A novel technique of lumbar hernia repair using bone anchor fixation

Sandwiching a Lumbar Hernia: A Case Report

A lumbar hernia is characterized by the protrusion of intra-abdominal contents through a defect in the muscles of the lumbar region. They can be classified as primary or secondary based on their etiology. We present a case of a 65-year-old male who had swelling in the right flank region for nearly 20 years and experienced sudden onset pain over the last 20 days. He was diagnosed with a primary lumbar hernia in the inferior triangle, which was confirmed by computed tomography. Open onlay mesh repair was performed using a recently developed technique known as the sandwich technique. In this method, the muscle and defect are sandwiched between two polypropylene meshes to improve tensile strength and provide support, preventing future recurrence. The patient was followed up at one week, one month, and six months post-procedure, with no recurrence or complications observed. This case report highlights a rare type of primary lumbar hernia and emphasizes the successful outcome of this novel repair technique.

Open repair of flank and lumbar hernias: 142 consecutive repairs at a high-volume hernia center

BACKGROUND

Flank and lumbar hernias (FLH) are challenging to repair. This study aimed to establish a reproducible management strategy and analyze elective flank and lumbar repair (FLHR) outcomes from a single institution.

METHODS

A prospective analysis using a hernia-specific database was performed examining patients undergoing open FLHR between 2004 and 2021. Variables included patient demographics and operative characteristics.

RESULTS

Of 142 patients, 106 presented with flank hernias, and 36 with lumbar hernias. Patients, primarily ASA Class 2 or 3, exhibited a mean age of 57.0 ​± ​13.4 years and BMI of 30.2 ​± ​5.7 ​kg/m2. Repairs predominantly utilized synthetic mesh in the preperitoneal space (95.1 ​%). After 29.9 ​± ​13.1 months follow-up, wound infections occurred in 8.3 ​%; hernia recurrence was 3.5 ​%. At 6 months postoperatively, 21.2 ​% of patients reported chronic pain with two-thirds of these individuals having preoperative pain.

CONCLUSIONS

Open preperitoneal FLHR provides a durable repair with low complication and hernia recurrence rates over 2.5 years of follow-up.

Robotic-Assisted Laparoscopic Repair of Petit's Hernia With Preperitoneal Mesh

Lumbar hernias are rare abdominal wall hernias that occur in the posterolateral abdominal wall. Intra-peritoneal or extra-peritoneal contents typically protrude through defects in one of two anatomical triangles. The superior lumbar triangle (Grynfeltt-Lesshaft triangle) is an inverted triangle bordered by the 12th rib superiorly, the internal oblique muscle laterally, and the erector spinae muscle medially. The inferior lumbar triangle (Petit's triangle) is an upright triangle bordered by the iliac crest inferiorly, the external oblique muscle laterally, and the latissimus dorsi muscle medially. Surgical repair has been described via open or laparoscopic approach. A 69-year-old male patient presented with right flank pain and swelling. He was involved in a motorcycle accident 10 months prior, which likely resulted in the development of a traumatic lumbar hernia which was demonstrated on the CT scan. The hernia was clinically incarcerated, and the defect contained the cecum and ileocecal valve. The defect was noted just superior to the iliac crest, by definition, making this an inferior lumbar hernia or a Petit's hernia. The hernia was repaired via robotic-assisted laparoscopic transabdominal approach. A peritoneal flap was created exposing the fascial defect. The fascia was primarily repaired with suture. The defect was reinforced with an 11.4 cm round Ventralight ST mesh in the preperitoneal space. The patient tolerated the procedure well with no acute complications. He was discharged the same day as an outpatient with appropriate pain control. Short-term follow-up demonstrated no recurrent hernia present and symptoms resolved. Lumbar hernias are a rare occurrence with no gold standard technique for repair. The benefits of the laparoscopic approach have been described over the open approach. This case report describes utilizing a minimally invasive approach to primarily repair a lumbar hernia defect while also reinforcing the hernia with mesh in the preperitoneal space.

Bone Anchor Fixation in the Repair of Blunt Traumatic Abdominal Wall Hernias: A Western Trauma Association Multicenter Study

BACKGROUND

Blunt traumatic abdominal wall hernias (TAWHs) are rare but require a variety of operative techniques to repair including bone anchor fixation (BAF) when tissue tears off bony structures. This study aimed to provide a descriptive analysis of BAF technique for blunt TAWH repair. Bone anchor fixation and no BAF repairs were compared, hypothesizing increased hernia recurrence with BAF repair.

