Retroperitoneoscopic tension-free repair of lumbar hernia

Endoscopic retroperitoneal repair of superior lumbar hernia (Grynfeltt hernia) using self-fixating mesh to prevent nerve injury: a case report

BACKGROUND

The primary superior lumbar hernia, also called the Grynfeltt Hernia, is a rare entity; hence, a standard surgical repair method has not been established. It is important for this repair procedure not only to prevent recurrence by placing an adequate size of mesh but also to avoid nerve injury. The endoscopic retroperitoneal approach is considered a useful technique for this procedure, requiring no mobilization of the colon and providing good visibility of the surrounding nerves. A self-fixating mesh does not require a traumatic fixation, which is considered advantageous for nerve preservation.

CASE PRESENTATION

A 72-year-old woman, complaining of left lumbar swelling, was diagnosed with a primary left superior lumbar hernia and underwent endoscopic retroperitoneal hernia repair. With the patient in the right lateral decubitus position, five small ports were inserted, and the retroperitoneal space was dissected. The 2.0 × 1.0-cm hernial orifice was found, and the 12th subcostal nerve above the hernial orifice and the iliohypogastric and the ilioinguinal nerves below the hernial orifice were identified. A 15 × 10-cm self-fixating mesh was placed in the retroperitoneal space without mesh tacking. The postoperative course was uneventful, and the patient was discharged on the first postoperative day. Two years after surgery, there was no sign of recurrence, and chronic pain and neuropathic symptoms were absent.

CONCLUSIONS

Endoscopic retroperitoneal repair of primary superior lumbar hernia using a self-fixating mesh seems to be useful for nerve preservation.

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.

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.

Retroperitoneal totally endoscopic prosthetic repair of primary lumbar hernia

PURPOSE

A primary lumbar hernia is a rare entity that requires surgical management, but the preferred technique has not been established. We herein describe a standardized and reproducible retroperitoneal totally endoscopic prosthetic (TEP) repair technique for primary lumbar hernias.

METHODS

Ten adult patients with primary lumbar hernias underwent retroperitoneal TEP repair from February 2019 to July 2020. A sufficient retroperitoneal space was established to accommodate a non-coated polypropylene mesh to reinforce the weakened flank area, and hernia content reduction and defect closure were then performed. The patients' clinical data were prospectively collected and analyzed.

RESULTS

Nine patients had a primary superior lumbar hernia and one patient had a primary diffuse lumbar hernia. All operations were successfully performed without serious intraoperative complications. The mean defect area was 6.4 ± 2.8 cm2 (range 4-12 cm2), and the mean mesh area was 144.6 cm2 (range 130-180 cm2). The average operative time (skin to skin) was 49.0 ± 5.7 min (range 40-60 min), and intraoperative bleeding was minimal. The mean visual analog pain scale score at rest on the first postoperative day was 2.2 (range 2-3). The average length of postoperative stay was 1.5 days (range 1-2 days). No serious postoperative complications occurred. No recurrence, chronic pain, or mesh infection occurred during a mean follow-up period of 7.5 months.

CONCLUSIONS

The retroperitoneal TEP repair for primary lumbar hernias is safe, efficient, and reproducible. Anti-adhesive coated meshes and fixation tackers are not required, making this a cost-effective procedure that is worthy of recommendation.

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.

Endoscopic totally extraperitoneal approach (TEA) technique for primary ventral hernia repair

Background

Up to now the totally extraperitoneal (TEP) technique is limited to the treatment of inguinal hernias. Applying this anatomical repair concept to the treatment of other abdominal wall hernias, we developed an endoscopic totally extraperitoneal approach (TEA) to treat primary midline ventral hernias, including umbilical and epigastric hernias, in which for mesh placement, an anatomical space is developed between the peritoneum and the posterior rectus sheath in the ventral part of the abdominal wall (preperitoneal space).

