Grynfeltt-Lesshaft lumbar hernia: a rare cause of bowel obstruction misdiagnosed as a lipoma

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.

The role of ultrasound in the diagnosis of Grynfeltt-Lesshaft lumbar hernia: A case report

Grynfeltt-Lesshaft hernia is a type of lumbar hernia located in the superior lumbar triangle. Lumbar hernias are rare hernias. Clinical diagnosis of lumbar hernias can be a challenging especially in obese or asymptomatic patients. Lumbar hernias have been frequently misdiagnosed and lead to serious complications. Surgery (open or laparoscopic) is recommended to correct the defect and to avoid the exacerbation of the hernia and associated complications. The majority of the reported cases in the past were diagnosed on a CT scan. This study presents a case of successful detection of a Grynfeltt-Lesshaft hernia by US scan then confirmed by a subsequent CT scan. The aim of this case report was to Increase knowledge of lumbar hernias and to demonstrate the role of US in the diagnosis of lumbar hernias.

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.

Primary superior lumbar hernia: a rare cause of lumbar swelling

BACKGROUND

Superior lumbar hernia is a rare posterolateral abdominal wall defect and herniation of abdominal contents through the superior lumbar triangle. A lumbar hernia is an unusual defect and only 300 cases of primary lumbar hernias have been reported since the first case report in 1731. To date, most clinicians are usually unfamiliar with the presentation of lumbar hernias, and the diagnosis is often done in a wrong way.

CASE REPORT

A 55-year-old female patient presented with complaints of right flank pain and swelling on the right lumbar region. On abdominal examination, there was round protruding swelling immediately beneath the 12th rib of the right upper flank area. The swelling was palpable and bowel sound was heard over it. The swelling was easily reducible and protruded when the patient was coughing or straining. The opposite side of the lumbar region was normal, and chest examination was clear and normal. The hematological and urine analysis laboratory findings were normal.

DISCUSSION

The ultrasound finding revealed the bowel contents within the hernial sac. With the diagnosis of primary acquired superior lumbar hernia, the patient underwent open surgery. The defect was reduced back and repaired using a retro-muscular or sublay prolene mesh (15 cm by 7.5 cm). The patient was discharged at post-operative day four and followed-up for four months.

CONCLUSION

In conclusion, the diagnosis of lumbar hernias should be considered in all patients presented with complaints of flank pain and swelling in the flank area. In the absence of obvious swelling in the flank region, ultrasound investigation might not establish the diagnosis of lumbar hernias. Hence, ultrasound would be the option to confirm the diagnosis when the swelling is palpable.

A primary inferior lumbar hernia misdiagnosed as a lipoma

Lumbar hernias can be superior (Grynfelt) and inferior (Petit). Inferior lumbar hernias are extremely rare and, therefore, are associated with diagnostic difficulty. We present a case of a primary spontaneous inferior lumbar hernia in a 79-year-old woman that was initially diagnosed as a large lipoma on ultrasound. The first operation was abandoned and an open mesh repair was conducted. Lumbar hernias can be primary acquired (55%), secondary acquired (25%) or congenital (20%). Cross-sectional imaging by CT or MRI appears to be the gold standard in diagnosis as ultrasound may lead to misdiagnosis. Strangulation, incarceration and obstruction are recognised complications, requiring prompt surgical intervention. There are currently no guidelines for surgical managements, although laparoscopic surgery may give the best results. In view of the scarcity of published cases, we aim to add to the literature to raise the index of suspicion and to promote prompt surgical management of lumbar hernias.