Laparoscopic repair of a lumbar hernia: report of a case and extensive review of the literature

Laparoscopic Transabdominal Preperitoneal Repair of a Primary Upper Lumbar Hernia: A Case Report

Lumbar hernias are a rare type of hernia, arising through posterolateral abdominal wall defects containing either intraperitoneal or extraperitoneal contents. Most lumbar hernias are primary, incisional, or trauma-related, while congenital lumbar hernias are uncommon. Surgical management comes down to two approaches: the classic repair technique with an open approach utilizing a lumbar incision and the laparoscopic approach, either transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP). We present the case of a 56-year-old female patient who was evaluated in the outpatient surgical clinic, complaining of pain located between the left midaxillary line and the left lumbar region. The patient underwent a CT scan, and a diagnosis of a left upper lumbar hernia was made. The patient underwent a laparoscopic TAPP repair and was discharged on postoperative day one. Our case highlights that lumbar hernias can present with vague symptoms and without an obvious lump/mass, a diagnosis of which could require a great degree of clinical suspicion especially when there is no history of trauma or surgery in the area. Early imaging can confirm the diagnosis, and surgical repair should be conducted to prevent possible complications.

A case of idiopathic superior lumbar hernia repaired using a transabdominal laparoscopic approach

The patient is a 78-year-old woman who presented to our hospital with left lumbar back pain as her chief complaint. She was diagnosed with superior lumbar hernia. There was no history of abdominal or lumbar surgery, or trauma, so the condition was considered idiopathic. Mesh was placed laparoscopically to repair the hernia. She was discharged on the second postoperative day. One year has passed since the surgery, and there has been no recurrence of the hernia, nor have there been any complications such as neuropathic pain. Superior lumbar hernia is a type of abdominal wall hernia that protrudes through the superior lumbar triangle and is a relatively rare condition. Due to the lack of an established standard surgical procedure, various surgical techniques have been employed depending on the facility. Laparoscopic surgery was considered a minimally invasive and reliable method for hernia repair, providing good visualization in cases without intra-abdominal adhesions.

Primary Lumbar Hernia, Review and Proposals for a Standardized Treatment

A lumbar abdominal wall hernia is a protrusion of intraperitoneal or extraperitoneal contents through a weakness in the posterior abdominal wall, usually through the superior or inferior lumbar triangle. Due to its rare occurrence, adequate knowledge of anatomy and methods for optimal diagnosis and treatment might be lacking with many surgeons. We believe a clear understanding of anatomy, a narrative review of the literature and a pragmatic proposal for a step-by-step approach for treatment will be helpful for physicians and surgeons confronted with this condition. We describe the anatomy of this condition and discuss the scarce literature on this topic concerning optimal diagnosis and treatment. Thereafter, we propose a step-by-step approach for a surgical technique supported by intraoperative images to treat this condition safely and prevent potential pitfalls. We believe this approach offers a technically easy way to perform effective reinforcement of the lumbar abdominal wall, offering a low recurrence rate and preventing important complications. After meticulously reading this manuscript and carefully following the suggested approach, any surgeon that is reasonably proficient in minimally invasive abdominal wall surgery (though likely not in lumbar hernia surgery), should be able to treat this condition safely and effectively. This manuscript cannot replace adequate training by an expert surgeon. However, we believe this condition occurs so infrequently that there is likely to be a lack of real experts. This manuscript could help guide the surgeon in understanding anatomy and performing better and safer surgery.

Retroperitoneal totally endoscopic prosthetic repair of lumbar hernia

Lumbar hernia is a rare lateral abdominal wall hernia. Various surgical repair strategies have been recorded, but there is currently no unified standard. A Chinese surgeon recently revealed a novel technique for treating primary lumbar hernia called retroperitoneal totally endoscopic prosthetic repair (R-TEP). We have made a further exploration of this method and successfully used it in the treatment of secondary lumbar hernia. We successfully performed R-TEP on three patients with lumbar hernias. All patients were female with an average age of 64 years (51-71 years). Two patients each had a primary upper lumbar hernia, while one patient had a secondary lumbar hernia. With a mean operative time of 77 min (60-105 min), all operations were performed successfully. The average visual analogue scale (VAS) was 1.3 points (1-2 points) on the second day following surgery. The mean postoperative hospital stay was 2.3 days (2-3 days). No postoperative complications occurred. During a mean follow-up period of 19 months (10-24 months), there was no recurrence of the hernia, chronic pain or mesh infection. Therefore, R-TEP is safe and effective for both primary and secondary lumbar hernia. Anti-adhesive coated meshes are not required, making this a cost-effective procedure that is worthy of recommendation.

Retrospective analysis of 16 cases of lumbar hernia

Background

Through a retrospective analysis of 16 cases of lumbar hernia, we discussed the anatomical basis, clinical manifestations, diagnosis, and treatment of this rare condition.

Methods

We collected medical data of 15 patients with a primary lumbar hernia and one patient with a secondary lumbar hernia treated in the General Surgery Department of Wuxi No.2 People's Hospital between January 2008 and June 2021 and analysed their demographic, preoperative, and postoperative data.

Results

All patients underwent elective surgery performed by the same treatment team for superior lumbar hernias. The median area of the hernia defect was 12 cm2. Fifteen patients underwent sublay repair, and one underwent onlay repair. The median operative time and blood loss were 48 min and 22 mL, respectively. The hernia contents were extraperitoneal fat in 15 patients and partial small intestine in one. The median visual analogue scale score on postoperative day 1 was 3. A postoperative drainage tube was placed in three cases but not used in 13. The median duration of hospital stay was 5 days. Postoperative incision infection occurred in one case. During the follow-up period, no postoperative complications, including haematoma, seroma, incision infection or rupture, recurrence, and chronic pain, occurred in the other 15 cases.