Methods

Between September 2017 and December 2019 according to the selection criterions, 28 consecutive primary midline ventral hernias were repaired using TEA. After extensive endoscopic development of the midline extraperitoneal plane, which was started in the suprasymphysic area, and reduction of the hernia sac, the hernia defect was closed and a large mesh was placed in the preperitoneal position to enforce the anterior abdominal wall.

Results

All operations were successfully performed without conversion to open surgery. The mean operation time was 103.3 min (range 85–145 min). Patient-reported postoperative pain was qualitatively mild with a mean pain visual analogue scale score of 1.9 on postoperative day 1. The average hospital stay was 1.9 days (range 1–3 days). Three patients developed minor complications and were treated with no long-term adverse effects. Readmissions within 30 days or hernia recurrences were not observed with a mean follow-up period of 18 months (range 10–27 months).

Conclusion

In selected cases, TEA is a safe and feasible minimally invasive alternative in treating primary ventral hernias. This technique preserves the anatomical and physiological structure of the abdominal wall and may significantly reduce trauma and postoperative complications. Additionally, anti-adhesion-coated meshes and fixation tackers are not required, thus being cost-effective. Further studies are necessary to proof the true clinical efficacy in comparison to well-known alternative techniques.

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.

Traumatic lumbar hernia: clinical features and management

Purpose

Traumatic lumbar hernia is rare, thus making diagnosis and proper treatment challenging. Accordingly, we aimed to investigate the clinical manifestations and proper management strategies of traumatic lumbar hernias.

Methods

The medical records of patients with traumatic lumbar hernia treated at Gachon University Gil Hospital from March 2006 to February 2015, were retrospectively reviewed.

Results

We included 5 men and 4 women (mean age, 55 years; range, 23–71 years). In 8 patients, most injuries were caused by motor vehicle collisions, including those wherein a pedestrian was struck (5 cases of car accidents, 2 falls, and 1 involving penetrating materials); in 1 patient, the probable cause was severe cough. Eight patients underwent hernia repair surgery (5 open and 3 laparoscopic), and a prosthetic mesh was used in 7 patients. Hernia repairs were elective in 7 patients; emergency hernia repair was performed with right hemicolectomy in 1 patient. No severe complication or recurrence was observed. Only 2 patients had mild complications, such as postoperative seroma.

Conclusion

Traumatic lumbar hernia is a relatively rare injury of the posteriolateral abdominal wall. Lumbar hernia should be suspected in patients with high-energy injuries of the torso, and all such patients should undergo abdominopelvic computed tomography. After diagnosis, hernia repair can be electively performed without complications in most cases.

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.

Petit lumbar hernia--a double-layer technique for tension-free repair

This report describes an alternative technique for Petit hernia repair. The treatment of lumbar hernias should follow the concept of tension-free surgery, and the preperitoneal space can be the best place for prosthesis placement. An obese patient had a bulge in the right lumbar region, which gradually grew and became symptomatic, limiting her daily activities and jeopardizing her quality of life. She had previously undergone 2 surgical procedures with different incisions. We created a preperitoneal space and attached a mesh in this position. Another prosthesis was placed on the muscles, with a suitable edge beyond the limits of the defect. There were no complications. It has been described as a safe and tension-free repair for Petit hernia. In larger defects, a second mesh can be used to prevent further enlargement of the triangle and also to provide additional protection beyond the bone limits.

Implementation of the trans-abdominal partial extra-peritoneal (TAPE) technique in laparoscopic lumbar hernia repair

Background

There is still not any standardized operative strategy that is well-accepted all over the world for lumbarhernia. We are here to investigate the feasibility of the trans-abdominal partial extra-peritoneal (TAPE) technique in lumbar hernia repair.

Methods

The TAPE technique was applied to 14 patients with lumbar hernia from May 2009 until January 2014. The surgical technique was described in details and follow-ups were performed for further evaluation.

