Grynfeltt Hernia: A Deceptive Lumbar Mass with a Lipoma-Like Presentation

Laparoscopic Transabdominal Preperitoneal Repair of a Primary Upper Lumbar Hernia: A Case Report

Lumbar hernias are a rare type of hernia, arising through posterolateral abdominal wall defects containing either intraperitoneal or extraperitoneal contents. Most lumbar hernias are primary, incisional, or trauma-related, while congenital lumbar hernias are uncommon. Surgical management comes down to two approaches: the classic repair technique with an open approach utilizing a lumbar incision and the laparoscopic approach, either transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP). We present the case of a 56-year-old female patient who was evaluated in the outpatient surgical clinic, complaining of pain located between the left midaxillary line and the left lumbar region. The patient underwent a CT scan, and a diagnosis of a left upper lumbar hernia was made. The patient underwent a laparoscopic TAPP repair and was discharged on postoperative day one. Our case highlights that lumbar hernias can present with vague symptoms and without an obvious lump/mass, a diagnosis of which could require a great degree of clinical suspicion especially when there is no history of trauma or surgery in the area. Early imaging can confirm the diagnosis, and surgical repair should be conducted to prevent possible complications.

Concurrent Spigelian and Grynfeltt-Lesshaft Hernias

Only 0.12% to 2% of diagnosed hernias are Spigelian type. Even less frequently encountered-Grynfeltt-Lesshaft hernias-hernias have unknown incidence. A Spigelian hernia is encountered along the Spigelian fascia and Grynfeltt-Lesshaft hernias are bounded by the superior lumbar triangle. These unique hernias can both be intermuscular, given their anatomical borders which allow concealment and preclusion of accurate diagnosis. Here, an 86-year-old male presented with symptoms consistent with small bowel obstruction. On physical exam, a right lower quadrant hernia and right posterior flank mass were appreciated. Computed tomography revealed obstruction secondary to bowel incarceration within Spigelian hernia and additional Grynfeltt-Lesshaft hernia. The patient underwent reduction and repair of Spigelian hernia with synthetic mesh, while repair of asymptomatic hernia was deferred. These unusual hernias are difficult to distinguish, given their negligible occurrence and unreliable exam findings. Clinicians must remain cognizant of their features to aid in diagnosis and mitigate potential sequelae.

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.

Primary Grynfeltt's hernia combined with intermuscular lipoma: A case report

INTRODUCTION

Grynfeltt's hernia (superior lumbar hernia) is a rare posterolateral abdominal wall defect and is often misdiagnosed as an abdominal wall lipoma. I recently experienced a case of primary Grynfeltt's hernia combined with intermuscular lipoma that was managed surgically.

PRESENTATION OF CASE

A 79-year-old man presented with a left flank mass. In the seated position, when the abdominal pressure was raised by deep breathing after left flank extension, the mass became clearer. Abdominal computed tomography (CT) findings showed herniated perirenal fat via the superior lumbar triangle and a surrounding intermuscular lipoma. After intermuscular lipoma removal, the hernia defect was closed with primary simple interrupted sutures. Currently, at 5 months postoperatively, no recurrence has been observed.

DISCUSSION

On physical examination of Grynfeltt's hernia, it may be difficult to identify the distinct mass because of the relatively large overlaying of the latissimus dorsi muscle. Thus, Grynfeltt's hernia can be misdiagnosed as soft tissue tumors, such as lipomas. Abdominal CT findings may provide an accurate diagnosis and reveal the anatomical structures and additional lesions. Proper surgical treatment should be planned based on the etiology, size of the hernia defect, condition of the surrounding structures, and presence of additional lesions.

CONCLUSION

Grynfeltt's hernia should be considered when a mass is palpable on the posterolateral abdominal wall and in cases where the size of the mass changes when changing position. CT examination of the abdomen may help make an accurate diagnosis, observe additional lesions, and develop a surgical-treatment plan.

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.

Sublay repair for primary superior lumbar hernia with the Kugel patch

Background

A superior lumbar hernia is a posterior ventral hernia that is rarely encountered in the clinical setting. However, no standard operative strategy exists for superior lumbar hernia repair at present.

Methods

Twelve patients with primary superior lumbar hernia who underwent sublay repair via the retroperitoneal space with the Kugel patch between December 2008 and June 2019 were included in this study. The demographic, peri‐operative and post‐operative data of the patients were collected to analyse the effectiveness of this technique.

Results

All patients underwent an uneventful operation. The median operative time was 60 min, and the median blood loss was 35 mL. The median hernia defect area was 16 cm². Five medium‐sized Kugel patches (11 cm × 14 cm) and seven large‐sized Kugel patches (14 cm × 17 cm) were used for the repairs. The median visual analogue scale score on post‐operative day 1 was 3. The median time to removal of drainage was 3 days. The median duration of the hospital stay was 3 days. No serious post‐operative complications, including seroma, haematoma, incision or mesh infection, recurrence and chronic pain, occurred during the follow‐up period.

