Iliolumbar hernia following bone grafting

Incarcerated Lumbar Hernia Complicated by Retroperitoneal Pseudoaneurysm 50 Years after Resection and Radiation Therapy of a Sarcoma

Background

Lumbar hernias are rare abdominal hernias. Surgery is the only treatment option but remains challenging. Posterior incisional hernias are even rarer especially with incarceration of intra-abdominal contents.

Case Presentation

A 68-year old female presented with a 3-day history of worsening acute abdominal pain and distension, with multiple episodes of emesis. A CT scan indicated a large incarcerated posterolateral abdominal hernia. The patient had a history of resection of a sarcoma on her back as a child and also received chemotherapy and radiation. During emergency laparoscopy, a hemorrhagic small bowel segment incarcerated in the hernia was reduced and resected, and the distended small bowel was decompressed. An elective hernia repair was scheduled. After temporary clinical improvement, the patient again developed abdominal pain, distention, and emesis. During emergency laparotomy, a large hematoma in the right flank was found and partially evacuated. The right colon was mobilized out of the hernia and the duodenum was kocherized. A 20 × 20 cm BIO-A mesh was placed on top of the Gerota fascia and cranially tucked under liver segment VI. Anteriorly, the mesh was fixated with absorbable tacks. The duodenum and colon were placed into the mesh pocket. A postoperative CT scan identified a 2 cm pseudoaneurysm of a side branch of a lumbar artery, and the bleeding source was embolized. The postoperative course was complicated by Clostridium difficile-associated colitis, but ultimately, the patient recovered fully. At 6-month follow-up, there was no evidence for a recurrent hernia.

Discussion

There is a paucity of literature concerning lumbar incisional hernias. Repair with bioabsorbable mesh seems feasible, but longer follow-up is necessary as the mesh was placed in an unusual fashion due to the retroperitoneal hematoma. The exact cause of the hemorrhage is unclear and may have been caused during the initial incarceration, during surgery, or may be a late complication of her previous radiation.

Iliolumbar incisional hernia following iliac bone harvesting: a rare complication

Incisional hernia is a common post-surgical complication, but hernias through iliac bone defects after the harvesting of an iliac bone graft is rare. The common presentation includes swelling and discomfort, and sometimes features of intestinal obstruction. A computerized tomography (CT) scan is commonly used for the diagnosis and to define the anatomical defect in the bone. Surgery is recommended because of high risk of strangulation. While various methods of repairing this type of hernia have been described, we chose to perform mesh repair for an iliolumbar incisional hernia.

Femoral Intertrochanteric Fracture With Spontaneous Lumbar Hernia: A Case Report

INTRODUCTION

The diagnosis of lumbar hernia can be easily missed, as it is a rare case to which most orthopedists are not exposed in their common clinical practice. Approximately 300 cases have been reported in the literature since it was first described by Barbette in 1672.

CASE PRESENTATION

A 76-year-old woman who had been diagnosed with a femoral intertrochanteric fracture was sent to our department. Physical examination revealed a smooth, soft, and movable mass, with no tenderness, palpable on her left flank, which had gradually increased during the last seven years and presented with a slight feeling of swelling. We initially misdiagnosed the case as a left lipoma combined with the femoral intertrochanteric fracture. However, after six hours, the patient presented with a sudden onset of nausea, vomiting, and abdominal distension. Afterward, computed tomography (CT) examination confirmed that the mass was a spontaneous lumbar hernia.

CONCLUSIONS

A lumbar hernia may, on rare occasions, become incarcerated or strangulated, with the consequent complication of mechanical bowel obstruction. We suggest that a patient with a flank mass should always raise suspicions of a lumbar hernia.

Donor site reconstruction in iliac crest tricortical bone graft: surgical technique

BACKGROUND AND PURPOSE

Autogenous bone grafts from the iliac crest are frequently harvested for autologous bone transplantation, because this is still the gold standard in the treatment of many bone defects. However, significant donor site morbidity must be considered. We have developed a simple method to treat the bone defect in the donor site in order to reduce some of the morbidity. In this method, the bone defect size and shape determines its application.

METHOD

After the conventional method of tricortical bone harvesting from the iliac crest, bone defect is repaired by means of a transversal fence of appropriate thin tricortical chips obtained from the posterior lateral wall of the bone defect itself. The mechanical stability of this fence results from impactation of the ends of the tricortical chips into both lateral cancellous bone walls of the repaired bone defect. Thus, no hardware is required, and both the bone defect and ilium contour are restored.