Results

The mean age of the 14 patients was 68 ± 8 years, with the average BMI 25.5 ± 2.1 kg/m². The etiology study showed that 13 cases after surgical operations and one case after trauma. The average size of the hernia defect was 86.8 ± 46.4 cm², while the mean size of the mesh implanted was 275 ± 61.2 cm². The mean operative time was 59.2 ± 8.2 min. There was no intra-operative visceral injury in this serial of cases. There was no conversion case and all patients accepted the TAPE technique successfully. The VAS was 3.8 ± 1.9 and 2.2 ± 1.6 on POD1 and POD3, respectively. The mean post-operative hospital stay was 4.0 ± 1.3 days. The median follow-up time was 33 months. All patients returned to unrestricted movement within 2 weeks after surgery. During the follow-ups, no complication as bulge, seroma, hematoma, wound infection, abscess in surgical area and chronic pain, nor recurrence was observed.

Conclusions

According to our experience in this series of investigations, the TAPE could be a feasible and easy-to-learn technique which can be applied to most of the lumbar hernia repairs.

Single-incision laparoscopic total extraperitoneal repair for a Grynfeltt hernia: a case report

Introduction

A superior lumbar hernia, which is also known as a Grynfeltt hernia, is a rare abdominal wall defect that can be primary or secondary to trauma or orthopedic surgery. The anatomic location of a lumbar hernia makes diagnosis and repair challenging. We successfully repaired a lumbar hernia using a single-incision laparoscopic total extraperitoneal approach. To the best of our knowledge, this is the first report of the use of this surgical technique in the treatment of a primary Grynfeltt hernia.

Case presentation

A 76-year-old Taiwanese man presented to our hospital with a left lower bulging mass noted for over three months. Abdominal computed tomography revealed a left Grynfeltt hernia. We performed a single-incision laparoscopic total extraperitoneal repair. Our patient was discharged uneventfully on the fourth day after the operation. There was no evidence of recurrence after six months of follow-up.

Conclusion

A laparoscopic total extraperitoneal repair for a lumbar hernia provides an excellent operative view and minimal invasiveness. The single-incision technique also provides better cosmetic outcomes. Our experience suggests that the single-incision laparoscopic total extraperitoneal approach may be a feasible and safe alterative to conventional approaches in lumbar hernia repair.

Underlay mesh repair for spontaneous lumbar hernia

INTRODUCTION

Lumbar hernia is a rare condition with fewer than 300 cases reported in the literature. It arises through posterolateral abdominal wall defects, named the inferior triangle (Petit) and superior triangle (Grynfelt). It can be congenital or acquired, primary or secondary, peritoneal or extraperitoneal, reducible or complicated.

PRESENTATION OF CASE

We report a 63 year old female patient who presented to our hospital with a reducible right superior lumbar hernia. She underwent repair with underlay mesh after inversion of the sac and had a smooth postoperative course.

DISCUSSION

In contrast to the classical procedure the underlay mesh modification saved us from enlarging the defect, and was quick and associated with minimal tissue injury.

CONCLUSION

Underlay mesh repair for spontaneous lumbar hernia is feasible when the defect is small.

Surgical options in lumbar hernia: laparoscopic versus open repair. A long-term prospective study

OBJECTIVE

To determine the safety and effectiveness of laparoscopic lumbar hernia repair.

DESIGN

Prospective clinical study.

SETTING

Abdominal wall unit, university hospital.

PATIENTS

Between January 1995 and December 2008, data from 55 consecutive patients who had undergone laparoscopic (n = 35) or open (n = 20) lumbar hernia repair.

MAIN OUTCOME MEASURES

The primary endpoint was recurrence; secondary endpoints were patient outcomes (morbidity, pain, and return to normal activity).