METHODS

A secondary analysis of the WTA blunt TAWH multicenter study was performed including all patients who underwent repair of their TAWH. Patients with BAF were compared to those with no BAF with bivariate analyses.

RESULTS

176 patients underwent repair of their TAWH with 41 (23.3%) undergoing BAF. 26 (63.4%) patients had tissue fixed to bone, with 7 of those reinforced with mesh. The remaining 15 (36.6%) patients had bridging mesh anchored to bone. The BAF group had a similar age, sex, body mass index, and injury severity score compared to the no BAF group. The time to repair (1 vs 1 days, P = .158), rate of hernia recurrence (9.8% vs 12.7%, P = .786), and surgical site infection (SSI) (12.5% vs 15.6%, P = .823) were all similar between cohorts.

CONCLUSIONS

This largest series to date found nearly one-quarter of TAWH repairs required BAF. Bone anchor fixation repairs had a similar rate of hernia recurrence and SSI compared to no BAF repairs, suggesting this is a reasonable option for repair of TAWH. However, future prospective studies are needed to compare specific BAF techniques and evaluate long-term outcomes including patient-centered outcomes such as pain and quality of life.

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.

Bone anchor as fixation method for abdominal wall reconstruction. A case report about a ten times recurred inguinal hernia

INTRODUCTION

While the use of bone anchor fixation for abdominal wall reconstruction for supra-pubic incisional hernia is well described (Yee et al., 2008 [1]), we show in this case report, written in line with the SCARE criteria (Agha et al., 2020 [2]), a novel use of this tool as an adjunct in the repair of a ten time recurrent inguinal hernia.

CASE REPORT

A 65 years old multiparous, diabetic non-obese female, with previous abdominoplasty was submitted for left inguinal hernia for ten times, between multiples complications between infection, more than one mesh excision by anterior approach and laparoscopic approach. The wide range of procedures culminated in a destruction of the abdominal wall, making it impossible for a usual fixation of mesh in the region. Therefore, a multidisciplinary approach was planned for the patient with a bone anchor as a mesh fixation method. With a year follow up we did not observe a local hernia recurrence.

CLINICAL DISCUSSION

Hernia itself is a multifactorial disease. As a anatomical defect, surgery is the only effective treatment. Our report brings a novel approach to a challenging case with many previous unsuccessful applications of conventional surgeries. Hence, we stimulate the multidisciplinary discussion for enhancing post operatory outcomes and a better point of care for the patient.

Reverse TAR may be added when necessary in open preperitoneal repair of lateral incisional hernias: a retrospective multicentric cohort study

BACKGROUND

The best approach for lateral incisional hernia is not known. Posterior component separation (reverse TAR) offers the possibility of using the retromuscular space for medial extension of the challenging preperitoneal plane. The aim of our multicenter study was to compare the operative and patient-reported outcomes measures (PROMs) using two open surgical techniques from the lateral approach: a totally preperitoneal vs a reverse TAR.

METHODS

A retrospective cohort study was performed since 2012 to 2020. Patients with lateral incisional hernia treated through a lateral approach were identified from a prospectively maintained multicenter database. Reverse TAR was added when the preperitoneal plane could not be safely dissected. The results obtained using these two lateral approaches were compared, including short- and long-term complications, as well as PROMs, using the specific tool EuraHSQoL.

RESULTS

A total of 61 patients were identified. Reverse TAR was performed in 33 patients and lateral retromuscular preperitoneal approach in 28 patients. Both groups were comparable in terms of sociodemographic and comorbidities variables. Surgical site occurrences occurred in 13 cases (21.3%), with 8 patients (13.1%) requiring procedural intervention. During a median follow-up of 34 months, no incisional hernia recurrence was registered. There was a case (1.6%) of symptomatic bulging that required reoperation. Also 12 patients (19.7%) presented an asymptomatic bulging. No statistically significant difference was identified in the complications and PROMs between the two procedures.

