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

Single-Incision Laparoscopic Totally Extraperitoneal Sublay Repair of Lumbar Hernia: A Novel Technique

Background: Lumbar hernia is a rare disease with low incidence, and no golden standard surgical procedure has been established for lumbar hernias. The single-incision laparoscopic totally extraperitoneal sublay (SIL-TES) technique became a novel surgical technique for lumbar hernias. Methods: This retrospective study included 20 patients who underwent SIL-TES repair for lumbar hernia between April 2020 and March 2024. The baseline patient characteristics, intraoperative data, postoperative data, satisfaction score, and Carolina Comfort Scale scores were collected. Results: The results revealed that the SIL-TES technique for lumbar hernia repair is associated with a low complication rate, nonrecurrence, high satisfaction score, and high quality of life after surgery. Conclusions: The SIL-TES technique could be a feasible and effective surgical technique for lumbar hernias. A controlled study is needed for further confirmation.

Traumatic lumbar hernia: A systematic review of the literature

PURPOSE

Traumatic lumbar hernia (TLH) constitutes a protrusion of content through a defect in the posterior abdominal wall, as a result of injury. This rare entity has been described in limited number of cases.

METHODS

A systematic review of the literature was performed according to the meta-analysis of observational studies in epidemiology guidelines. The English literature from 1990 until 2021 was reviewed, using PubMed, EMBASE and Google Scholar bibliographic databases, to identify case reports and case series with patients that were diagnosed with TLH. For each eligible study, demographics, clinical presentation, hernia characteristics, preoperative imaging investigations, operation details, and postoperative data were extracted for assessment. Statistical analysis was performed on SPSS, version 20.0.

RESULTS

A total of 62 studies were included for review, with 164 patients with TLH. Mean age was (42.6 ± 14.3) years (47.6% males, 31.1% females, gender not specified in 35 cases). Mean diameter of hernia neck was (6.3 ± 3.1) cm, while the triangles of Petit and Grynfeltt were affected in 74.5% and 14.6%, respectively. Patients diagnosed in the emergency setting account for 54.2%, with CT scan establishing diagnosis in all but one case (97.7%). A delayed diagnosis was made in 45.8%, at a mean 1 year following trauma. Flank bulging (82.8%) and chronic back pain (34.3%) were the most frequent symptoms. In both delayed and acute group, open surgery (63.6% and 92.3%, respectively) was the preferred surgical approach. Postoperative complications were reported in 11.4% of acute and 15.0% of delayed patients. Hernia recurrence was 7%.

CONCLUSIONS

TLH is uncommon with 164 cases described since 1990. CT scan is the gold standard in diagnosis. Open surgery is generally the preferred approach, particularly in the emergency setting. Acute TLH can be treated either by primary suture repair or mesh, depending on the local conditions, whereas delayed cases usually require a mesh.

Retrospective analysis of 16 cases of lumbar hernia

Background

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

Methods

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

Results

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

Conclusion

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

Novel Technique for Mesh Fixation to the Bone in Recurrent Post Traumatic Lumbar Hernia

BACKGROUND

Traumatic lumbar hernia is due to shearing of bony insertions of the muscle in the lumbar region. In recurrent cases, there is more attenuation of muscles. This makes fixation of the mesh extremely difficult. Hence, the need to develop a new technique.

CASE REPORT

A 27-year-old male presented with a recurrent post-traumatic right- sided lumbar hernia. He had a severe two wheeler accident. Following the accident he had undergone various surgical interventions for a fractured pelvis with a deglowing injury involving the right gluteal region and upper thigh. He had also developed a post-traumatic lumbar hernia for which he had undergone open mesh repair. Subsequently he developed recurrence of the post traumatic right-sided lumbar hernia. After complete investigation he underwent open mesh repair for the recurrent post traumatic lumbar hernia. The defect was wide and was devoid of healthy surrounding muscles. The mesh was fixed to the ileal bone with bone anchors and to the twelfth rib with trans-osseous fiber sutures passed through holes drilled in the twelfth rib. Flaps were created from the remnant surrounding attenuated muscles. They were double-breasted to cover the mesh. Postoperative outcome was excellent with no recurrence for the last six months.

DISCUSSION

The various anatomical and technical considerations of bone fixation of the mesh for hernia repair are discussed.

CONCLUSION

Bone fixation of the mesh with bone anchors is a viable option especially in cases where there is severe attenuation of adjacent muscles for mesh fixation.

Traumatic abdominal wall hernias: a single-center case series of surgical management

Background

Traumatic abdominal wall hernias (TAWHs) are a rare clinical entity that can be difficult to diagnose and manage. There is no consensus on management of TAWH due to its low incidence and complex concomitant injury patterns. We hereby present the largest single-center case series in the USA to characterize associated injury patterns, identify optimal strategies for hernia management, and determine outcomes.

Methods

Patients who presented with a TAWH from blunt trauma requiring operative management were retrospectively identified over a 14-year period. Demographic data, Injury Severity Score (ISS), associated injuries, type of repair, durability of repair, and complications were collected, and descriptive statistics were calculated.

Results

Fifteen patients were identified. The average age was 31±11 years, ISS 15±9, and body mass index 33.4±7.1 kg/m². Mechanisms included falls (13%), motor vehicle collisions (60%), motorcycle accidents (20%), and pedestrian versus motor vehicle collisions (7%). The most commonly associated injuries included colonic injuries (53%), long bone fractures (47%), pelvic fractures (40%), and small bowel injuries (33%). Nineteen hernia repairs were performed: 6 underwent primary suture repair (32%) and 13 used mesh (68%). There were four recurrences. We could not find any significant relationship between contamination and mesh use or recurrence. There was one mortality related to sepsis.