Conclusion

Lumbar hernias are rare and can be safely and effectively treated by open tension-free repair.

A novel mini-open sublay hernioplasty combined with D10 mesh for primary lumbar hernia: a retrospective analysis of 48 cases

BACKGROUND

The aim of this study was to explore the safety and efficacy of a novel mini-open sublay hernioplasty with D10 mesh for primary lumbar hernias.

METHODS

This retrospective study included 48 patients with primary lumbar hernias who underwent mini-open sublay hernioplasty with D10 mesh from January 2015 to January 2022 in our hospital. Observation indicators were intraoperative measured diameter of hernia ring defect, operation time, length of hospital stay, postoperative follow-up, complications, postoperative visual analog scale (VAS) score, chronic pain.

RESULTS

The operations were completed successfully in all 48 cases. The mean diameter of hernia ring was 2.66 ± 0.57 cm (range 1.5-3.0 cm), the mean operation time was 41.54 ± 13.21 min (range 25-70 min), the intraoperative blood loss was 9.89 ± 6.16 ml (range 5-30 ml), and the mean hospital stay was 3.14 ± 1.53 days (range 1-6 days). The mean preoperative and postoperative VAS scores at 24 h were 0.29 ± 0.53 (range 0-2) and 2.52 ± 0.61 (range 2-6), respectively. All cases were followed-up for 53.4 ± 24.3 months (range 12-96 months) without seroma, hematoma, incision or mesh infection, recurrence, and obvious chronic pain.

CONCLUSION

A novel mini-open sublay hernioplasty with D10 mesh for primary lumbar hernias is safe and feasible. Its efficacy in the short term is favorable.

Identifying the Hernial Orifice in Superior Lumbar Hernia Repair by Utilizing Anatomical Landmarks on Preoperative CT

Superior lumbar hernias are extremely rare, and surgical repair is essential for their treatment. However, the direct observation of the hernial orifice is frequently difficult because the hernia disappears in prone or lateral positions, which is an issue when using the open approach. Therefore, using anatomical landmarks to detect the hernial orifice on preoperative CT scans may be useful for correct identification and visualization. Here, we report two cases of superior lumbar hernias successfully treated using the abovementioned method.

Primary Petit Hernia: From Diagnosis to Open Surgical Approach

Lumbar hernias are quite rare, even more so when primary or of spontaneous nature. These defects in the lumbar region demand a comprehensive knowledge of the anatomy of the lateral abdominal wall and paraspinal muscles. Given the proximity of bone structures, they can pose a surgical challenge when trying to achieve an ideal dissection and appropriate mesh overlap. The authors report the case of a primary Petit's hernia that underwent an open anterior surgical approach with the use of a preperitoneal mesh. In addition to the described surgical technique, the article also aims to detail the diagnosis and anatomic classification of this rare pathology.

Primary upper lumbar hernia repaired by transabdominal preperitoneal approach technique using a self-expanding mesh with a memory-recoil ring, report of a case

BACKGROUND

Upper lumber hernia is a rare entity which can cause obstruction and strangulation. Laparoscopic technique has been considered effective for such hernia repairs; however, there is no report of use of the self-expanding mesh.

CASE PRESENTATION

A 77-year-old woman visited to our hospital complaining of a bulge of about 5 cm in the left lumbar dorsal region while standing. Abdominal CT and MRI scans showed a fascial defect in the left lumbar abdominal wall and confirmed the presence of a hernia, in which retroperitoneal fatty tissue and the descending colon protruded. Transabdominal preperitoneal repair (TAPP) was performed and the operative findings revealed the hernia orifice, 3 × 2.5 cm in diameter, between two intercostal nerves. To avoid nerve injury or entrapment, the number of mesh fixation was desirable minimum; therefore, a self-expanding mesh with a memory-recoil ring was used. The mesh, 9.5 × 13 cm in diameter, was placed and tacked to the abdominal wall at two points, 1 cm ventral and dorsal to the hernia orifice. The postoperative course was uneventful and no pain or recurrence was observed with follow-up of 6 months.

CONCLUSION

We herein present a case of upper lumber hernia successfully repaired by TAPP with a self-expanding mesh.

Laparoscopic transabdominal preperitoneal repair of lumbar hernia

Lumbar hernias are rare and its posterior location presents challenges in its repair. This article provides a pictorial description of the approach to repairing a lumbar hernia demonstrating a laparoscopic transabdominal preperitoneal technique that is easy to follow and take up.

Quality of life and surgical outcomes of robotic retromuscular ventral hernia repair using a new hybrid mesh reinforcement

PURPOSE

The purpose of this study is to prospectively evaluate surgical and quality of life (QoL) outcomes of robotic retromuscular ventral hernia repair (rRMVHR) using a new hybrid mesh in high-risk patients.

METHODS

Data was prospectively collected for patients classified as high-risk based on the modified ventral hernia working group (VHWG) grading system, who underwent rRMVHR using Synecor™ Pre hybrid mesh in a single center, between 2019 and 2020. Pre-, intra- and postoperative variables including hernia recurrence, surgical site events (SSE), hernia-specific quality of life (QoL), and financial costs were analyzed. QoL assessments were obtained from preoperative and postoperative patient visits. Kaplan-Meier survival analysis was performed to analyze the estimated recurrence-free time.

RESULTS

Fifty-two high-risk patients, with a mean (±SD) age of 58.6 ± 13.7 years and BMI of 36.9 ± 6.6 kg/m2, were followed for a mean (±SD) period of 22.4 ± 7.1 months. A total of 11 (21.2%) patients experienced postoperative complications, out of which eight were SSEs, including 7 (13.5%) seromas, 1 (1.9%) hematoma, and no infections. Procedural interventions were required for 2 (3.8%) surgical site occurrences. Recurrence was seen in 1 (1.9%) patient. The estimated mean (95% confidence interval) recurrence-free time was 33 (32.3-34.5) months. Postoperative QoL assessments demonstrated significant improvements in comparison to preoperative QoL, with a minimum ∆mean (±SD) of -15.5 ± 2.2 at one month (p < 0.001). The mean (±SD) procedure cost was $13,924.18 ± 7856.95 which includes the average mesh cost ($5390.12 ± 3817.03).