RESULTS

Mean operating time (P = .01), hospital stay, return to normal activity, analgesic consumption, and pain at 1 month (P < .001) were significantly less in the laparoscopic group. Complications were similar in the 2 groups (37% vs 40%, respectively; P = .50). Traumatic hernias increased local complications versus incisional lumbar hernias (71.4% vs 29%; P = .007). Consumption of analgesics (6.8 ± 6.5 vs 18.1 ± 9.1; P < .001) and pain during the first month (no pain: 90% vs 54.3%; P = .015) were significantly less with a lightweight versus medium-weight mesh. The risk factors associated with recurrences development were localization (P = .01) and size (P = .008). Recurrence rates were 2.9% in the laparoscopic group and 15% in the open group (P = .13).

CONCLUSIONS

Outcomes did not differ with respect to morbidity and recurrence rate after long-term follow-up; however, this study suggested that laparoscopic approach for lumbar hernia is safe, effective, and more efficient than open repair and can be considered the procedure of choice. Open surgery may be considered the best option in the diffuse hernias with size larger than 15 cm.

Combined intraperitoneal monitoring and total extraperitoneal repair of McBurney's incisional hernia

BACKGROUND

McBurney's incisional hernia after appendectomy is rare. Although the open surgical approach, either through direct suturing or through mesh repairs, mostly achieves a satisfactory outcome, postoperative wound pain usually impedes patient's early ambulation. Accordingly, laparoscopic ventral hernia repair has emerged as a minimally invasive technique in modern surgical practice. We described a different approach of laparoscopic incisional hernia repair.

CASE REPORT

A 76-year-old woman with a history of appendectomy presenting with a bulging mass over the right lower quadrant of the abdomen beneath the operation scar was admitted to our hospital. Computed tomography revealed defects in the abdominal muscle layers without evidence of bowel incarceration. The patient was diagnosed with postappendectomy incisional hernia for which laparoscopic hernia repair was performed through a combined intraperitoneal and extraperitoneal approach. The patient's postoperative course was excellent.

CONCLUSIONS

Combined extraperitoneal approach and intraperitoneal monitoring for McBurney's incisional hernia is feasible in selected cases.

Laparoscopic transabdominal extraperitoneal mesh repair of lumbar hernia

Lumbar hernias are rare posterolateral abdominal wall defects that may be congenital or acquired. There are two types of lumbar hernia, the superior lumbar hernia through Grynfeltt triangle, and the inferior lumbar hernia through Petit triangle. Many techniques have been described for the surgical repair of lumbar hernias including primary repair, local tissue flaps, and conventional mesh repair. But these open techniques require a large skin incision. We report a case of superior lumbar hernia, which was successfully repaired using a laparoscopic approach.

Laparoscopic total extraperitoneal repair of lumbar hernia

Lumbar hernia is a rare surgical entity without a standard method of repair. With advancements in laparoscopic techniques, successful lumbar herniorrhaphy can be achieved by the creation of a completely extraperitoneal working space and secure fixation of a wide posterior mesh. We present a total extraperitoneal laparoendoscopic repair of lumbar hernia, which allowed for minimal invasiveness while providing excellent anatomical identification, easy mobilization of contents and wide secure mesh fixation. A total extraperitoneal method of lumbar hernia repair by laparoscopic approach is feasible and may be an ideal option.

Sutureless Meshplasty in Lumbar Hernia

Background. Lumbar hernia is a rare hernia arising through posterolateral abdominal wall defects. Different techniques of repair are reported in the literature. Methods. The authors present their experience of 4 lumbar hernias during a short span of 9 months. All surgical repairs were performed using synthetic mesh placed in the extraperitoneal space, below the muscular layers, using a sutureless tension-free technique. Results. The patients were 3 children and 1 adult, all males. All hernias were through superior triangle. Duration of surgery ranged between 60 and 80 minutes. There were no surgical complications. The mean hospital stay was 2.5 days. All patients are well on follow-up till date. Conclusions. Sutureless tension-free meshplasty of these rare hernias can be successfully performed with the posterior approach. This method of repair is easy, safe, and effective.