CONCLUSION

The open lateral retromuscular reconstruction using very large meshes that reach the midline has excellent long-term results with acceptable postoperative complications, including PROMs. A reverse TAR may be added, when necessary, without increasing complications and obtaining similar long-term results.

Lumbar and para-iliac hernias: an alternative technique

Lumbar and para-iliac hernias are rare and occur after removal of an iliac bone graft, nephrectomies, retroperitoneal aortic surgery, or after blunt trauma to the abdomen. The incidence of hernia after the removal of these grafts ranges from 0.5 to 10%. These hernias are a problem that surgeons will face, since bone grafts from the iliac crest are being used more routinely. The goal of this article was to report the technique to correct these complex hernias, using the technique of fixing the propylene mesh to the iliac bone and the result of this approach. In the period of 5 years, 165 patients were treated at the complex hernia service, 10 (6%) with hernia in the supra-iliac and lumbar region, managed with the technique of fixing the mesh to the iliac bone with correction of the failure. During the mean follow-up of 33 months (minimum of 2 and maximum of 48 months), there was no recurrence of the hernias.

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.

Outcomes of abdominal wall reconstruction in patients with the combination of complex midline and lateral incisional hernias

BACKGROUND

The best treatment for the combined defects of midline and lateral incisional hernia is not known. The aim of our multicenter study was to evaluate the operative and patient-reported outcomes using a modified posterior component separation in patients who present with the combination of midline and lateral incisional hernia.

METHODS

We identified patients from a prospective, multicenter database who underwent operative repairs of a midline and lateral incisional hernia at 4 centers with minimum 2-year follow-up. Hernias were divided into a main hernia based on the larger size and associated abdominal wall hernias. Outcomes reported were short- and long-term complications, including recurrence, pain, and bulging. Quality of life was assessed with the European Registry for Abdominal Wall Hernias Quality of Life score.

RESULTS

Fifty-eight patients were identified. Almost 70% of patients presented with a midline defect as the main incisional hernia. The operative technique was a transversus abdominis release in 26 patients (45%), a modification of transversus abdominis release 27 (47%), a reverse transversus abdominis release in 3 (5%), and a primary, lateral retromuscular preperitoneal approach in 2 (3%). Surgical site occurrences occurred in 22 patients (38%), with only 8 patients (14%) requiring procedural intervention. During a mean follow-up of 30.1 ± 14.4 months, 2 (3%) cases of recurrence were diagnosed and required reoperation. There were also 4 (7%) patients with asymptomatic but visible bulging. The European Registry for Abdominal Wall Hernias Quality of Life score showed a statistically significant decrease in the 3 domains (pain, restriction, and cosmetic) in the postoperative score compared with the preoperative score.

CONCLUSION

The different techniques of posterior component separation in the treatment of combined midline and lateral incisional hernia show acceptable results, despite the associated high complexity. Patient-reported outcomes after measurement of the European Registry for Abdominal Wall Hernias Quality of Life score demonstrated a clinically important improvement in quality of life and pain.

Lumbar Incisional Hernia Repair: Complete Reconstruction of the Deficient Myofascial Component Using Christmas Tree Bone Anchors

Lumbar incisional hernias are difficult to repair because one of the hernia margins is bone, namely, the iliac crest. Previous studies have described the use of orthopedic bone anchors that fix a mesh onto the iliac crest. We present a novel technique for open repair of large lumbar incisional hernias using a double-mesh technique in combination with suture-loaded bone anchors to reattach the abdominal wall musculature onto the iliac crest. The surgical technique involves creating a preperitoneal plane behind the transversus abdominus and above the iliac crest and iliacus, below the iliac crest, with application of a Prolene mesh in this layer. This is followed by the drilling of suture-loaded Christmas Tree bone anchors™ along the rim of the iliac crest. The preloaded sutures are used to attach the myofascial component on the iliac crest, followed by the placement of a second Prolene mesh in an on-lay fashion. Drains are left in the preperitoneal and subcutaneous spaces. Unlike other reported techniques in the literature which only fix mesh onto the iliac crest, our technique with the use of Christmas Tree bone anchors™ allows for complete reconstruction of the lumbar abdominal wall defect and its myofascial components.

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.