CONCLUSION

Our study showed favorable early and mid-term outcomes, in addition to significant improvements in QoL, after rRMVHR using Synecor™ hybrid mesh in high-risk patients.

The role of ultrasound in the diagnosis of Grynfeltt-Lesshaft lumbar hernia: A case report

Grynfeltt-Lesshaft hernia is a type of lumbar hernia located in the superior lumbar triangle. Lumbar hernias are rare hernias. Clinical diagnosis of lumbar hernias can be a challenging especially in obese or asymptomatic patients. Lumbar hernias have been frequently misdiagnosed and lead to serious complications. Surgery (open or laparoscopic) is recommended to correct the defect and to avoid the exacerbation of the hernia and associated complications. The majority of the reported cases in the past were diagnosed on a CT scan. This study presents a case of successful detection of a Grynfeltt-Lesshaft hernia by US scan then confirmed by a subsequent CT scan. The aim of this case report was to Increase knowledge of lumbar hernias and to demonstrate the role of US in the diagnosis of lumbar hernias.

Donor Site Morbidity after Lumbar Artery Perforator Flap Breast Reconstruction

BACKGROUND

 The lumbar artery perforator flap is a second-choice flap in autologous breast reconstruction whenever a deep inferior epigastric artery perforator (DIEP) flap is not possible. Ideal candidates are pear-shaped women who do not have enough bulk on the abdomen or thighs. Patient-reported "satisfaction with breasts" is excellent but we were curious about the donor site morbidity.

METHODS

 We performed a retrospective study of all lumbar flap breast reconstructions performed between 2010 and 2019. Patients were invited by e-mail and telephone to take part in a BREAST-Q survey.

RESULTS

 One hundred fifty-four flaps were performed in 110 patients. Sixty-three patients filled out the BREAST-Q questionnaire. The most frequently observed donor site complications are seroma (35.1%), dehiscence (8.4%), and hematoma (3.2%). Correction of the donor site scar was performed in 31.8% of patients, lipofilling of the donor flank in 5.2%, and liposuction of the contralateral flank in 18.3% of patients. Body mass index (BMI) was the only significant risk factor for donor site complications. Patient-reported "satisfaction with donor site appearance" was good but significantly lower for primary reconstructions compared with secondary and tertiary procedures. Flap weight significantly influences patient-reported "physical wellbeing of the donor site." Ninety-seven percent of patients would recommend the surgery to someone in a similar position and would do it all over.

CONCLUSION

 The lumbar artery perforator flap is a good alternative for breast reconstruction in selected patients. The donor site issues consist mainly of seromas, prolonged discomfort, and a scar that might be noticeable to others, but patient-reported satisfaction is very high.

Repair of a large recurrent congenital lumbar hernia with free composite anterolateral thigh flap, tensor fascia lata flap, and vastus lateralis flap and meshes: A case report

Congenital lumbar hernia (LH) is a rare abdominal wall herniation and associated with lumbocostovertebral syndrome, including vertebral anomalies, costal defects and LH. There are reports using extraperitoneal placement of mesh, patches, and local flaps for repairing the LH. In this report we present a case of repair of a large recurrent congenital LH with free composite anterolateral thigh flap, tensor fascia lata flap and vastus lateralis flap (ALT-TFL-VL flap) and meshes. The patient underwent multiple cutaneous neurofibroma excisions before the treatment of LH. Recurrent neurofibroma and congenital aplasia of lumbar muscles at right flank may contribute to the patient's diffuse congenital LH development. Considering a large fascia defect (12 cm × 15 cm) with absence of lumbar muscles at the herniation site, using mesh alone is not strong enough to stop the herniation of bowel. Transposition of right pedicled ALT-TFL-VL flap (35 cm × 12 cm) with mesh was first attempted but proven to be futile, since the right lumbar wall bulged out from the distal border of previous reconstructed fascia. Thus, another free composite ALT-TFL-VL flap (35 cm × 15 cm) from left thigh was transferred on top of the previous pedicled flap, followed by delayed free flap advancement and surgical mesh addition. Post-operative course was smooth without complications. Twenty-one months after the surgery, computed tomography showed no recurrence of LH. Such case with large recurrent diffuse LH may be treated by a combination of conventional method with meshes and serial reconstruction with pedicled and free flaps for dynamic reconstruction of abdominal wall.

Primary Grynfeltt's hernia combined with intermuscular lipoma: A case report

INTRODUCTION

Grynfeltt's hernia (superior lumbar hernia) is a rare posterolateral abdominal wall defect and is often misdiagnosed as an abdominal wall lipoma. I recently experienced a case of primary Grynfeltt's hernia combined with intermuscular lipoma that was managed surgically.

PRESENTATION OF CASE

A 79-year-old man presented with a left flank mass. In the seated position, when the abdominal pressure was raised by deep breathing after left flank extension, the mass became clearer. Abdominal computed tomography (CT) findings showed herniated perirenal fat via the superior lumbar triangle and a surrounding intermuscular lipoma. After intermuscular lipoma removal, the hernia defect was closed with primary simple interrupted sutures. Currently, at 5 months postoperatively, no recurrence has been observed.