RESULTS

This simple method allows ilium bone defect healing and bone contour recovery after graft harvest, by using the same gold standard graft. Although not much time is necessary to reconstruct the donor site, the bone defect size and shape determine its application.

INTERPRETATION

This method may be a recommendable option for bone defect reconstruction after iliac crest tricortical bone graft harvest as the primary procedure. The advantages of this technique are bone defect healing and bone contour restoration with prevention of a visible deformity over the groin, with no foreign material insertion, thus avoiding additional cost.

Lumbar Hernia: Surgical Anatomy, Embryology, and Technique of Repair

Lumbar hernia is the protrusion of intraperitoneal or extraperitoneal contents through a defect of the posterolateral abdominal wall. Barbette was the first, in 1672, to suggest the existence of lumbar hernias. The first case was reported by Garangeot in 1731. Petit and Grynfeltt delineated the boundaries of the inferior and superior lumbar triangles in 1783 and 1866, respectively. These two anatomical sites account for about 95 per cent of lumbar hernias. Approximately 20 per cent of lumbar hernias are congenital. The rest are either primarily or secondarily acquired. The most common cause of primarily acquired lumbar hernias is increased intra-abdominal pressure. Secondarily acquired lumbar hernias are associated with prior surgical incisions, trauma, and abscess formation. During embryologic development, weakening of the area of the aponeuroses of the layered abdominal muscles that derive from somitic mesoderm, which invades the somatopleure, may potentially lead to lumbar hernias. Repair of lumbar hernias should be performed as early as possible to avoid incarceration and strangulation. The classic repair technique uses the open approach, where closure of the defect is performed either directly or using prosthetic mesh. The laparoscopic approach, either transabdominal or extraperitoneal, is an alternative.

An Alternative Source of Autograft Bone for Spinal Fusion: the Femur: Technical Case Report

Objective:

Autograft bone obtained from the iliac crest remains the “gold standard” for spinal fusion. For various reasons, including previous harvesting or pelvic dysmorphism, the iliac crest bone graft may not be available to the spinal surgeon. We present a novel use of a common orthopedic procedure, intramedullary reaming, for obtaining autograft for revision spinal fusion.

Methods:

A 47-year-old woman presented with failed back syndrome after multiple lumbar surgeries with previous bilateral iliac crest bone harvest. A commercially available reaming system (Synthes Reamer-Irrigator-Aspirator; Synthes USA, West Chester, PA) was introduced into the left intramedullary canal of the femur while the patient remained in the prone position. Using continuous irrigation and aspiration, the reaming debris was collected and used as autograft for the subsequent spinal fusion.

Results:

The patient underwent a successful L4–L5, L5–S1 transforaminal lumbar inter-body fusion with L3–S1 pedicle screw fixation. No complications from the femoral reaming were observed, and 6-month follow-up x-rays demonstrated osseous fusion.

Conclusion:

Femoral reaming provides an alternative source of autograft bone when other sources are unavailable.

Titanium plate reconstruction of the osseous defect after harvest of a composite free flap using the deep circumflex iliac artery

Hernia formation following harvest of bicortical iliac crest bone occurs infrequently as a late complication and may lead to chronic pain at the donor site and rarely to obstruction and strangulation of bowel. We describe the use of a custom-made titanium plate used to reconstruct the iliac donor site following harvest of a DCIA composite free flap. A pre-operative 3D CT and stereolithography model of the ilium are used to fabricate a titanium plate of the desired shape and size. This plate is used to reconstruct the donor site defect at the time of primary surgery. This technique may reduce late complications following DCIA composite free flap harvest.

Incisional hernia from iliac bone grafting site--a report of two cases

Incisional hernia is a fairly common problem in India, although there is a paucity of data from the region. The commonly implicated operations in the aetiology of incisional hernia in our setup are lower segment cesarean sections and surgery for peritonitis. Incisional hernia following iliac bone grafting is rare, despite the frequency of performance of the procedure. Two patients with incisional hernia arising from the donor site of iliac bone grafting were seen in our department over the last year. They underwent mesh hernioplasty using polypropylene mesh that was placed as an onlay. Both the patients are presently well on follow-up, with no recurrence of the hernia. Mesh hernioplasty of hernia following iliac bone grafting gives good results and may be considered the method of choice of repair of this uncommon type of hernia.

Abdominal wall hernias: a cross-sectional pictorial review

The classification of abdominal wall hernias is often made difficult by confusing eponymous and anatomic nomenclature. In this article, we review the anatomy that defines the various types of hernias. The specific cross-sectional radiologic features required to correctly identify each type are then emphasized. The appropriate clinical context and the merits of the various imaging techniques available for the investigation of abdominal wall hernias are also discussed.