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

Management of Lumbar Hernia Secondary to Retroperitoneal Abscess Drainage

Lumbar hernia is a rare defect that develops through the posterolateral abdominal wall. It can be classified as either congenital or acquired and may occur secondary to traumatic, iatrogenic, or infectious etiologies. Surgical management is the standard approach, with laparoscopic techniques emerging as the preferred method.A 47-year-old woman presented with swelling and pain in the left flank several months after undergoing a left laparoscopic adrenalectomy, which resulted in an abscess formation requiring interventional radiologic (IR) drainage. A computed tomography (CT) scan confirmed a left lumbar hernia, and an open mesh repair was performed. Due to their rare presentation, lumbar hernias do not have a standardized treatment algorithm. Both open and laparoscopic approaches can be utilized, but mesh repair is usually required to prevent hernia recurrence. Considering the surrounding musculature and bony prominences, knowledge of the anatomy is key to a successful and durable repair. Lumbar hernias should be considered a potential complication arising from drain placement in the flank. Surgical repair is appropriate for symptomatic lumbar hernias. The choice between laparoscopic and open approaches is made based on various patient-related considerations.

Management of post-traumatic non-iatrogenic lumbar/flank hernias: diagnosis and treatment options-systematic review, meta-analysis and management algorithm

BACKGROUND

Post-traumatic non-iatrogenic lumbar/flank hernias (LFH) represent a unique and important subset of abdominal wall hernias that can develop following either blunt or penetrating trauma to the abdomen. There is paucity of evidence guiding the management and identification of associated complications of this hernia type in the literature. We aim to pool available cases in the literature and summarize the diagnostic and management approaches of traumatic LFH.

METHODS

PUBMED, EMBASE and Scopus databases were queried, and relevant articles were selected following PRISMA guideline for systematic reviews. Studies in English and with complete data on post-traumatic non-iatrogenic LFH, including case reports, were included.

RESULTS

A total of 211 cases of post-traumatic non-iatrogenic lumbar/flank hernias (LFH) from 62 articles published between 1993 and 2023 were included, with mean age of 52.1 years (interquartile range IQR: 25.8-62.7 years). Most patients had CT-confirmed diagnosis (96.1%), had inferiorly located LFHs (86.8%), and fell into Type B Moreno-Egea class (74.6%). Flank pain was the commonest presenting complaint (13.4%) with flank hematoma present at presentation in 8.6% of the cohort. Post-traumatic non-iatrogenic LFHs were diagnosed at index hospitalization/presentation in 75.5% and repaired during the same admission in 48.2% of patients. Open repair with mesh was the most common method of repair (59.8%), followed by open repair without mesh in 28.7% and by minimally invasive laparoscopic approach in 11.5% cases. Overall recurrence rate (for all repair types) was 8% at mean follow up of 15.4 months (IQR: 12.5-25.0 months). Hernia defect size of ≥ 8 cm was 100% sensitive and 52.9% specific for the prediction of mesenteric injuries. Flank hematoma/seatbelt sign was 100% sensitive and 81.8% specific for the prediction of mesenteric injuries in traumatic LFHs.

CONCLUSIONS

Patients presenting with flank pain and flank hematoma following a blunt abdominal wall trauma should receive a thorough radiologic evaluation, particularly a CT scan, for post-traumatic non-iatrogenic LFHs. Complications such as mesenteric avulsion must be considered with high suspicion in patients whose hernia is associated with flank hematoma or with hernia diameter ≥ 8 cm. Long term follow-up after repair still requires further study. Open repair with extraperitoneal mesh reinforcement is the standard of care for hernias ≥ 8 cm repaired acutely or electively, and minimally invasive laparoscopic approach is typically utilized for hernias < 8 cm.

Totally Extraperitoneal Repair of Grynfeltt's Hernia: Easy Solution for a Rare Problem

Lumbar hernias are a rare form of abdomen wall hernias. As this is a rare disease, treatment options are not standardized. Most case reports, even recent ones, describe open techniques. A minimally invasive method, though feasible, is not done by most surgeons. Among the minimally invasive techniques, the transabdominal method is commonly performed. A totally extraperitoneal (TEP) approach is a good alternative, which can be done with minimal complications. Here, we describe a case report of a patient who had a superior lumbar hernia (Grynfeltt's) and inguinal hernia, who successfully underwent simultaneous TEP repair for the lumbar and inguinal hernia.

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.

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.

Retrospective analysis of 16 cases of lumbar hernia

Background

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

Methods

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

Results

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

Conclusion

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Primary Petit Hernia: From Diagnosis to Open Surgical Approach

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

A Case of an Atraumatic Posterior Perirenal Lumbar Hernia

Retroperitoneal lumbar hernias are a rare entity. Atraumatic posterior perirenal hernias are an exceptionally rare form of retroperitoneal lumbar hernias. Because of their infrequency, there are no standardized methods of surgical care for the treatment of atraumatic (primary spontaneous) posterior perirenal hernias. This report documents the finding and management of an atraumatic posterior perirenal lumbar hernia in a 69-year-old female.

