Lumbar hernia: A commonly misevaluated condition of the bilateral costoiliac spaces

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.

A rare case of renal eventration in a domestic cat

This case report discusses a unique case of renal eventration in a cat resulting from a lumbar hernia possibly of traumatic origin. A two-year-old indoor/outdoor male neutered domestic shorthair was evaluated for a rapidly growing mass noted in the right lumbar region. Initial physical examination revealed a firm, circular and slightly mobile mass in the lumbar region, along with pain and tenderness on palpation. Abdominal ultrasound revealed muscle discontinuity in the lumbar region consistent with a hernia, with eventration of the right kidney possibly caused by abdominal trauma. A paralumbar celiotomy was performed over the area of increased volume, revealing the right kidney with a hematoma on its surface and partial rupture of the renal capsule. The muscular defect was identified, and the kidney replaced in its anatomical location. The patient recovered quickly and was discharged from hospital 46 h later, with no reported complications. Recheck 2 months post-operatively confirmed unremarkable biochemical assessment (creatinine, urea and USG within normal limits) and abdominal ultrasound findings, and 2 years post procedure the patient remained clinically well. This unusual case emphasizes the importance of including renal eventration in the differential diagnosis for acutely presenting masses in the lumbar region of cats.

The morphology of the lumbar vertebrae: a systematic review with meta-analysis of 1481 individuals with implications for spine surgery

INTRODUCTION

The aim of the present meta-analysis was to provide the most up-to-date and evidence-based results regarding the morphometric properties of the lumbar vertebrae.

METHODS

Medical databases such as PubMed, Scopus, Embase, Web of Science, Google Scholar, and Cochrane Library were searched through.

RESULTS

The results of this meta-analysis were established based on a total of 1481 patients. New results were established in 27 categories for each lumbar vertebra separately. The findings from this study reveal that the width of the spinal canal progressively increases towards the lower end of the lumbar spine (L1 = 22.04 mm, L5 = 26.46 mm). Additionally, the transverse processes exhibit a similar trend, widening as they approach the lower lumbar vertebrae (L1 = 68.08 mm, L5 = 85.91 mm). The pedicle height decreased from L1 to L4, with an increase observed at L5 (14.73 mm). No significant differences were observed between the measurements of the left and right pedicles.

CONCLUSION

The presented results provide physicians with normative morphometric data on the lumbar vertebrae. Having adequate knowledge of the anatomy of the lumbar vertebrae may be of immense use for surgeons performing various spinal surgeries, such as pedicle screw fixation, percutaneous endoscopic transforaminal discectomy, or lumbar disc replacement.

A Rare Co-occurrence of Lumbo-Costo-Vertebral Syndrome With Congenital Lumbar Hernia in a Six-Year-Old Child

Lumbo-costo-vertebral syndrome (LCVS) is a very rare congenital disorder seen in children. It is characterized by a congenital absence of ribs, vertebral anomalies, scoliosis, meningocele, and hypoplastic abdominal wall muscles presenting as abdominal wall hernia. We present a case of a six-year-old Indian female who came with complaints of swelling in the left lumbar region since birth, which was evident in coughing and scoliosis. On auscultation, bowel sounds were heard over the swelling. Physical examination revealed a left lumbar hernia and scoliosis. Abdominal X-rays revealed the absence of the 12th rib on the left side and vertebral anomalies with kyphoscoliosis. Abdominal ultrasonography (USG) showed a left lumbar hernia with bowel loops as its content. Computed tomography (CT) was done, which confirmed the X-ray and USG findings. Based on clinical and radiological findings, a diagnosis of LCVS associated with congenital lumbar hernia (CLH) was made. The patient was then referred to the surgery department for further management. This case illustrates a unique link between two extremely rare conditions and emphasizes the necessity of thorough clinical and radiological evaluation in suspected patients for early diagnosis and treatment.

Blunt Traumatic Abdominal Wall Hernias: An Indicator for Emergent Laparotomy?

BACKGROUND

Traumatic abdominal wall hernias (TAWH) are relatively uncommon; however, the shearing force that results in fascial disruption could indicate an increased risk of visceral injury. The aim of our study was to evaluate whether the presence of a TAWH was associated with intra-abdominal injury requiring emergent laparotomy.

METHODS

The trauma registry was queried over an 8-year period (7/2012-7/2020) for adult patients with blunt thoracoabdominal trauma diagnosed with a TAWH. Those patients who were identified with a TAWH and greater than 15 years of age were included in the study. Demographics, mechanism of injury, ISS, BMI, length of stay, TAWH size, type of TAWH repair, and outcomes were analyzed.

