Laparoscopic retroperitoneal repair of recurrent postoperative lumbar hernia

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

BACKGROUND

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

CASE PRESENTATION

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

CONCLUSIONS

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

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.

Superior lumbar hernia after gastrectomy repaired via an open approach in the prone position: A case report

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Lumbar hernia is a rare hernia occurring in the posterolateral abdominal wall and

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suitable for laparoscopic hernioplasty.

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Intraabdominal approach is sometimes difficult for superior lumber hernia after gastrectomy with expected visceral adhesions.

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Open hernioplasty with underlay mesh in prone position is an optional approach to avoid internal visceral adhesion.

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Mesh must be set between Zuckerkandl’s fascia and internal oblique to avoid prolapse of abdominal and retroperitoneal organs.

Introduction

Lumbar hernia is a rare hernia in the posterolateral abdominal wall and only about 310 cases are known to have been reported to date. Laparoscopic hernioplasty is a common surgical approach but is unsuitable for patients who have previously undergone laparotomy and are expected to have extensive visceral adhesions.

Presentation of Case

An 84-year-old woman who had undergone an open distal gastrectomy was referred to our hospital with an enlarging but easily reducible bulge in the right upper back. On computed tomography, the hernial orifice was located in the lateral side of the right quadratus lumborum under the costal arch. The bulge was diagnosed as a superior lumbar hernia. We performed an open hernioplasty in the prone position to avoid internal visceral adhesions. The hernia sac was detected in the latissimus dorsi in the back, and was found to contain the ileocecum, which was rigidly adherent to the sac. Hernioplasty was performed by inserting polypropylene mesh between Zuckerkandl’s fascia and the internal oblique.

Discussion

Mechanical ileus after open distal gastrectomy is common complication and sometimes position was simple procedure without the influence of visceral adhesion and easily reinforced by underlay mesh.

Conclusions

Open hernioplasty in the prone position using a mesh underlay is an optional approach in a patient with a superior lumbar hernia after gastrectomy.

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.

Laparoscopic mesh repair for lumbar hernia after iliac crest bone harvest

Lumbar hernia after iliac crest bone harvest is relatively rare. When it does occur, it presents as a flank abdominal protrusion through a lateroposterior abdominal wall defect. A laparoscopic approach for this type of hernia is reported to have advantages over the classic open method. Here, we present a case of a 49-year-old Caucasian man who presented with an enlarged left flank mass after iliac bone harvest for pseudarthrosis. He had undergone open onlay mesh repair for inferior lumbar hernia, but the hernia recurred 3 months postoperatively. Laparoscopic intraperitoneal onlay mesh repair using a composite mesh was performed 7 months after recurrence. The patient was discharged 6 days postoperatively without complications. No signs of recurrence were detected during 1-year follow-up period. The laparoscopic approach for lumbar hernia conferred excellent visualization of the hernia defect and enabled a safe mesh repair using intra-abdominal pressure to hold it in position. This approach provided all the benefits of minimally invasive surgery.

Iliac Crest Herniation Secondary to Autogenous Bone Grafting Found on Osteopathic Examination

Surgical repair of difficult or nonunion fractures is frequently performed with autogenous bone grafts, most commonly from the iliac crest. Complications from this procedure may include vessel injury, nerve injury, pelvic instability, bowel herniation, and ileus. The authors report a case of iliac crest herniation in a patient presenting with a small-bowel obstruction 2 years after anterior iliac crest graft harvest for an open reduction and internal fixation repair of a right humeral shaft fracture. An emergency operation revealed that the right colon had herniated through an opening in the right iliac crest. The appendix had adhered to new osseous bone formed postoperatively, requiring an appendectomy. The hernia defect was successfully repaired with polypropylene mesh. A high index of suspicion for graft site herniation is needed for patients with a history of iliac crest bone grafting who present with symptoms of abdominal pain, flank or hip pain, ileus, or small-bowel obstruction.

Case report and review of lumbar hernia

Lumbar hernias are uncommon and about 300 cases have been reported till date. They commonly occur due to trauma, surgery and infection. They are increasingly being reported after motor vehicle collision injuries. However, spontaneous lumbar hernias are rare and are reported infrequently. It is treated with different surgical approaches and methods. We report a case of primary spontaneous lumbar hernia which was repaired by transperitonial laparoscopic approach using Vypro (polypropylene/polyglactin) mesh and covered with a peritoneal flap.

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.

Small bowel obstruction caused by an incarcerated hernia after iliac crest bone harvest

The iliac crest has become an often used site for autogenous bone graft, because of the easy access it affords. One of the less common complications that can occur after removal is a graft-site hernia. It was first reported in 1945 (see the work by Oldfield, 1945). We report a case of iliac crest bone hernia in a 53-year-old male who was admitted for elective resection of a pseudarthrosis and reconstruction of the left femur with iliac crest bone from the right side. One and a half months after initial surgery, the patient presented with increasing abdominal pain and signs of bowel obstruction. A CT scan of the abdominal cavity showed an obstruction of the small bowel caused by the bone defect of the right iliac crest. A laparoscopy showed a herniation of the small bowel. Due to collateral vessels of the peritoneum caused by portal hypertension, an IPOM (intraperitoneal onlay-mesh) occlusion could not be performed. We performed a conventional ventral hernia repair with an onlay mesh. The recovery was uneventful.