PAIN INTENSITY AND FUNCTIONALITY AFTER PERCUTANEOUS ENDOSCOPIC DISCECTOMY: A RETROSPECTIVE COHORT STUDY

ABSTRACT Objectives To evaluate pain intensity and functional status before and 30 days following percutaneous lumbar endoscopic discectomy. Methods A retrospective cohort study that included patients who underwent percutaneous endoscopic discectomy from January 2019 to October 2020 at the Irmandade Santa Casa de Misericórdia Hospital, in Porto Alegre. The data were collected from the electronic medical records of the patients by two independent physicians. Clinical outcomes were assessed using visual analog scale (VAS) and Oswestry Disability Index (ODI) scores. Results Forty-six patients with a mean age of 52.6 ± 15.8 years, 27 of whom (58.7%) were male, were evaluated. Regarding clinical outcomes, a statistically significant improvement was observed in the comparison between the pre- and 30-day postoperative VAS and ODI scores, with no significant difference in relation to sex. No peri- or postoperative complications were observed. All patients successfully completed surgery and were discharged after recovery from anesthesia. Conclusion There was a significant improvement in pain and functional status 30 days after percutaneous endoscopic discectomy performed to correct lumbar disc herniation, with no difference in relation to sex. In addition, no peri- or postoperative complications were observed. Future studies, with longer follow-up times, comparing clinical outcomes from the various techniques of percutaneous endoscopic discectomy are necessary. Level of evidence III; Retrospective comparative study.

Clinical, surgical characteristics and long-term outcomes of lumbar hernia

BACKGROUND/AIM

Lumbar hernia is caused by a defect in the abdominal wall. Due to its rarity, there is no established consensus on optimal treatment for lumbar hernia yet. Thus, we here investigated the clinical, surgical characteristics and outcomes of lumbar hernia by collecting 28 such patients from our hospital.

METHODS

Patients diagnosed with lumbar hernia from our institution between April 2011 and August 2020 were retrospectively collected in this study. Demographics, clinical characteristics and surgical information were recorded.

RESULTS

A consecutive series of 28 patients with lumbar hernia were retrospectively collected, including 13 males (46%) and 15 females (54%). The ages of the patients ranged from 5 to 79 years (median: 55 years), with a mean age of 55.6 ± 14.9 years. A total of 7 cases had a history of previous lumbar trauma or surgery. There were 11 (39%), 15 (54%) and 2 (7.1%) cases had right, left and bilateral lumbar hernia, respectively. Superior and inferior lumbar hernia were found in 25 (89%) and 3 (11%) patients. General anesthesia was adopted in 16 cases (group A), whereas 12 patients received local anesthesia (group B). Patients in the group B had a shorter hospital stay than that of the group A (3.5 ± 1.3 days vs. 7.1 ± 3.2 days, p = 0.001), as well as total hospitalization expenses between the two groups (2989 ± 1269 dollars vs. 1299 ± 229 dollars, p < 0.001). With a median follow-up duration of 45.9 months (range: 1-113 months), only 1 (3%) lumbar hernias recurred for the entire cohort.

CONCLUSIONS

Lumbar hernia is a relatively rare entity, and inferior lumbar hernia is rarer. It is feasible to repair lumbar hernia under local anesthesia.

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.

Renal pelvis and ureteropelvic junction incarceration in a Grynfeltt-Lesshaft hernia: a case report and review of the literature

Background

Grynfeltt–Lesshaft hernia is a kind of lumbar abdominal wall hernia in which clinical presentations may vary from an asymptomatic bulge in the lumbar area to a symptomatic lumbar mass with back pain. It has been accepted to be a rare entity, and incarceration of the kidney through this hernia is shown to be very rare, and very few previous cases have been reported in this regard.

We present a case of renal pelvic and ureteropelvic junction incarceration in a Grynfeltt-Lesshaft hernia and provide an overview of the existing literature on it.

Case presentation

A 76-year-old lady presented to the outpatient clinic with the chief complaint of right flank pain and swelling. Computed tomography (CT) scan of the abdomen was revealed a large herniated sac (60*30 mm) in the upper lumbar triangle with protrusion of retroperitoneal and omental fat, right renal pelvis, ureteropelvic junction and proximal ureter with consecutive hydronephrosis. Herniated retroperitoneal and omental fat was reduced, and closure of the abdominal wall defect was done using retro-muscular Mesh and was fixed to the fascia. The patient was discharged 24 h after the surgery without any complications.

Conclusion

Kidney herniation through the lumbar triangle is extremely rare, and the diagnosis requires careful clinical evaluation. CT scan is the modality of choice for the assessment. Management through surgery should be done in symptomatic patients.

Single-incision retroperitoneal laparoscopic repair of superior lumbar hernia using self-fixating ProGrip mesh: A case report

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Superior lumbar hernia is an uncommon hernia.

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We performed single-incision retroperitoneal laparoscopic repair.

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Self-fixating mesh without fixation is useful because of no risk of nerve injury.

Introduction

Lumbar hernia is rare and represents less than 1–2% of all abdominal hernias. There are mainly two types of lumbar hernia: superior lumbar hernia and inferior lumbar hernia.

Case presentation

A 65-year-old woman was admitted complaining of a mass in her left lumbar area. Under a diagnosis of superior lumbar hernia, single-incision laparoscopic retroperitoneal repair was performed. A single, 2-cm-long incision was made and the retroperitoneal space was dissected gradually. The hernia orifice was recognized and hernia sac was slipped from the hernia orifice. The collateral branch of subcostal nerve and iliohypogastric nerve were recognized. Laparoscopic self-fixating mesh was placed to cover the hernia orifice without mesh fixation. The patient remained well with no signs of recurrence.

Discussion

In laparoscopic lumbar hernia repair, it is important to be careful not to damage subcostal nerve and iliohypogastric nerve. Self-fixating mesh without fixation is useful due to the prevention from nerve injury. To our best knowledge, this is the first report of single-incision laparoscopic repair for superior lumbar hernia. Single-incision laparoscopic surgery could provide good cosmetic results with minimal incision.

Conclusion

We successfully performed single-incision retroperitoneal laparoscopic repair of superior lumbar hernia using self-fixating mesh.