Flank and Lumbar Hernia Repair

Flank and lumbar hernias are challenging because of their rarity and anatomic location. Several challenges exist when approaching these specific abdominal wall defects, including location, innervation of the lateral abdominal wall musculature, and their proximity to bony landmarks. These hernias are confined by the costal margin, spine, and pelvic brim, which makes closure of the defect, including mesh placement, difficult. This article discusses the anatomy of lumbar and flank hernias, the various etiologies for these hernias, and the procedural steps for open and robotic preperitoneal approaches. The available clinical evidence regarding outcomes for various repair techniques is also reviewed.

Laparoscopic repair of traumatic flank hernias

INTRODUCTION

Traumatic flank hernias (TFH) are caused by a blunt abdominal trauma with resultant detachment of the oblique musculofascial complex at the iliac crest and/or costal margin. Given such proximity to the bony structures and essential absence of healthy fascia to anchor the mesh, TFH represent a challenging surgical problem. Although laparoscopic repair of ventral hernias has become very common, no series of laparoscopic repairs of TFH has been reported to date. We present a series of patients undergoing laparoscopic repair of TFH.

METHODS

After retrospective review of prospective hernia database at two Hernia centers, patients undergoing laparoscopic TFH repair were identified and analyzed. Main outcome measures included patient demographics, surgical technique, intraoperative data, and post-operative outcomes.

RESULTS

From December 2007 to December 2013, 14 patients underwent laparoscopic repair of a TFH. Eleven patients had chronically incarcerated viscera within the defect. Operative steps included complete reduction of the hernia sac, pre/retroperitoneal dissection to expose the entire lateral edge of a psoas muscle, defect closure with transabdominal sutures, wide mesh overlap, and transabdominal suture fixation with selective use of bone anchors. The mean operative time was 174 min (range 125-230). Mean estimated blood loss was 65 cc. Mean mesh size was 295 cm². There were no peri-operative complications. Mean hospital stay was 3.1 days and all patients returned to full activities by 6 weeks. At a mean follow-up of 35 months, there have been no recurrences.

CONCLUSION

Laparoscopic approach to TFH is feasible and safe. It is associated with minimal hospital stay and fast functional recovery. The key components of our approach include wide pre/retroperitoneal with defect closure and subsequent wide mesh underlay coverage with fixation to bony structures using anchors/screws. We believe that the laparoscopic approach should safely considered for the majority of patients with TFH.

Flank Hernia Repair with Suture Anchor Mesh Fixation to the Iliac Crest

Traumatic or postsurgical flank hernias are complex and prone to recurrence, particularly at the border of the iliac crest. We reviewed our experience using suture anchors drilled into the iliac crest to fixate the mesh to bone. Our study of 10 repairs in eight patients was Institutional Review Board exempt. We obtained demographics, body mass index, diabetes, methicillin-resistant Staphylococcus aureus (MRSA) history, smoking status, steroid use, number of prior repairs, defect size, mesh size, number of anchors, and recurrence and infection at follow-up. We performed Kaplan-Meier analysis using a composite of recurrence or infection. Three of eight (interquartile range, 37.5%) patients were male. Median age and body mass index were 47.5 years (31.0, 54.7) and 32.2 (29.0, 36.0), respectively. Three patients had prior repairs, one each with two, three, and five prior attempts at fixation. One of eight patients (12.5%) had a history of MRSA infection. One of eight patients (12.5%) had a history of intermittent steroid use for sarcoidosis. Defect size was 90 cm2 (62.2, 165) and mesh size was 155 cm2 (150, 232) with four anchors (4, 5.5). Procedural complications included 2/10 (20%) with recurrence and 1/10 (10%) with postoperative MRSA infection. Follow-up was 12 months (3.0, 25.0). Mean freedom from recurrence and mesh infection (Kaplan-Meier) was 43.5 months (95% confidence interval = 24.2, 62.8). In conclusion, our series is one of the largest in the literature involving the suture anchor technique. Despite a high-risk patient population due to trauma, obesity, and prior smoking and MRSA history, we achieved an acceptable recurrence rate. Further study may benefit from a randomized trial design.