Discussion

TAWHs have an associated injury pattern involving fractures and abdominopelvic visceral injuries where a tailored approach is advisable. Without hollow viscous injuries and gross contamination, these hernias can be repaired safely with mesh in the acute setting. However, in patients with gross contamination or hemodynamic instability, the risk of recurrence with primary repair must be weighed against the risk of infection and prolonged surgery with mesh repair. In those cases, a delayed reconstruction in the elective setting may be optimal.

Hybrid laparoscopic and open repair of post-nephrectomy flank hernia

Surgical repair of flank hernia is not routinely performed, due to perceived technical difficulties with the surgery and risk of recurrence, or the misconception that flank hernia is solely due to a denervation injury. Due to the rareness of flank hernia in the literature, there is no general consensus on the best method of surgical repair. We present the case of a patient with a symptomatic large flank hernia following open nephrectomy, in which a hybrid technique of open and laparoscopic flank hernia repair with sublay mesh and bone anchor fixation was successfully performed with good outcome. This case highlights the benefits of the hybrid approach, which allowed a laparoscopic assessment of the defect and adhesiolysis, followed by the open repair which enabled adequate mesh overlap, fixation to surrounding tissues and bone anchor fixation.

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.

Abdominal herniation associated with bullhorn injury as a separate entity from traumatic abdominal wall hernias

Bullhorn injury is a rare mechanism causing traumatic abdominal wall hernia (TAWH). Bullhorn injury needs to be discussed as a separate sub-entity among TAWHs as the mechanism of injury is such that the great force is generated at a relatively small area of impact for a short duration of time which may lead to muscle defect without compromising integrity of overlying skin (referred to as sheathed goring) leading to herniation of abdominal viscera. The purpose of this review was to discuss abdominal herniation's associated with bullhorn injury as a separate entity from TAWHs; recognize the common presentations, mechanism of injury, and modalities of treatment currently utilized for this rare condition. A comprehensive online English, Spanish, Portuguese, and French language medical literature search was done using various electronic search databases. Different search terms including MeSH related to bullhorn-injury associated injuries including abdominal wall hernias were used. An advanced search was further conducted by combining all the search fields in abstracts, keywords, and titles. We summarized the data from the searched articles and found 12 cases who underwent emergency or elective herniorrhaphy with or without the use of mesh. We have proposed a treatment algorithm for such cases in light of the present era of laparoscopy and propose the usage of the term “bullhorn-injury associated traumatic hernia” for such cases. We present here the first most comprehensive discussion of all such cases reported till date.

Case report of traumatic abdominal wall hernia caused by seat belt

RATIONALE

Traumatic abdominal wall hernia (TAWH) is a rare form of hernia that is caused by disruption of the abdominal wall musculature and fascia. The diagnostic criteria and classification of TAWH are still unclear; furthermore, the ideal timing and method of surgical treatment are still unclear. Herein, we report a case of TAWH and describe the surgical approach used.

PATIENT CONCERNS

A 71-year-old Han Chinese female presented for swelling in the right lower abdominal quadrant. The patient underwent exploratory laparotomy because of a car collision before 1 year ago.

DIAGNOSIS

She was finally diagnosed with TAWH according to the abdominal computed tomography (CT) and surgery.

INTERVENTIONS

She was performed with an open surgery to repair the TAWH.

OUTCOMES

The patient was discharged without complications and showed no recurrence or complications during a follow-up period of 6 months.

LESSONS

TAWH is a rare form of hernia that presents a diagnostic and therapeutic challenge. The appropriate timing and approach of surgical treatment for TAWH depend on a case-by-case basis. This case highlights that delayed selective surgery may be more suitable for stable patients.

Reconstruction of traumatic lumbar hernias: A case report

BACKROUND

Traumatic lumbar hernias are not common hernias that are encountered by general or plastic surgery teams, however it is important to understand the anatomy of the hernia in order to be able to correct the flank defect. In our patient, the oblique muscles were sheared off the iliac crest periosteum, however the attachments to the ribs and spine were maintained. We were able to successfully place a pre-peritoneal polypropylene mesh which was secured to the musculature, and re-approximate the oblique muscles to the iliac crest using Mitek QUICKANCHOR® sutures. Our case study has been reported in line with the SCARE criteria ([8] Agha et al., 2016).

CASE REPORT

The subject in our case was a 47-year-old gentleman who was involved in a motor vehicle accident, and sustained a traumatic lumbar hernia due to the 3-point seatbelt he was wearing. He was transported via ambulance to our trauma center.

CONCLUSION

Understanding the anatomy and mechanism of injury is the key to reconstructing traumatic lumber hernias. Although not required, mesh reinforcement has significantly reduced the recurrence of all hernias. This is the simplest and most effective way, in our opinion, to return the flank muscles to their native position while providing mesh reinforcement.

A rare case of a superior lumbar hernia secondary to penetrating injury

Lumbar hernias are rare occurrences, with only 300 cases reported in the literature. We present a unique case of a superior lumbar hernia secondary to penetrating trauma to the right flank. We performed a herniorrhaphy using porcine mesh, and provided additional support by mobilizing the external oblique and latissimus dorsi into the defect. At follow up three months after repair, the patient was asymptomatic and exam revealed an intact lumbar abdominal wall with normal contour. Although literature displays a consensus on the need for lumbar hernia repair, specific repair techniques must be tailored to defect etiology, size, location, and contents.

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.

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.

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.