Anatomical and Surgical Considerations on Lumbar Hernias

Lumbar hernias, which are rare hernias of the posterolateral abdominal wall, can be divided into two groups: primary lumbar hernias, often the expression of a congenital defect, which typically arise in two areas of weakness, the superior triangle and inferior triangle and acquired (or diffuse) lumbar hernias which are usually due to previous lumbar trauma or surgery. Clinical examination may be adjuvated by ultrasound or CT scan, which can reveal the abdominal wall defect with the hernia content (viscera or extraperitoneal tissue). Surgical repair of lumbar hernias, both primary and acquired, has rapidly developed through recent years, similarly to the treatment of more frequent kinds of hernia (groin, epigastric), evolving from direct repair to mini-invasive techniques, even if, since the rarity of these hernias, precise knowledge of this complex anatomic region is required. Nowadays there are two valid alternatives: open tension-free repair (with use of mesh), and mini-invasive repair. Both are safe and effective, even if smaller hernias can be treated by open approach, with loco-regional anesthesia and good cosmetic effect. Larger hernias, or hernias with suspected viscera involvement, should require larger incisions and viscera exploration. For this reason laparoscopic access would be preferable.

Laparoscopic incisional lumbar hernia repair

PURPOSE

Incisional lumbar hernia is an uncommon hernia type. Open surgical procedures have significant postoperative morbidity and patient dissatisfaction, therefore, for the repair of seven incisional lumbar hernias, we attempted using an intraperitoneal laparoscopic technique that was described to have good short-term results and decreased morbidity.

METHODS

We applied a laparoscopic technique using polypropylene meshes in five patients and composite meshes in two patients to cover the defect, then placed prolene sutures and hernia staples to secure the mesh intraperitoneally.

RESULT

The technique was successful in all patients, and they tolerated the procedure well. All did well after surgery, ambulating and eating a regular diet on postoperative day 1. No postoperative complications developed. At a mean follow-up of 34.1 months (range 17-43 months) none of them had pain, mass, or evidence of recurrence, and furthermore, cosmesis was excellent.

CONCLUSIONS

We believe that the laparoscopic approach is feasible, safe, and the least invasive choice for repairing difficult hernias such as incisional lumbar hernias.

Lumbar hernia: anatomical basis and clinical aspects

INTRODUCTION

The purpose of this study was to describe the anatomy of the two orifices of the abdominal posterior wall where lumbar hernias could appear. They may protrude through the superficial lumbar triangle (JL Petit) or the deepest superior orifice (Grynfeltt).

METHODS

The exact limits were precised by dissections in cadavers to explain the main differences of these two locations. We report two cases of spontaneous lumbar hernias discovered in outpatient clinic.

RESULTS

Clinical diagnosis was difficult and both the patients were sent for lumbar lipoma but a meticulous examination gave us a clue. MRI was useful to confirm the defect in the posterior abdominal wall under the 12th rib. Only one patient was operated by a direct approach with a reinforcement of an unabsorbable mesh. No recurrence appeared during follow-up.

CONCLUSION

Thanks to clinical and anatomical knowledge, these rare superior lumbar hernias were diagnosed and a correct surgical treatment permitted a quick recovery.

Laparoscopic transperitoneal repair of lumbar incisional hernias: a combined suture and 'double-mesh' technique

BACKGROUND

Lumbar hernias that occur after surgery are called lumbar incisional hernias. Recently, laparoscopic repair of these hernias has been reported with excellent outcomes. This is a retrospective study of our series of patients with lumbar incisional hernias.

PATIENTS AND METHODS

We managed 11 patients with lumbar incisional hernias from 1996-2006. All the patients had undergone either nephrectomy or pyeloplasty in the past. Laparoscopic suturing of the defect and reinforcement with mesh were successfully performed for all the patients.

RESULTS

There were more males than females, the age range was 42-65 years, and mean operating time was 120 min; discharge was at 1-2 postoperative days. There was no recurrence or mortality. Three cases had seroma, out of which two required aspiration after 60 days.