A Large Single-Center ‘Experience of Open Lateral Abdominal Wall Hernia Repairs

Lateral abdominal wall hernias may occur after a variety of procedures, including anterior spine exposure, urologic procedures, ostomy closures, or after trauma. Anatomically, these hernias are challenging and require a complete understanding of abdominal wall, interparietal and retroperitoneal, anatomy for successful repair. Mesh placement requires extensive dissection of often unfamiliar planes, and its fixation is difficult. We report our experience with open mesh repair of lateral abdominal wall hernias. A retrospective review of a prospectively maintained database was performed to identify patients with a classification of lateral abdominal wall hernia who underwent an open repair. A total of 61 patients underwent open lateral hernia repairs. Mean patient age was 58 years (range 25–78), with a mean body mass index of 32 kg/m2 (range 19.0–59.1). According to the European Hernia Society classification, defects were located subcostal (L1, 14 patients), flank (L2, 33 patients), iliac (L3, 11 patients), and lumber (L4, 3 patients). Mean defect size was 78.6 cm2, with a mean greatest single dimension of 9.2 cm (range 2–25 cm). Retromuscular or interparietal repair was performed in 50.8 per cent, preperitoneal in 41.0 per cent, intraperitoneal in 6.6 per cent, and onlay in 1.6 per cent. The rate of surgical site occurrence was 49.2 per cent, primarily seroma and surgical site infection rate was 13.1 per cent. With a mean follow-up of 15.4 months, seven patients (11.5%) have documented recurrence. Synthetic mesh reconstruction of lateral wall hernias is challenging. Our experience demonstrates the safety and success of repair using synthetic mesh primarily in the retromuscular, interparietal, or preperitoneal planes.

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.

Traumatic lumbar hernia repair: experience at the Royal Brisbane and Women's Hospital

BACKGROUND

Traumatic lumbar hernias (TLH) are a rare clinical entity with fewer than 100 cases reported in the English literature worldwide. Due to the surrounding anatomy, surgical repair is often difficult. There is currently no consensus on the timing of operative repair of TLH. The aim of this study is to present a case series on the management of TLH performed at the Royal Brisbane and Women's Hospital (RBWH) utilizing both open and laparoscopic techniques with both early and delayed repairs being undertaken.

METHODS

Cases were identified retrospectively from the Trauma Database at the RBWH, a tertiary-level hospital in Brisbane, Australia.

RESULTS

Four cases of TLH were identified from 2009 to 2014. The diagnosis was confirmed pre-operatively on CT imaging. Early repair was undertaken when the patient was stable from other associated injuries. Herniation was managed in three cases by open repair (2x open lumbar approaches, 1 via midline laparotomy) with sublay extraperitoneal mesh placement. The remaining case was managed by laparoscopic extra-peritoneal mesh repair. At a minimal 4 months follow-up, no evidence of recurrence or complications was detected in three cases. One patient was lost to follow-up.

CONCLUSIONS

TLH are a rare clinical entity. Operative management can be achieved via open or laparoscopic techniques, with placement of mesh in the extraperitoneal plane. Both early, when the patients clinical status allows, and delayed repair appear to have good short-term results. Long-term data are not available at this stage.

Bone Anchor Fixation in Abdominal Wall Reconstruction: A Useful Adjunct in Suprapubic and Para-iliac Hernia Repair

Suprapubic hernias, parailiac or flank hernias, and lumbar hernias are difficult to repair and are associated with high-recurrence rates owing to difficulty in obtaining substantive overlap and especially mesh fixation due to bone being a margin of the hernia. Orthopedic suture anchors used for ligament reconstruction have been used to attach prosthetic material to bony surfaces and can be used in the repair of these hernias where suture fixation was impossible. A prospective, single institution study of ventral hernia repairs involving bone anchor mesh fixation was performed. Demographics, operative details, and outcomes data were collected. Twenty patients were identified, with a mean age 53 (range: 35–70 years) and mean body mass index 28.4 kg/m2 (range 21–38). Ten lumbar, seven suprapubic, and three parailiac hernias were studied. The majority were recurrent hernias (n = 13), with one to seven previously failed repairs. The mean hernia defect size was very large (270 cm2; range: 56–832 cm2) with average mesh size of 1090 cm2 (range 224–3640 cm2). Both Mitek GII (Depuy, Raynham, MA) and JuggerKnot 2.9-mm (Biomet, Biomedical Instruments, Warsaw, IN) anchors were used, with an average of four anchors/case (range: 1–16). Mean operative time was 218 minutes (120–495). There were three minor complications, no operative mortality, and no recurrences during an average follow-up of 24 months. Pelvic bone anchors permit mesh fixation in high-recurrence areas not amenable to traditional suture fixation. The ability to safely and effectively use bone anchor fixation is an essential tool in complex open ventral hernia repair.

