Epiploic appendagitis within a Spigelian hernia

A 49-year-old female presented to the emergency room with a one week history of continuous pain in the left iliac fossa. Local tenderness was present and a painful olive-shaped mass was clearly palpable in this area. Ultrasound revealed an 18 x 10 mm painful hyperechoic avascular mass (Fig. A, sagittal and axial view) which was trespassing the abdominal wall through a 7-millimetre orifice. It was prolonged by a small intra abdominal pedicle ending on the sigmoid colon (white arrow).