DISCUSSION

Laparoscopic repair provides all the benefits of minimally invasive surgery, and the principles involved in repair of ventral hernias are applied in lumbar incisional hernias as well. Our technique involved suturing of the defect before placing a mesh over the defect. We theorize that approximating the ends of the muscles restores normal anatomy and results in functional improvement. For the larger hernias, we used two meshes to cover the defect--polypropylene and Parietex, sizes being 15 x 15 cm.

CONCLUSION

Laparoscopic repair with prosthetic reinforcement is feasible and effective in the treatment of lumbar incisional hernias. Also, suturing of the defect may provide additional benefits.

Laparoscopic hernioplasty in secondary lumbar hernias

BACKGROUND

Lumbar hernia is an uncommon defect of the posterior abdominal wall, and surgical treatment is still controversial. The aim of this study was to analyze the utility of the laparoscopic approach in the repair of these hernias.

MATERIALS AND METHODS

We undertook a descriptive analysis of 15 patients diagnosed with lumbar hernia who underwent surgery with transabdominal laparoscopy between 1997 and 2004. The following variables were analyzed: clinical data, intraoperative and postoperative complications, operative time, length of hospital stay, analgesic consumption, and recurrences. The technique was evaluated aesthetically by measuring the abdominal perimeter using a tape measure. The mean follow-up was 32 months (range, 12-55 months).

RESULTS

Intraoperative morbidity consisted of two cases of bleeding caused by the mechanical suture. Postoperative morbidity consisted of 3 cases of hematomas, 2 of seromas, and 2 of transitory pain. Seven patients (47%) were treated as day cases, and only one required admission due to pain. At 12-month follow-up we found one recurrence and a significant reduction in abdominal perimeter (P < 0.05).

CONCLUSION

The transabdominal laparoscopic approach offers good clinical and aesthetic results both for the patient and the hospital, as almost half of the cases can be treated as day cases. We believe it should be considered the technique of choice for incisional lumbar hernia repair.

Lumbar Hernia Repaired Using a New Technique

Lumbar hernia is uncommon and occurs in Grynfeltt's triangle on the left side, more frequently in men than in women. Acquired lumbar hernias are the result of iliac crest bone harvest or blunt trauma and seat belt injuries in road accidents. Many surgical options have been reported for repairing this hernia through primary closure of the defect or through use of aponeurotic or prosthetic materials. The Dowd technique is the technique most often used. The authors describe a patient with posttraumatic inferior triangle lumbar hernia who underwent laparoscopy and, 10 days later, laparotomy. Both procedures failed. Finally, a novel lumbotomic surgical approach was used, involving the Dowd technique and prosthetic mesh. The patient was free of recurrence 3 months after the procedure.

Retroperitoneoscopy to Extract Dropped Gallstones After Laparoscopic Cholecystectomy

Complications resulting from gallstones left in the peritoneal cavity are most often reported after laparoscopic treatment of cholelitiasis. Gallstones are frequently dropped in the posterior subhepatic space, which can lead to the development of abscesses that usually require laparotomy for extraction of the stones. We present a novel technique for treating collections associated with dropped gallstones, using retroperitoneoscopy with two 10-mm ports after ultrasound localization of the abscess. We carried out this procedure in two patients and successfully extracted the gallstones without postoperative complications or recurrences. We consider this approach to be technically feasible, safe, and effective. It avoids the usual inefficacy of simple percutaneous drainage of these collections and the complications associated with the drainage of intra-abdominal abscesses by laparotomy.

Laparoscopic Lumbar Hernia Repair

Lumbar hernias are rare clinical entities that often pose a challenge for repair. Because of the surrounding anatomy, adequate surgical herniorraphy is often difficult. Minimally invasive surgery has become an option for these hernias. Herein, we describe two patients with lumbar hernias (one with a recurrent traumatic hernia and one with an incisional hernia). Both of these hernias were successfully repaired laparoscopically.

