney to her sister .
her initial evaluation revealed normal renal function and excellent health with the exception of obesity . at our transplant program , we have set a limit of a body mass index of 40 for patients to be accepted as living kidney donors .
she was told that such a procedure would not prevent her from being an organ donor .
eight months after her bariatric surgery , the patient had lost a significant amount of weight and had a body mass index of less than 40 .
repeat history , physical examination , and laboratory testing did not reveal any contraindications to kidney donation .
trocars and hand - assist port placement were sited in the usual manner ( figure 1 ) .
adequate exposure required lysis of some adhesions resulting from the previous surgery , but these were not extensive .
the kidney was removed through an 8-cm lower midline incision made early during the procedure for hand - assistance with the pneumosleeve device .
the midline fascia was closed with a running suture at the end of the procedure .
she began a liquid diet the evening of surgery and required only oral narcotics for pain .
on the morning of the first postoperative day , the patient stated that she felt ready to go home .
however , 2 hours later , while walking in the hall , she noted a large  bulge  on the right side of her abdomen and mild to moderate abdominal pain and nausea .
a physical examination revealed a 6 x 8-cm nonreducible mass to the right of the umbilicus .
a ct scan was obtained that demonstrated herniation of the small bowel through a right - sided fascial defect lateral to the midline .
operative exploration through the midline incision made for hand - assisted laparoscopy revealed a fascial defect with herniation of the small bowel at the lateral border of the rectus muscle at the semilunar line of douglas .
the hernia defect was 4 to 5 cm lateral to the hand - assist midline incision .
the abdominal wall tissue in this area was noted to be quite thin and weak .
this is the first known report of a previously undiagnosed spigelian hernia becoming manifest 1 day after a laparoscopic procedure .
we believe this spigelian hernia occurred through a preexisting fascial weakness but that the herniation itself was the result of pneumoperitoneum .
the patient had abdominal ct scanning 2 weeks prior to the laparoscopic nephrectomy , which did not reveal any evidence of an abdominal hernia .
this is most likely due to the patient being in the right lateral decubitus position , because the bowel tends to settle against the lower abdominal wall making inspection of this area impossible .
spigelian hernias occur through the spigelia fascia , which is the part of the trans - verses abdominus aponeurosis lying between the semilunar line and the lateral edge of the rectus muscle .
spigelian hernias may contain preperitoneal fat , greater omentum , small intestine or colon , or rarely other organs .
however , the symptoms , location , and severity are quite variable , and may be intermittent , making diagnosis difficult .
trocar site hernias following laparoscopic surgery are well known and have been reported as causing bowel obstruction and potential strangulation . in our patient ,
herniation through the lower midline incision used for the hand - assisted technique was initially felt to be the most likely site for a hernia causing the patient 's symptoms so soon after surgery .
however , due to the physical examination findings of a palpable nonreducible mass , lateral to the edge of the rectus muscle , the diagnosis of spigelian hernia was considered and a ct scan was performed that confirmed this diagnosis ( figure 2 ) .
no evidence existed that the 7-cm midline incision made for hand - assisted laparoscopy was related to the spigelian hernia defect .
we believe it is unlikely that the hand - port incision itself contributed to the development of the spigelian hernias due to their relative anatomic separation .
in addition , by virtue of the patient 's right lateral decubitus position during the nephrectomy , the location of the hernia was completely obscured throughout the original procedure .
laparoscopic techniques for repair of spigelian hernias have also been reported . in our patient , we chose to repair the hernia through the lower midline incision created during the nephrectomy .
bowel obstruction following abdominal surgery would rarely be attributed to a previously undiagnosed spigelian hernia .
we postulate that our patient had a preexisting weakness in the spigelian fascia and that the hernia developed as a result of the pneumoperitoneum . due to the potential for asymptomatic hernias to become incarcerated due to increased intraabdominal pressure , we advise repair if discovered during laparoscopy .
 we present the case of an incarcerated spigelian hernia that manifested 24 hours after a laparoscopic living - donor nephrectomy . 
 the differential diagnosis , proposed management , and a review of the literature is presented.bowel obstruction occurring within a few days following laparoscopic surgery is most often attributed to a hernia at a trocar site.1 , 2 in the case of living - donor nephrectomy , the hernia could also occur at the incision made for removal of the kidney . 
 spigelian hernia has not been reported as a complication of laparoscopic surgery in the past and , therefore , would not normally be considered in the differential diagnosis of any complications following laparoscopic surgery.with the increasing use of laparoscopy , unsuspected intraabdominal conditions may be diagnosed during the procedure or become manifest because of increased intraabdominal pressure created by the pneumoperitoneum . here 
 we report the diagnosis and repair of a spigelian hernia that became manifest 1 day after laparoscopic nephrectomy . 
INTRODUCTION
CASE REPORT
DISCUSSION