DISCUSSION

On physical examination of Grynfeltt's hernia, it may be difficult to identify the distinct mass because of the relatively large overlaying of the latissimus dorsi muscle. Thus, Grynfeltt's hernia can be misdiagnosed as soft tissue tumors, such as lipomas. Abdominal CT findings may provide an accurate diagnosis and reveal the anatomical structures and additional lesions. Proper surgical treatment should be planned based on the etiology, size of the hernia defect, condition of the surrounding structures, and presence of additional lesions.

CONCLUSION

Grynfeltt's hernia should be considered when a mass is palpable on the posterolateral abdominal wall and in cases where the size of the mass changes when changing position. CT examination of the abdomen may help make an accurate diagnosis, observe additional lesions, and develop a surgical-treatment plan.

Totally endoscopic sublay (TES) repair for lateral abdominal wall hernias: technique and first results

BACKGROUND

The optimal surgical treatment for lateral hernias of the abdominal wall remains unclear. The presented prospective study assesses for the first time in detail the clinical value of a totally endoscopic sublay (TES) technique for the repair of these hernias.

METHODS

Twenty-four consecutive patients with a lateral abdominal wall hernia underwent TES repair. This technique is naturally combined with a transversus abdominis release maneuver to create a sufficient retromuscular/preperitoneal space that can accommodate, if necessary, a giant prosthetic mesh.

RESULTS

The operations were successful in all but one patient who required open conversion because of dense intestinal adhesion. The mean defect width was 6.7 ± 3.9 cm. The mean defect area was 78.0 ± 102.4 cm² (range 4-500 cm²). The mean mesh size used was 330.2 ± 165.4 cm² (range 108-900 cm²). The mean operative time was 170.2 ± 73.8 min (range, 60-360 min). The mean visual analog scale score for pain at rest on the first day was 2.5 (range 1-4). The average postoperative stay was 3.4 days (range 2-7 days). No serious complications (Dindo-Clavien Grade 2-4) were seen within a mean follow-up period of 13.3 months.

CONCLUSIONS

A totally endoscopic technique (TES) for the treatment of lateral hernias is described. The technique revealed to be reliable, safe and cost-effective. The first results are promising, but larger studies with longer follow-up periods are recommended to determine the real clinical value.

Grynfeltt hernia repair using a Kugel patch

PURPOSE

To introduce a surgical technique for repairing Grynfeltt hernia using a Bard Kugel patch mesh.

METHOD

After incision and dissection, hernia was found behind the latissimus dorsi muscle. The retroperitoneal fat or sac was isolated from surrounding tissues and the retro muscular preperitoneal space was developed using blunt dissection at least 5 cm beyond the margins of defect in all directions. A proper size Kugel patch was placed into the place at least 3 cm beyond the muscular or rib edges. The defect was reduced and the mesh was fixed by interrupted sutures. Then the fibers of the latissimus dorsi muscle were reapproximated by loose absorbable suture. The skin was closed by continuous absorbable suture without any drainage.

RESULTS

The patients had a mean hospital stay of 3.22 days. The follow-up ranged from 4 months to 2 years and there were no recurrences or any other significant postoperative complications.

CONCLUSION

Repairing Grynfeltt hernias using a Kugel patch can be successfully performed with the posterior approach. This method of repair is easy, safe, and effective.

Incisional lumbar hernia after the use of a lumbar artery perforator flap for breast reconstruction

Autologous breast reconstruction with a perforator flap has become increasingly popular. The free lumbar artery perforator (LAP) flap has been described as a good alternative for autologous breast reconstruction. The LAP flap is a perforator flap based on a single pedicle. This flap is easy to harvest, with minimal donor-site morbidity. We present a case of a lumbar incisional hernia after LAP flap breast reconstruction in a 53-year-old patient. The patient had been treated with a bilateral mastectomy for cancer. Secondary breast reconstruction was performed with a bilateral DIEP flap. Reoperation was necessary because of a failed DIEP flap at the left side. Reconstruction was performed with a free LAP flap. The patient was referred for a right lumbar incisional hernia at the donor-site of the LAP flap. Open repair was performed with a retroperitoneal mesh. The thoracolumbar fascia was closed in with a running suture. Lumbar artery perforator is a perforator flap based on a single pedicle. Although it does not sacrifice any muscle and seems to be associated with minimal donor-site morbidity, we present the first report of a lumbar incisional hernia repair after LAP flap breast reconstruction treated using an open retroperitoneal mesh repair.

Sublay repair for primary superior lumbar hernia with the Kugel patch

Background

A superior lumbar hernia is a posterior ventral hernia that is rarely encountered in the clinical setting. However, no standard operative strategy exists for superior lumbar hernia repair at present.

Methods

Twelve patients with primary superior lumbar hernia who underwent sublay repair via the retroperitoneal space with the Kugel patch between December 2008 and June 2019 were included in this study. The demographic, peri‐operative and post‐operative data of the patients were collected to analyse the effectiveness of this technique.

Results

All patients underwent an uneventful operation. The median operative time was 60 min, and the median blood loss was 35 mL. The median hernia defect area was 16 cm². Five medium‐sized Kugel patches (11 cm × 14 cm) and seven large‐sized Kugel patches (14 cm × 17 cm) were used for the repairs. The median visual analogue scale score on post‐operative day 1 was 3. The median time to removal of drainage was 3 days. The median duration of the hospital stay was 3 days. No serious post‐operative complications, including seroma, haematoma, incision or mesh infection, recurrence and chronic pain, occurred during the follow‐up period.

Conclusion

Sublay repair for primary superior lumbar hernia with the Kugel patch shows benefits including a reliable repair, minimal invasiveness and few post‐operative complications.

EHS and AHS guidelines for treatment of primary ventral hernias in rare locations or special circumstances

Background

Rare locations of hernias, as well as primary ventral hernias under certain circumstances (cirrhosis, dialysis, rectus diastasis, subsequent pregnancy), might be technically challenging. The aim was to identify situations where the treatment strategy might deviate from routine management.