Laparoscopic total extraperitoneal repair of lumbar hernia

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

Laparoscopic repair of left lumbar hernia after laparoscopic left nephrectomy

Laparoscopic transabdominal preperitoneal repair of a lumber hernia after laparoscopic retroperitoneal surgery can be performed safely with minimum postoperative pain.

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.

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.

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.

Laparoscopic hernia repair following iliac crest harvest

The repair of hernias through iliac crest defects is challenging secondary to the inherent weakness of the abdominal musculature and the rigidity of the pelvis. The defect is surrounded by inadequate tissue to properly buttress the repair. Full-thickness tricortical bone harvested from the iliac may result in an incisional hernia through the bony defect. Options for repair include using the aponeurosis of the gluteus muscle, prosthetic material, or straightening the iliac crest. We report two patients who had their defects repaired laparoscopically using polytetrafluoroethylene (PTFE) mesh. Two patients with hernias following full-thickness iliac crest bone harvest presented secondary to increasing pain and size of their hernias. Both defects were repaired laparoscopically using spiral tacks laterally, medially, and superiorly, and with an intracorporeal stitch inferiorly at the iliac crest to secure the mesh. The two defects averaged 24.5 cm(2) in size and were repaired with PTFE mesh. For adequate visualization, the cecum was mobilized and the mesh repair overlapped the defects by a 4-cm margin. Both patients were discharged after 2.5 days. There were no infectious or neurologic complications, and neither patient has recurred. The laparoscopic approach to the repair of hernias resulting from tricortical iliac crest bone harvest is safe and may be preferable to open repair. Advantages include durable repair, better interoperative visualization, and reduced post-operative pain, morbidity, and hospital stay.

Laparoscopic incisional lumbar hernia repair

PURPOSE

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

METHODS

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

RESULT

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

CONCLUSIONS

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

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.

Laparoscopic hernioplasty in secondary lumbar hernias

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Lumbar Hernia Repaired Using a New Technique

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

Traumatic lumbar hernia: report of cases and comprehensive review of the literature

BACKGROUND

Acute lumbar hernia secondary to blunt trauma is an uncommon injury of the abdominal wall and, when encountered, is a difficult challenge for the trauma surgeon.

METHODS

Three cases of lumbar hernia secondary to blunt trauma are described and a review of the literature was conducted for other such cases. Clinical, anatomic, and demographic data were extracted from these reports and analyzed.

RESULTS

Sixty-three cases of lumbar hernia secondary to blunt trauma were found in the English literature and three cases are described here. Hernias occurred most commonly in the inferior lumbar triangle (70%) and were most frequently a result of a motor vehicle collision (71%). Physical examination findings were variable and reported in only a minority of cases (palpable hernia, 33%; flank hematoma, 27%) and associated intra-abdominal injuries were common (61%). Most traumatic lumbar hernias were diagnosed immediately, and computed tomography was 98% sensitive for diagnosis. Fifty-eight percent of patients were managed initially with exploratory laparotomy. Timing of hernia repair was variable.

CONCLUSION

Traumatic lumbar hernias are associated with a high incidence of intra-abdominal injury and should be considered in all cases of severe blunt abdominal trauma. Computed tomography should be implemented when the diagnosis is suspected in a hemodynamically stable patient. Repair should be performed by mesh patching techniques at a time based on clinical correlation.

Laparoscopic Lumbar Hernia Repair

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

A novel technique of lumbar hernia repair using bone anchor fixation

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

A novel technique for the repair of lumbar hernias after iliac crest bone harvest

BACKGROUND

Lumbar hernia is a clinical entity that has been increasingly more common since the advent of iliac bone harvest for bone grafting procedures. These can be very technically difficult to repair and have a high recurrence rate.

METHODS

Using a corkscrew anchor suture device, we have developed a novel and simple way to repair these hernias with no recurrence. Here we present our experience with the corkscrew suture anchor device.

RESULTS

This technique has been performed in 2 patients at our institution, and in both cases, the hernia was successfully repaired. Our 1-year follow-up on this technique demonstrates intact repairs with no sign of recurrence.

CONCLUSIONS

The placement of corkscrew suture anchors along the iliac crest remnant is a simple technique requiring minimal bony exposure. The anchors facilitate the long-term fixation of mesh despite the lack of fascia in this area. We conclude that this is a simple and effective approach for repair of these challenging hernias.