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.

Retromuscular preperitoneal repair of flank hernias

INTRODUCTION

Flank hernias represent a challenging problem to reconstructive surgeons. Their anatomic proximity to the bony prominence and major neurovascular structures limits fixation options and restricts mesh overlap. We present our technique and outcomes of a preperitoneal repair with wide mesh overlap.

METHODS

This study is a retrospective analysis of patients undergoing open flank hernia repair with a retromuscular preperitoneal approach.

RESULTS

Between September 2007 and April 2011, 16 patients, mean age 55 years (range 34-80) and BMI 33 kg/m² (range 26-46), underwent open flank hernia repair. Eight were recurrent hernias; six previously had mesh placed; nine were incarcerated. Mean hernia defect size was 232 cm² (range 25-800). Mean operative time was 178 min (range 105-245). One intraoperative complication, ureteral injury in a transplant recipient, occurred and was primarily repaired without sequela. Two patients developed wound complications, one requiring superficial debridement and another requiring partial excision (<5 %) of the mesh with secondary healing. With a mean follow-up of 16.8 months (range 2-49), no recurrent hernias were noted.

CONCLUSION

Open retromuscular preperitoneal repair of flank hernias with iliac bone fixation is technically feasible, allowing wide mesh overlap for a durable repair. This approach may offer advantages of treating abdominal wall laxity and repair of larger defects when compared to laparoscopic approaches.

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 repair of incisional and other complex abdominal wall hernias

Incisional hernia is one of the most common complications of abdominal surgery, with a reported occurrence rate of up to 20% after laparotomy. The high incidence of hernia formation significantly contributes to both patient morbidity and health care costs. Although a variety of approaches have been described to repair these defects, historically the results have been disappointing. Recurrence rates after primary repair have been reported to range from 24% to 54%. The recent advent of laparoscopic ventral hernia repair (LVHR) has offered promising outcomes by combining tension-free repair using a prosthesis with minimally invasive techniques, lowering reported recurrence rates to <10%. This review discusses standardized, well-researched techniques that have contributed to the success of LVHR. We also discuss how these techniques have been modified for laparoscopic repair of suprapubic lumbar hernias, hernias near the iliac crest, and parastomal hernias. In addition, we review our own experience with LVHR in the context of the principles discussed.

Inferior lumbar triangle hernia as a rarely reported cause of low back pain: a report of 4 cases

OBJECTIVE

Lumbar triangle hernias are rarely reported causes of low back pain. We describe the symptoms, signs, and anatomical location of 2 possible defects in the posterior abdominal wall where lumbar hernias may appear. The clinical diagnosis was challenging, and advanced imaging failed to initially uncover the conditions.

CLINICAL FEATURES

We report 4 patients with spontaneous inferior lumbar triangle hernias (Petit triangle hernias) initially presenting to a primary care clinic with the primary complaint of low back pain.

INTERVENTION AND OUTCOMES

Thorough histories and examinations led to successful outcomes. All 4 patients were operated on to correct the defect. No recurrence has occurred.

CONCLUSIONS

Anatomical knowledge and clinical acumen led to correct diagnosis of these rare lumbar hernias. This information should help both medical and chiropractic clinicians detect these conditions, and aid in appropriate management.

Successful laparoscopic repair of a lumbar hernia occurring after iliac bone harvest

INTRODUCTION

Many techniques have been described for the surgical repair of lumbar hernias, including primary repair, local tissue flaps, and conventional mesh repair. All these open techniques require a large incision plus extensive dissection to expose the hernia ring. This report presents a case of a recurrent lumbar hernia, which was successfully repaired using a laparoscopic approach.

CASE REPORT

A 75-year-old female presented with a symptomatic right lumbar hernia, 1-year after an iliac bone harvest for knee surgery. Under general anesthesia, the patient was placed in a lateral decubitus position. A 3 trocar technique was used to do adhesiolysis of the surrounding tissues, to provide an ample working space to identify the hernia. A composix dual mesh (bard) was tailored so that it would overlap the defect with intermittent fixation by a spiral tacker (protac). No hernia recurrence occurred over 2 years after surgery.