Methods

The guideline group consisted of surgeons from the European and Americas Hernia Societies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used in formulating the recommendations. The Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists were used to evaluate the quality of full‐text papers. A systematic literature search was performed on 1 May 2018 and updated 1 February 2019. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was followed.

Results

Literature was limited in quantity and quality. A majority of the recommendations were graded as weak, based on low quality of evidence. In patients with cirrhosis or on dialysis, a preperitoneal mesh repair is suggested. Subsequent pregnancy is a risk factor for recurrence. Repair should be postponed until after the last pregnancy. For patients with a concomitant rectus diastasis or those with a Spigelian or lumbar hernia, no recommendation could be made for treatment strategy owing to lack of evidence.

Conclusion

This is the first European and American guideline on the treatment of umbilical and epigastric hernias in patients with special conditions, including Spigelian and lumbar hernias. All recommendations were weak owing to a lack of evidence. Further studies are needed on patients with rectus diastasis, Spigelian and lumbar hernias.

Minimally invasive repair of a lumbar hernia utilizing the subcutaneous space only

Lumbar hernias are from weakened areas in the posterior lateral abdominal wall. Minimally invasive techniques are recommended for nonmidline abdominal wall hernias. Endoscopic methods utilizing the subcutaneous space only are rarely reported. A 66-year-old man presented with abdominal pain and a computed tomography (CT) scan revealing a lumbar hernia. The procedure was done utilizing the subcutaneous space to open the hernia sac and repair the defect in layers. A sublay mesh and an onlay mesh were used within the subcutaneous pocket. The patient had an uneventful postoperative course and was discharged home. A subsequent CT scan showed that the completed repair remained intact. Few endoscopic lumbar hernia repairs are reported despite the advantageous aspects of the procedure in avoiding the peritoneal cavity and the retroperitoneum.

Bilateral Fat Containing Lumbar Hernia: A Case Report and Literature Review

Patient: Female, 84

Final Diagnosis: Bilateral fat containing lumbar hernia

Symptoms: Abdominal pain

Medication: —

Clinical Procedure: —

Specialty: Surgery

Pitfalls and clinical recommendations for the primary lumbar hernia based on a systematic review of the literature

PURPOSE

The lumbar abdominal wall hernia is a rare hernia in which abdominal contents protrude through a defect in the dorsal abdominal wall, which can be of iatrogenic, congenital, or traumatic origin. Two anatomical locations are known: the superior and the inferior lumbar triangle. The aim of this systematic review is to provide a clear overview of the existing literature and make practical clinical recommendations for proper diagnosis and treatment of the primary lumbar hernia.

METHODS

The systematic review was conducted according to the PRISMA guidelines. A systematic search in PubMed, MEDLINE, and EMBASE was performed, and all studies reporting on primary lumbar hernias were included. No exclusion based on study design was performed. Data regarding incarceration, recurrence, complications, and surgical management were extracted.

RESULTS

Out of 670 eligible articles, 14 were included and additional single case reports were analysed separately. The average quality of the included articles was 4.7 on the MINORS index (0-16). Risk factors are related to increased intra-abdominal pressure. CT scanning should be performed during pre-operative workup. Available evidence favours laparoscopic mesh reinforcement, saving open repair for larger defects. Incarceration was observed in 30.8% of the cases and 2.0% had a recurrence after surgical repair. Hematomas and seromas are common complications, but surgical site infections are relatively rare.

CONCLUSION

The high risks of incarceration in lumbar hernias demand a relatively fast elective repair. The use of a mesh is recommended, but the surgical approach should be tailored to individual patient characteristics and risk factors.

Combined open and laparoscopic approach for repair of flank hernias: technique description and medium-term outcomes of a single surgeon

PURPOSE

A residual bulge in the lateral abdominal wall is a reason for patient dissatisfaction after flank hernia repair (FHR). We hypothesized that combining a laparoscopically-placed intraperitoneal mesh (IPOM) with onlay hernia repair performed through a small open incision would increase repair durability and decrease such residual bulges. We aim to report our medium-term outcomes with this technique.

METHODS

Patients who have undergone FHR using the technique described above from March 2013 through June 2017 were identified in a prospectively maintained database. Outcomes of interest included surgical site infections (SSI), surgical site occurrences (SSO), surgical site occurrences requiring procedural intervention (SSOPI) and hernia recurrence.

RESULTS

Sixteen patients were identified (62% females; mean age 59 ± 8 years, mean body mass index 29.5 kg/m²). Mean hernia width was. 6.4 ± 3 cm and 31% were recurrent hernias previously repaired through an onlay approach. Mean operative time was 159 ± 40 min, fascial closure was achieved in all cases, and there were no intraoperative complications. Median length of stay was 3 days (IQR 3-4), and there were no unplanned readmissions or reoperations. At a median 37-month follow-up (IQR 21-55), wound morbidity rate was 12.5% (2 seromas). There were no SSI/SSOPI and one hernia recurrence (6%) was detected at 12 months postoperatively.

CONCLUSION

Combining laparoscopic IPOM with open onlay hernia repair resulted in low recurrence and acceptable wound morbidity rates, with no residual bulges noted at medium-term follow-up. Further studies with larger number of patients and other surgeon's experiences are necessary to determine the role of such technique in the surgical armamentarium for flank hernia repair.