[Abdominal wall hernias of unusual presentation]

INTRODUCTION

Abdominal wall hernias (AWH) of unusual presentation include Spigelian hernia (SH), obturator hernia (OH), lumbar hernia (LH) and intraparietal hernia (IPH), among others. Their diagnosis requires of a high index of suspicion and frequent use of imaging studies.

PATIENTS AND METHOD

We performed a retrospective review of the AWH treated between 1990 and 2004. Of a total of 2,973 hernias, 16 (0.53%) were in infrequent locations: 12 SH (0.4%), 2 OH (0.06%), 1 LH (0.03%), 1 IPH (0.03%). All the SH showed a palpable mass. They were more frequent in men (7 men and 5 women). Emergency surgery was performed in 25%. When imaging studies were carried out, ultrasonography confirmed only 20% while computed tomography (CT) confirmed 100%. In all patients who underwent surgery for HS, the diagnosis was made preoperatively. Seven small defects were repaired by simple closure (with 1 recurrence); 5 were repaired by a polypropylene mesh cone through the anterior extraperitoneal route. Fifty percent were associated with other AWH. Two OH presented with intestinal obstruction and preoperative diagnosis was made by CT. One IPH also presented with intestinal obstruction and preoperative diagnosis was made by ultrasonography; in 2 patients intestinal resections were performed with mesh repair. The LH had a preoperative diagnosis of lipoma by CT.

CONCLUSIONS

AWH of unusual presentation can present as acute complications. Treatment is indicated after diagnosis. Surgical repair can be performed by primary closure or mesh repair through the open or laparoscopic route. The most suitable repair technique for each type of hernia should be selected.

Laparoscopic management of inferior lumbar hernia (Petit triangle hernia)

Lumbar hernias are rare defects in the posterolateral abdominal wall that may be congenital or acquired. We present a case of laparoscopic approach to repair an acquired inferior triangle (Petit) lumbar hernia in a woman by using polytetrafluoroethylene mesh. The size of the hernia was 8 x 10 cm. The length of her hospital stay was 2 days. The patient resumed normal activities in less than 2 weeks. The main advantage of this approach is excellent operative visualization, thus avoiding injury to structures near the hernia during repair. Patients benefit from a minimally invasive approach with less pain, shortened hospital course, less analgesic requirements, better cosmetic result, and minimal life-style interference.

A Grynfeltt hernia: Report of a case

Superior lumbar hernia (Grynfeltt hernia) is an uncommon variety of abdominal wall defect. There are three types of lumbar hernia: congenital, acquired, and incisional hernias. Diagnosis depends largely on the capacity for clinical suspicion, and confirmation is based on imaging tests. We report a case of an acquired lumbar hernia diagnosed by computed tomography (CT), which was treated successfully at our institution.

A novel technique of lumbar hernia repair using bone anchor fixation

Lumbar hernias are difficult to repair due to their proximity to bone and inadequate surrounding tissue to buttress the repair. We analyzed the outcome of patients undergoing a novel retromuscular lumbar hernia repair technique. The repair was performed in ten patients using a polypropylene or polytetrafluoroethylene mesh placed in an extraperitoneal, retromuscular position with at least 5 cm overlap of the hernia defect. The mesh was fixed with circumferential, transfascial, permanent sutures and inferiorly fixed to the iliac crest by suture bone anchors. Five hernias were recurrent, and five were incarcerated; seven were incisional hernias, and three were posttraumatic. Back and abdominal pain was the most common presenting symptom. Mean hernia size was 227 cm(2) (60-504) with a mesh size of 620 cm(2) (224-936). Mean operative time was 181 min (120-269), with a mean blood loss of 128 ml (50-200). Mean length of stay was 5.2 days (2-10), and morphine equivalent requirement was 200 mg (47-460). There were no postoperative complications or deaths. After a mean follow-up of 40 months (3-99) there have been no recurrences. Our sublay repair of lumbar hernias with permanent suture fixation is safe and to date has resulted in no recurrences. Suture bone anchors ensure secure fixation of the mesh to the iliac crest and may eliminate a common area of recurrence.