Laparoscopic tension-free hernioplasty for lumbar hernia

Lumbar hernia, a defect of the posterior abdominal wall, is a very rare condition. The repair of a posterior abdominal wall hernia by simply closing the hernia port with sutures may not be adequate, especially when the herniation is due to a weakness in the abdominal wall. Recently, a simple, logical method of tension-free repair has become a popular means for the treatment of various abdominal wall hernias. Previous studies have advocated the use of tension-free repair for lumbar hernia; the technique uses a mesh replacement and requires an extensive incision. Herein we present a case of superior lumbar hernia. Our technique consisted of a laparoscopic tension-free hernioplasty with the application of a Prolene mesh. This technique, which provides an excellent operative view, is safe, feasible, and minimally invasive. We conclude that laparoscopic tension-free repair should be the preferred option for the treatment of lumbar hernia.

Retroperitoneoscopic tension-free repair of lumbar hernia

Lumbar hernia is an infrequent pathology that is difficult to treat through open surgery. A 65-year-old man presented with a right-sided lumbar mass responsible for pain. This was a fatty mass of 10 x 15 cm, located in the lumbar fossa. A CT scan showed the hernia and the defect. Through a small incision in the flank, dissection was initiated with one finger; a 10-mm trocar was inserted into this incision and the retroperitoneal space inflated. Under direct vision, dissection of retroperitoneal fat was undertaken with the scope. A 5-mm trocar was inserted beyond the 11th rib. Fat in the lumbar hernia was reintegrated into the retroperitoneal space, allowing the lumbar wall defect to be seen. A polypropylene mesh was applied and stapled onto the lumbar wall to widely cover the defect. Under trans-abdominoretroperitoneal laparoscopy, lateral peritoneum, colon, and ureter are detached to explore the lumbar wall and are reinserted at the end of the procedure. Under retroperitoneoscopy, even if the space is small, retroperitoneal fat is easily detached at a distance from the colon and ureter. The defect is covered with a polypropylene mesh. It is covered with an ePTFE mesh if the retroperitoneal space cannot be closed. Surgery and follow-up were uneventful with no recurrence in this case or in the published cases. Retroperitoneoscopy and trans-abdominoretroperitoneal laparoscopy are two easy approaches for a tension-free repair of lumbar hernia.

Totally extraperitoneal laparoendoscopic repair of lumbar hernia

BACKGROUND

The repair of congenital and acquired lumbar hernias has remained a significant surgical challenge for over three centuries. Transperitoneal laparoendoscopic techniques have been reported that have achieved success in repairing these difficult hernias using a variety of synthetic mesh. Careful review of the surgical literature addressing the repair of lumbar hernia reveals that only fourteen successful cases have been reported using minimally invasive techniques. All of these cases elected a transperitonal approach to repair. Encouraged by established success in the repair of inguinal hernia using an extraperitoneal approach, the repair of a large inferior triangle lumbar hernia was attempted using overlapping synthetic mesh technique while remaining entirely in an extraperitoneal plane.

METHODS

A seventy-eight-year-old patient presented for repair of a large symptomatic right lumbar hernia, one year following iliac bone harvest for lumbar laminectomy/fusion. Under general anesthesia, the patient was placed in a lateral decubitus position with lumbar roll in place. Using a muscle splitting dissection through the lateral abdominal musculature, a plane was developed bluntly between the transversalus muscle and the peritoneum. Using a three trocar technique, the plane was matured posteriorly, achieving an ample working space to identify the hernia and complete a synthetic mesh (PTFE) repair.

RESULTS

A large inferior triangle lumbar hernia was successfully repaired using overlapping synthetic mesh technique while remaining entirely in an extraperitoneal plane. Eighteen month reevaluation including physical examination and computer tomographic (CT) study confirms successful repair without recurrence of symptoms.

CONCLUSIONS

A totally extraperitoneal approach to the identification, mobilization, and repair of lumbar hernia can be successfully accomplished using established laparoendoscopic surgical techniques.

[Retroperitoneoscopy in tension-free repair of lumbar hernia in adults]

A 65 year-old-patient who had a right-side 10 x 15 cm wide lumbar hernia, with a 3 x 4 cm wide parietal defect was operated in a left lateral position, under retroperitoneoscopy. The procedure consisted in dissection of the retroperitoneal fat, reduction of the hernia and insertion of a polypropylene mesh stapled on the lumbar wall. This approach provided a good postoperative comfort, a short hospital stay and an early recovery of autonomy and activities.

[Colon hernia through a defect in the iliac crest after bone graft harvesting]

A case of a patient with an hernia through a defect in the iliac crest after bone graft harvesting is described. The osseous defect provides a rigid ring against which repeated sudden elevations in abdominal pressure can result in disruption of soft tissue and herniation of abdominal contents. Standard plain radiographs and barium studies are of limited interest and may even be misleading in diagnosing the herniation. Findings on computed tomography led to detection of this abnormality, and should be the first line exam in these cases.