Laparoscopic repair via the transabdominal preperitoneal procedure for bilateral lumbar hernia: Three cases report and review of literature

A lumbar hernia is a rare entity, and a bilateral lumbar hernia is much rarer. From May 2015 to October 2017, we treated only three patients with bilateral lumbar hernias. One patient came to the hospital presenting with right-sided abdominal pain, and the other two patients presented with bilateral lumbar masses. The previous bilateral lumbar hernia reported in the literature was repaired by open surgery. The laparoscopic approach via the transabdominal preperitoneal (TAPP) procedure with the self-gripping Parietex ProGrip™ mesh was performed at our center. The laparoscopic repair was conducted by a skilled hernia surgeon, and was successfully performed in the three patients. The patients resumed a semi-liquid diet and had no activity restriction after six hours following the operation. No antibiotics were used after the surgery. The operative times of the three patients were 120 min, 85 min, and 130 min. The blood loss volumes of the three patients were 20 mL, 5 mL, and 5 mL. The visual analogue scale pain scores of the three patients were 1, 2, and 2 on postoperative day 1, and were 1, 2, and 1 on postoperative day 3. No perioperative complications, such as bulge, wound infection and hematoma, occurred after the surgery. All of the patients were discharged on the third day after the operation. There was no chronic pain and no hernia recurrence during the follow-up. This study showed that the laparoscopic TAPP approach with the self-gripping mesh is safe and feasible, and can be considered an alternative method for the treatment of bilateral lumbar hernias.

Primary Jean Louis Petit and Grynfeltt-Lesshaft concomitant hernias: A case report

•

Primary lumbar hernia.

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Concomitant lumbar hernias : Jean Louis Petit and Grynfeltt-Lesshaft.

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Misdiagnosis hernia.

•

Surgical approach.

Introduction

Posterior abdominal wall hernias are rare, mainly post traumatic or post-operative. This case is particular first by its mechanism, it is a primary lumbar hernia and secondly it is a concomitant hernia of the Jean Louis Petit triangle and the Grynfeltt triangle.

Presentation of case

The patient was a 67 years old man, a former farmer. He complaint of a painful tumefaction on his back evolving for the last 2 years. After clinical examination, a diagnosis of lumbar hernia was retained. The CT scan which is the gold standard was not performed due to financial limitations. An hernioplasty with a porcine collagen mesh was done, in per operative we found a Jean Louis Petit hernia and a Grynfeltt-Lesshaft hernia. Any post-operative complications.

Discussion

Lumbar hernia is not a common diagnosis, and most of time is misdiagnosed. Acquired primary lumbar hernia can be due to profession involving lumbar constraints leading to the weakness of muscles. This was the case of our patient. Another particularity was the double hernia, the upper and lower lumbar triangles. We already know the impact of his profession and may be 20 years of this leaded to the double hernia? An hernioplasty in open surgery was proposed for multiples reasons: the age of the patient, the weakness of the muscle, a large exploration of the hernia, to reinforce the posterior lumbar wall and to prevent a recidivism.

Conclusion

Jean Louis Petit and Grynfeltt-Lesshaft hernias are very uncommon. Few cases have been reported.

Repair of a Grynfeltt-Lesshaft hernia with the PROCEED™ VENTRAL PATCH: a case report

Background

Primary hernias in the triangle of Grynfeltt are very rare and therefore pose a difficulty in diagnosis and treatment. Due to the lack of systematic studies, the surgical approach must be chosen individually for each patient. Here, we describe an easy and safe surgical approach.

Case presentation

We report the case of a 53-year-old male patient with a history of mental disability and pronounced scoliosis, who presented with a Grynfeltt-Lesshaft hernia with protrusion of the ascending colon and the right ureter.

The hernia was repaired via a dorsal, extraperitoneal approach. The hernia gap with a diameter of approximately 1 cm was closed with insertion of a 6.4 × 6.4 cm PROCEED™ VENTRAL PATCH (Ethicon, Norderstedt, Germany). The operating time was 33 min and the patient was discharged the next day and showed no signs of recurrence at 1-year follow up.

Conclusion

The technique described here is favorable because it requires very little dissection of the surrounding tissue and no trans-/intraabdominal dissection. The technique was chosen in this particular case to guarantee a fast postoperative recovery and prompt hospital discharge.

LAPAROSCOPIC REPAIR OF LUMBAR HERNIA (GRYNFELT): TECHNICAL DESCRIPTION

Background:

Lumbar hernias are rare. Usually manifest with reducible volume increase in the post-lateral region of the abdomen and may occur in two specific anatomic defects: the triangles of Grynfelt (upper) and Petit (lower). Despite controversies with better repair, laparoscopic approach, following the same principle of the treatment of inguinal hernias, seems to present significant advantages compared to conventional/open surgeries. However, some technical and anatomical details of the region, non usual to general surgeons, are fundamental for proper repair.

Aim:

To present systematization of laparoscopic transabdominal technique for repair of lumbar hernias with emphasis on anatomical details.

Method

: Patient is placed in the lateral decubitus. Laparoscopic access to abdominal cavity is performed by open technique on the left flank, 1.5 cm incision, followed by introduction of 11 mm trocar for a 30º scope. Two other 5 mm trocars, in the left anterior axillary line, are inserted into the abdominal cavity. The peritoneum of the left paracolic gutter is incised from the 10^th rib to the iliac crest. Peritoneum and retroperitoneal is dissected. Reduction of all hernia contents is performed to demonstrate the hernia and its size. A 10x10 cm polypropylene mesh is introduced into the retroperitoneal space and fixed with absorbable staples covering the defect with at least 3-4 cm overlap. Subsequently, is carried out the closure of the peritoneum of paracolic gutter.

Results:

This technique was used in one patient with painful increased volume in the left lower back and bulging on the left lumbar region. CT scan was performed and revealed left superior lumbar hernia. Operative time was 45 min and there were no complications and hospitalization time of 24 h.

Conclusion:

As in inguinal hernia repair, laparoscopic approach is safe and effective for the repair of lumbar hernias, especially if the anatomical details are adequately respected.