CONCLUSION

The laparoscopic approach has significant advantages for the repair a lumbar hernia: it enables the exact localization of the anatomic defect, and the mesh can be placed deep into the defect, thus allowing the intraabdominal pressure to hold it in position.

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.

Traumatic lumbar hernia repair: a laparoscopic technique for mesh fixation with an iliac crest suture anchor

Traumatic lumbar hernia (TLH) is a rare presentation. Traditionally, these have been repaired via an open approach. Recurrence can be a problem due to the often limited tissue available for mesh fixation at the inferior aspect of the hernia defect. We report the successful use of bone suture anchors placed in the iliac crest during transperitoneal laparoscopy for mesh fixation to repair a recurrent TLH. This technique may be particularly useful after previous failed attempts at open TLH repair.

Laparoscopic repair of left lumbar hernia after laparoscopic left nephrectomy

Lumbar hernias, rarely seen in clinical practice, can be acquired after open or laparoscopic flank surgery. We describe a successful laparoscopic preperitoneal mesh repair of multiple trocar-site hernias after extraperitoneal nephrectomy. All the key steps including creating a peritoneal flap, reducing the hernia contents, and fixation of the mesh are described. A review of the literature on this infrequent operation is presented. Laparoscopic repair of lumbar hernias has all the advantages of laparoscopic ventral hernia repair.

Timing of traumatic lumbar hernia repair: is delayed repair safe? Report of two cases and review of the literature

Fewer than 100 cases of traumatic lumbar hernias are described in the English literature. The herniation has been described as a consequence of a combination of local tangential shearing forces combined with an acute increase in intra-abdominal pressure secondary to sudden deceleration sustained during blunt abdominal trauma. Delayed diagnosis is not uncommon, as nearly a quarter of these are missed at initial presentation. These hernias are best managed by operative intervention; however, there is no well-defined treatment strategy regarding either the timing or the type of repair. Several approaches, including laparoscopy, have been described to repair these defects. Various techniques, including primary repair, musculoaponeurotic reconstruction, and prosthetic mesh repair, have been described. These repairs are usually complicated because of the lack of musculoaponeurotic tissue inferiorly near the iliac crest. We describe here two cases of traumatic lumbar hernia managed by initial watchful waiting and subsequent elective repair using a combined laparoscopic and open technique and one with and one without bone anchor fixation.

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 mesh repair of incisional hernia following right lower quadrant renal transplantation

The development of an incisional hernia after lower quadrant renal transplantation is an infrequent complication, but poses a difficult surgical challenge due to the proximity of the incision to the allograft and the pelvic rim. We describe the first such case of a laparoscopic repair of a recurrent incisional hernia after renal transplantation in the literature.

Bone anchor mesh fixation for complex laparoscopic ventral hernia repair

BACKGROUND

Laparoscopic ventral hernia repair (LVHR) has gained wide acceptance by both surgeons and patients, but hernias that approach a bony prominence are more complex due to the difficulty of proper fixation. This study was conducted to evaluate the use of bone anchor mesh fixation for complex LVHR.

METHODS

A prospective study of patients having complex LVHR with bone anchors was conducted using patients from 2 academic institutions between July 2003 and December 2007. Patient demographic data, characteristics of the hernia, operative details, and postoperative outcomes were recorded.

RESULTS

A total of 30 patients who had LVHR using bone anchors were evaluated (20 women, 10 men; mean age 60.9 years, range 41-83 years). In all, 17 suprapubic and 13 lateral hernias were included, requiring a mean of 2.8 and 3.2 bone anchors, respectively. The average hernia defect was 263 cm(2) (range 35-690 cm(2)), and the average mesh size was 663 cm(2) (range 255-1360 cm(2)). Mean operative time was 218 minutes (range 98-420 minutes), with an estimated blood loss of 46 mL (range 10-100 mL). The average length of stay was 5.2 days (range 1-26 days). Seven patients (23.3%) developed postoperative complications, and 1 patient in this study died (mortality 3.3%). During follow-up of 13.2 months (range 1-26 months), 2 patients (6.7%) developed a recurrent hernia.