RESULTS

Overall, 38,749 trauma patients were admitted over the study period, of which 64 (.17%) had a TAWH. Patients were commonly male (n = 42, 65.6%); the median age was 39 years (range 16-79 years) and a mean ISS of 21. Twenty-eight percent had a clinical seatbelt sign. Twenty-seven (42.2%) went emergently to the operating room, the majority for perforated viscus requiring bowel resection (n = 16, 25.0%), and 6 patients (9.4%) who were initially managed nonoperatively underwent delayed laparotomy. Average ventilator days was 14 days, with a mean ICU LOS of 14 days and mean hospital LOS of 18 days. About half of the hernias were repaired at the index operation, 6 of which were repaired primarily and 10 with mesh.

CONCLUSION

The presence of a TAWH alone was an indication for immediate laparotomy to evaluate for intra-abdominal injury. In the absence of other indications for exploration, nonoperative management may be safe.

Primary Superior Lumbar Hernia with Nephrotic-range Orthostatic Proteinuria

Lumbar hernias are extremely rare. The posterolateral abdominal wall has two susceptible areas - the superior (Grynfeltt-Lesshaft's triangle) and the inferior (Petit's triangle) lumbar triangles - that cause superior and inferior lumbar hernias, respectively. We herein report a 67-year-old woman with nephrotic-range proteinuria caused by primary superior lumbar hernia. Superior lumbar hernias should be considered as a differential disease causing massive orthostatic proteinuria in adults. The present case highlights the importance of considering lumbar hernia in patients with flank swelling and the potential complications that may result from a missed diagnosis.

Dual repair of traumatic flank hernia using laparoscopic and open approaches: a case report

Traumatic flank hernia (TFH) is rare and prone to recurrence, which makes appropriate treatment challenging. No current guidelines define the optimal timing and method of repair. Meanwhile, recent advances in laparoscopic techniques are reshaping the options for the treatment of TFH. A dual approach that utilizes both laparoscopic and open methods has not previously been reported. Herein, we present the successful treatment of TFH after blunt trauma. A 46-year-old male patient underwent elective herniorrhaphy on hospital day 3, in which laparoscopic implantation of a sublay mesh and extracorporeal implantation of an onlay mesh were performed. Such techniques may be appropriate and result in feasible outcomes in hemodynamically stable patients with large TFH who are strongly suspected of having bowel herniation or concomitant intraperitoneal injuries. Larger studies are needed to assess the long-term results.

Bilateral Lumbar Hernias Following Spine Surgery: A Case Report and Laparoscopic Transabdominal Repair

Lumbar hernias are rare abdominal wall defects. Fewer than 400 cases have been reported in the literature and account for 2% of all abdominal wall hernias. Lumbar hernias are divided into Grynfelt-Lesshaft or Petit hernias. The former are hernia defects through the superior lumbar triangle, while the latter are defects of the inferior lumbar triangle. Primary lumbar hernias are further subdivided into congenital or acquired hernias and can further be classified as either primary or secondary. Secondary hernias occur after previous flank surgeries, iatrogenic muscular disruption, infection, or trauma. We review a rare presentation of metachronous symptomatic bilateral secondary acquired lumbar hernia following spine surgery. A successful laparoscopic transabdominal lumbar hernia repair with extraperitoneal mesh placement was performed, with resolution of the hernia symptoms. An extensive literature review regarding lumbar hernia and different types of repairs was performed.

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.

Management of incidental lumboiliac hernia during spinal cord stimulator implant: a case report

Lumboiliac or lumbar hernia is a rare defect in the posterolateral abdominal wall that may be inadvertently misidentified and interfere with the implantable pulse generator (IPG) portion of spinal cord stimulator (SCS) implants. We report the case of a 54-year-old Caucasian man with an incidental finding of a lumboiliac hernia in the inferior lumbar triangle of Petit with placement of an IPG in a SCS implant. With the assistance of surgical colleagues, the correct diagnosis was made intraoperatively. We describe the operative repair of the lumboiliac hernia with a synthetic mesh. A new IPG pocket was created above the mesh prior to proceeding with IPG placement. No recurrence of the hernia defect was observed on 2-month follow-up. It is important that pain physicians and neurosurgeons who perform SCS implants are aware of lumboiliac hernias to avoid potential diagnostic or management errors. Lumboiliac hernias should be included on the differential diagnosis of lumbar or flank masses. Confirmation with imaging may be necessary and definitive surgical treatment should be pursued.