Laparoscopic mesh repair for lumbar hernia after iliac crest bone harvest

Lumbar hernia after iliac crest bone harvest is relatively rare. When it does occur, it presents as a flank abdominal protrusion through a lateroposterior abdominal wall defect. A laparoscopic approach for this type of hernia is reported to have advantages over the classic open method. Here, we present a case of a 49-year-old Caucasian man who presented with an enlarged left flank mass after iliac bone harvest for pseudarthrosis. He had undergone open onlay mesh repair for inferior lumbar hernia, but the hernia recurred 3 months postoperatively. Laparoscopic intraperitoneal onlay mesh repair using a composite mesh was performed 7 months after recurrence. The patient was discharged 6 days postoperatively without complications. No signs of recurrence were detected during 1-year follow-up period. The laparoscopic approach for lumbar hernia conferred excellent visualization of the hernia defect and enabled a safe mesh repair using intra-abdominal pressure to hold it in position. This approach provided all the benefits of minimally invasive surgery.

Strangulated lumber hernias in adults: A case report and review of the literature

Strangulated lumbar hernia is a very rare condition, with no more than 30 cases reported in the literature so far. Therefore, there is no specific management guideline and the diagnosis remains difficult. By reporting the case of a Senegalese male patient who had a preoperative diagnosis of strangulated lumbar hernia, we aim to discuss the diagnosis and therapeutic modalities of this rare entity, which is often misdiagnosed.

The triangles of Grynfeltt and Petit and the lumbar tunnel: an anatomo-radiologic study

PURPOSE

Lumbar hernias are protrusions of intra-abdominal contents classically through the superior (Grynfeltt) and inferior (Petit) lumbar triangles. The anatomy of the triangles is variable and quantitative data are few. No radiological data on the anatomy of the triangles are available.

METHODS

Fifty computed tomography angiography of the upper abdomen (M25, F25, mean age 72.5-year-old) were analyzed. The dimensions and the contents of the lumbar triangles were analyzed. The characteristics of the space between the two triangles were also documented.

RESULTS

The superior lumbar triangle showed a mean surface area of 5.10 ± 2.6 cm². In the area of the triangle, the 12th intercostal pedicle and the 1st lumbar branches of the iliolumbar vessels were found in 42 and 46 %, respectively. The inferior lumbar triangle had a mean surface of area 18.7 ± 8.4 cm². In this area, the 2nd, 3rd, and 4th lumbar branches were found in 9, 67, and 8 %, respectively. On oblique coronal images, a direct tunnel between the superior and the inferior lumbar triangles was found, showing an oblique course, with a postero-anterior direction (mean length 36.5 ± 5.8 mm, mean caliber 7.4 ± 3.1 mm).

CONCLUSIONS

Among the anatomical factors of weakening of the abdominal wall, the course of branches of the lumbar vessels was documented not only in the superior but also in the inferior lumbar triangle. A real musculoaponeurotic tunnel between the superior and the inferior lumbar triangles located in the oblique coronal plane was found, that could play a role in the development of incarceration or strangulation of lumbar hernias.

Grynfelt-Lesshaft hernia a case report and review of the literature

INTRODUCTION

Lumbar hernia account for less than 2% of al abdominal hernias, been the Grynfelt-Lesshaft's hernia (GLH) more frequent than the others. With approximately 300 cases published in the literature, the general surgeon may have the chance of treat it ones in their professional life.

CASE REPORT

A 42-years old male with human immunodeficiency virus and Diabetes Mellitus presented to the outpatient clinic with a GLH. Preoperative classified as a type "A" lumbar hernia an open approach was scheduled. We performed a Sandwich technique with a sublay and onlay ULTRAPRO(®) mesh fixed with PDS(®) II suture without complications and discharged the patient 24-h after. After six months, the patient denied any complication.

DISCUSSION

Primary (spontaneous) lumbar hernias represent 50-60% of all GLH. The preoperative classification of a lumbar hernia is mandatory to propose the best surgical approach. According to the classification of Moreno-Egea A et al., the best technique for our patient was an open approach. The Sandwich technique has demonstrated good outcomes in the management of the GLH.

CONCLUSION

The surgical approach should be according to the classification proposed and to the experience of the surgeon. The Sandwich technique has good outcomes.

Grynfeltt Hernia: A Deceptive Lumbar Mass with a Lipoma-Like Presentation

The Grynfeltt-Lesshaft hernia is a rare posterior abdominal wall defect that allows for the herniation of retro- and intraperitoneal structures through the upper lumbar triangle. While this hernia may initially present as a small asymptomatic bulge, the defect typically enlarges over time and can become symptomatic with potentially serious complications. In order to avoid that outcome, it is advisable to electively repair Grynfeltt hernias in patients without significant contraindications to surgery. Due to the limited number of lumbar hernioplasties performed, there has not been a large study that definitively identifies the best repair technique. It is generally accepted that abdominal hernias such as these should be repaired by tension-free methods. Both laparoscopic and open techniques are described in modern literature with unique advantages and complications for each. We present the case of an unexpected Grynfeltt hernia diagnosed following an attempted lipoma resection. We chose to perform an open repair involving a combination of fascial approximation and dual-layer polypropylene mesh placement. The patient's recovery was uneventful and there has been no evidence of recurrence at over six months. Our goal herein is to increase awareness of upper lumbar hernias and to discuss approaches to their surgical management.

Lumbar (Petit's) hernia: A rare entity

Lumbar hernias are rare and diagnostically challenging for surgeons. We present the case of a middle-aged patient who presented with swelling in the left back. Subcutaneous lipoma was included in the differential diagnosis. Following diagnostic studies, computed tomography confirmed left lumbar hernia. Elective surgery was performed, and the results revealed Petit's hernia. The hernia was repaired with mesh.