CONCLUSIONS

Bone anchors can be used successfully in the laparoscopic repair of complex ventral hernias, particularly with suprapubic and lateral hernias that approach a bony prominence. The complication rate is acceptable, with a short hospital stay and low recurrence rate.

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.

Primary lumbar hernia repair: the open approach

BACKGROUND

Lumbar hernias arise through posterolateral abdominal wall defects, named inferior triangle (Petit) and superior triangle (Grynfelt). Most of the lumbar hernias are secondary to trauma or previous surgery, while primary lumbar hernias are rare. There are two possible surgical approaches: the anterior approach with lumbar incision and the laparoscopic (transabdominal or totally extraperitoneal) approach.

METHODS

We present a series of nine surgical procedures for primary lumbar hernia in 7 adult patients (2 affected by bilateral hernias). Seven were Grynfelt hernias, and two were Petit hernias. All surgical repairs were performed using synthetic mesh placed in the extraperitoneal space, below the muscular layers, using a tension-free technique.

RESULTS

There was no surgical complication, except for 1 case with a subcutaneous haematoma. The mean hospital stay was 2.3 days. All patients returned to normal daily activities within 15 days after surgery. After a median follow-up period of 25 months, there was no case of recurrence or postsurgical sequelae, such as pain or muscular weakness.

CONCLUSIONS

Primary lumbar hernias are rare congenital defects of the abdominal wall. Repair of these rare hernias can be successfully performed via the anterior approach with the use of synthetic mesh - this method of repair is easy, safe, and effective.

An alternative classification of incisional hernias enlisting morphology, body type and risk factors in the assessment of prognosis and tailoring of surgical technique

Incisional hernias occur in 5-10% of patients who have undergone laparotomy and are associated with a high morbidity and significant socioeconomic costs. Better understanding of the anatomy and improved methods for reinforcement of the abdominal wall with alloplastic meshes have reduced the recurrence rate to 1-10% depending on the type of hernia and the technique employed. A number of surgical repair techniques and mesh types are available. However, precise criteria for incorporating patient body type, risk factors for recurrence, hernia morphology, and the available biomaterials into planning of the surgical approach (open versus laparoscopic) have yet to be established. The elaboration of such criteria would require comparative evaluation of long-term results in a sufficiently large number of patients, e.g. in multicentre trials or meta-analyses of standardised data from different centres. Current classifications have the drawback that they fail to take account of prognostically relevant risk factors for recurrence and are not self-explanatory. The authors present a classification of incisional hernias that is self-explanatory and practicable in routine clinical practice. Based on the cornerstones of morphology (M), hernia size in cm (S), and risk factors for recurrence (RF), the scheme enables easy description and documentation of the hernia, and provides evidence for the indications and limitations of the main surgical repair techniques. Since randomised studies can scarcely be conducted on incisional hernias due to the numerous morphological variables, the classification presented here may offer an alternative means for comparative data analysis.

The management of incisional hernia

Many thousand laparotomy incisions are created each year and the failure rate for closure of these abdominal wounds is between 10-15%, creating a large problem of incisional hernia. In the past many of these hernias have been neglected and treated with abdominal trusses or inadequately managed with high failure rates. The introduction of mesh has not had a significant impact because surgeons are not aware of modern effective techniques which may be used to reconstruct defects of the abdominal wall. This review will cover recent advances in incisional hernia surgery which affect the general surgeon, and also briefly review advanced techniques employed by specialist surgeons in anterior abdominal wall surgery.

Incisional intercostal hernia after a nephrectomy

The aim of the present case report is to present the diagnostic and therapeutic challenge of intercostal incisional hernia. We report on a female patient with leftsided intercostal incisional hernia between the eleventh and twelfth rib due to preceding lumbar incision for tumor nephrectomy. Because of its infrequence, diagnosis was established late although simple clinical examination and ultrasound investigation displayed the hernia. At laparotomy, a 5x5 cm(2) fascial defect with a colonic sliding hernia was found. Hernia repair using permanent mesh reinforcement in the retromuscular position is described. Abdominal incisional hernia in the intercostal region is rare and therefore easily overlooked. As with other incisional hernias, the hernia repair using mesh implantation in the retromuscular region is technically feasible and represents the treatment of choice.