SUN-729 - Incarcerated Spigelian Hernia Following Rapid Tirzepatide-Induced Weight Loss

Introduction: GLP-1 agonists have increasingly become a pillar of weight loss and obesity medicine in the western world. Beyond aesthetic factors, safe and efficient weight loss comes with a multitude of metabolic and cardiac benefits. However, it is important to note that GLP-1 induced weight loss, especially if rapid, can come with its own dangers. This can be in the form of sarcopenia, gastro-intestinal complications such as gallstones, or potentially even structural complications such as hernia incarceration.

Case presentation: We present the case of a 62-year-old male who presented following acute onset of left lower quadrant pain and the development of a bulge in his abdomen. The patient had a previously known and unrepaired left spigelian hernia. The patient had been diagnosed with diabetes mellitus one and a half years prior to presentation after which he was initiated on tirzepatide once weekly. At that time, BMI was 31. In combination with aggressive lifestyle modification, the patient experienced rapid weight loss, losing a total of 60 pounds eight months post initiation. Over this time, A1c improved from 13.3% to 5.6%. The patient was diagnosed with an incarcerated left spigelian hernia and underwent laparoscopic repair with retro-rectus mesh placement without complication. The abdominal defect was noted to be 3.0 x 3.0 cm during surgical intervention. Following surgery, the patient was able to tolerate regular diet and ambulation by POD 1 prior to discharge home.

Discussion: Obesity, specifically BMIs greater than 30 kg/m2 has been recognized as a risk factor for hernia development, recurrence, and increased complications following repair. As such, GLP-1 agonists such as tirzepatide have been recognized as a potential means to improve preoperative weight loss, and therefore to avoid obesity related complications, prior to elective abdominal wall hernia surgeries. However, it is important to note that this may not be true for all categories of abdominal hernias. Contrary to other presentations, spigelian hernias, which occur through defects in the anterior abdominal wall adjacent to the semilunar line, are very uncommon, constituting only about 0.12% of all abdominal wall hernias. Causes are often multifactorial and sometimes hard to pinpoint, with major suspects being multiple pregnancies in women, trauma, congenital defects, obesity, or, most importantly to the current discussion, rapid weight loss. The case presented indicates that, in patients with known spigelian hernias, GLP-1 agonists may need to be used with caution and regular oversight. Furthermore, even in those without known spigelian hernias, patients who present with acute abdominal pain after rapid GLP-1 induced weight loss should be evaluated for spigelian hernias with imaging and, if positive, prompt surgical intervention.

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