Laparoscopic ventral/incisional hernia repair: updated Consensus Development Conference based guidelines [corrected]

BACKGROUND

The Executive board of the Italian Society for Endoscopic Surgery (SICE) promoted an update of the first evidence-based Italian Consensus Conference Guidelines 2010 because a large amount of literature has been published in the last 4 years about the topics examined and new relevant issues.

METHODS

The scientific committee selected the topics to be addressed: indications to surgical treatment including special conditions (obesity, cirrhosis, diastasis recti abdominis, acute presentation); safety and outcome of intraperitoneal meshes (synthetic and biologic); fixing devices (absorbable/non-absorbable); abdominal border and parastomal hernia; intraoperative and perioperative complications; and recurrent ventral/incisional hernia. All the recommendations are the result of a careful and complete literature review examined with autonomous judgment by the entire panel. The process was supervised by experts in methodology and epidemiology from the most qualified Italian institution. Two external reviewers were designed by the EAES and EHS to guarantee the most objective, transparent, and reliable work. The Oxford hierarchy (OCEBM Levels of Evidence Working Group*. "The Oxford 2011 Levels of Evidence") was used by the panel to grade clinical outcomes according to levels of evidence. The recommendations were based on the grading system suggested by the GRADE working group.

RESULTS AND CONCLUSIONS

The availability of recent level 1 evidence (a meta-analysis of 10 RCTs) allowed to recommend that not only laparoscopic repair is an acceptable alternative to the open repair, but also it is advantageous in terms of shorter hospital stay and wound infection rate. This conclusion appears to be extremely relevant in a clinical setting. Indications about specific conditions could also be issued: laparoscopy is recommended for the treatment of recurrent ventral hernias and obese patients, while it is a potential option for compensated cirrhotic and childbearing-age female patients. Many relevant and controversial topics were thoroughly examined by this consensus conference for the first time. Among them are the issue of safety of the intraperitoneal mesh placement, traditionally considered a major drawback of the laparoscopic technique, the role for the biologic meshes, and various aspects of the laparoscopic approach for particular locations of the defect such as the abdominal border or parastomal hernias.

Gallstone ileus obstructing within an incarcerated lumbar hernia: an unusual presentation of a rare diagnosis

We describe an unusual case of a 74-year-old woman who presented with signs and symptoms of small-bowel obstruction and a clinically appreciable, irreducible, left-sided lumbar hernia associated with previous iliac crest bone graft harvesting. Palpation of the hernia demonstrated a small, firm mass within the loops of herniated bowel. CT scanning recognised an intraluminal gallstone at the transition point, establishing the diagnosis of gallstone ileus within an incarcerated lumbar hernia. The proposed explanatory mechanism is that of a gallstone migrating into an easily reducible hernia containing small bowel causing obstruction at the hernia neck by a ball-valve mechanism, resulting in proximal bowel dilation and thus hernia incarceration; it remains unclear when the stone entered the hernia, and whether it enlarged in situ or prior to entering the enteral tract. This is only the second reported instance in the literature of an intraluminal gallstone causing hernia incarceration.

Strangulated or incarcerated spontaneous lumbar hernia as exceptional cause of intestinal obstruction: case report and review of the literature

Lumbar hernias are rare conditions and about 300 cases have been reported since the first description by Barbette in 1672. Therefore strangulation or incarceration are also exceptionally encountered. We present a 62 -year-old-man who had strangulated left lumbar hernia and consequent mechanical small-bowel obstruction, alongside with a non strangulated right lumbar hernia. Through a median laparotomy, an intestinal necrosis was found. A bowel resection with end to end anastomosis was performed and the lumbar hernias were repaired on both sides. The recovery was uneventfull. To the best of our knowlwdge thanks to the litterature review presented here, this is the 19th case of incarcerated or strangulated spontaneous lumbar hernia described in the surgical litterature since 1889.

Perforated sigmoid diverticulitis in a lumbar hernia after iliac crest bone graft--a case report

Background

The combination of perforated diverticulitis in a lumbar hernia constitutes an extremely rare condition.

Case presentation

We report a case of a 66 year old Caucasian woman presenting with perforated sigmoid diverticulitis localized in a lumbar hernia following iliac crest bone graft performed 18 years ago. Emergency treatment consisted of laparoscopic peritoneal lavage. Elective sigmoid resection was scheduled four months later. At the same time a laparoscopic hernia repair with a biologic mesh graft was performed.

Conclusion

This case shows a very seldom clinical presentation of lumbar hernia. Secondary colonic resection and concurrent hernia repair with a biologic implant have proven useful in treating this rare condition.

Lumbar hernia: a diagnostic dilemma

Lumbar hernia is one of the rare cases that most surgeons are not exposed to. Hence the diagnosis can be easily missed. This leads to delay in the treatment causing increased morbidity. We report a case of lumbar hernia in a middle-aged woman. It was misdiagnosed as lipoma by another surgeon. It was a case of primary acquired lumbar hernia in the superior lumbar triangle. Clinical and MRI findings were correlated to reach the diagnosis. We also highlight the types, the process of diagnosis and the surgical repair of lumbar hernias. We wish to alert our fellow surgeons to keep the differential diagnosis of the lumbar hernia in mind before diagnosing any lumbar swelling as lipoma.

Traumatic lumbar hernia: can't afford to miss

We describe the radiological and surgical correlation of an uncommon case of a traumatic lumbar hernia in a 22-year-old man presenting to the emergency department following a motor vehicle accident. Computed tomography (CT) of the abdomen revealed a right-sided traumatic inferior lumbar hernia containing a small amount of fat through the posterior lateral internal oblique muscle with hematoma in the subcutaneous fat and adjacent abdominal wall musculature, which was repaired surgically via primary closure on emergent basis. The purpose of this article is to emphasize the importance of diagnosing traumatic lumbar hernia on CT and need for urgent repair to avoid potential complications of bowel incarceration and strangulation.