Conclusion

Sublay repair for primary superior lumbar hernia with the Kugel patch shows benefits including a reliable repair, minimal invasiveness and few post‐operative complications.

Incarcerated Lumbar Hernia Complicated by Retroperitoneal Pseudoaneurysm 50 Years after Resection and Radiation Therapy of a Sarcoma

Background

Lumbar hernias are rare abdominal hernias. Surgery is the only treatment option but remains challenging. Posterior incisional hernias are even rarer especially with incarceration of intra-abdominal contents.

Case Presentation

A 68-year old female presented with a 3-day history of worsening acute abdominal pain and distension, with multiple episodes of emesis. A CT scan indicated a large incarcerated posterolateral abdominal hernia. The patient had a history of resection of a sarcoma on her back as a child and also received chemotherapy and radiation. During emergency laparoscopy, a hemorrhagic small bowel segment incarcerated in the hernia was reduced and resected, and the distended small bowel was decompressed. An elective hernia repair was scheduled. After temporary clinical improvement, the patient again developed abdominal pain, distention, and emesis. During emergency laparotomy, a large hematoma in the right flank was found and partially evacuated. The right colon was mobilized out of the hernia and the duodenum was kocherized. A 20 × 20 cm BIO-A mesh was placed on top of the Gerota fascia and cranially tucked under liver segment VI. Anteriorly, the mesh was fixated with absorbable tacks. The duodenum and colon were placed into the mesh pocket. A postoperative CT scan identified a 2 cm pseudoaneurysm of a side branch of a lumbar artery, and the bleeding source was embolized. The postoperative course was complicated by Clostridium difficile-associated colitis, but ultimately, the patient recovered fully. At 6-month follow-up, there was no evidence for a recurrent hernia.

Discussion

There is a paucity of literature concerning lumbar incisional hernias. Repair with bioabsorbable mesh seems feasible, but longer follow-up is necessary as the mesh was placed in an unusual fashion due to the retroperitoneal hematoma. The exact cause of the hemorrhage is unclear and may have been caused during the initial incarceration, during surgery, or may be a late complication of her previous radiation.

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

PURPOSE

The lumbar abdominal wall hernia is a rare hernia in which abdominal contents protrude through a defect in the dorsal abdominal wall, which can be of iatrogenic, congenital, or traumatic origin. Two anatomical locations are known: the superior and the inferior lumbar triangle. The aim of this systematic review is to provide a clear overview of the existing literature and make practical clinical recommendations for proper diagnosis and treatment of the primary lumbar hernia.

METHODS

The systematic review was conducted according to the PRISMA guidelines. A systematic search in PubMed, MEDLINE, and EMBASE was performed, and all studies reporting on primary lumbar hernias were included. No exclusion based on study design was performed. Data regarding incarceration, recurrence, complications, and surgical management were extracted.

RESULTS

Out of 670 eligible articles, 14 were included and additional single case reports were analysed separately. The average quality of the included articles was 4.7 on the MINORS index (0-16). Risk factors are related to increased intra-abdominal pressure. CT scanning should be performed during pre-operative workup. Available evidence favours laparoscopic mesh reinforcement, saving open repair for larger defects. Incarceration was observed in 30.8% of the cases and 2.0% had a recurrence after surgical repair. Hematomas and seromas are common complications, but surgical site infections are relatively rare.

CONCLUSION

The high risks of incarceration in lumbar hernias demand a relatively fast elective repair. The use of a mesh is recommended, but the surgical approach should be tailored to individual patient characteristics and risk factors.

Primary Jean Louis Petit and Grynfeltt-Lesshaft concomitant hernias: A case report

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Primary lumbar hernia.

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Concomitant lumbar hernias : Jean Louis Petit and Grynfeltt-Lesshaft.

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Misdiagnosis hernia.

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Surgical approach.

Introduction

Posterior abdominal wall hernias are rare, mainly post traumatic or post-operative. This case is particular first by its mechanism, it is a primary lumbar hernia and secondly it is a concomitant hernia of the Jean Louis Petit triangle and the Grynfeltt triangle.

Presentation of case

The patient was a 67 years old man, a former farmer. He complaint of a painful tumefaction on his back evolving for the last 2 years. After clinical examination, a diagnosis of lumbar hernia was retained. The CT scan which is the gold standard was not performed due to financial limitations. An hernioplasty with a porcine collagen mesh was done, in per operative we found a Jean Louis Petit hernia and a Grynfeltt-Lesshaft hernia. Any post-operative complications.

Discussion

Lumbar hernia is not a common diagnosis, and most of time is misdiagnosed. Acquired primary lumbar hernia can be due to profession involving lumbar constraints leading to the weakness of muscles. This was the case of our patient. Another particularity was the double hernia, the upper and lower lumbar triangles. We already know the impact of his profession and may be 20 years of this leaded to the double hernia? An hernioplasty in open surgery was proposed for multiples reasons: the age of the patient, the weakness of the muscle, a large exploration of the hernia, to reinforce the posterior lumbar wall and to prevent a recidivism.

Conclusion

Jean Louis Petit and Grynfeltt-Lesshaft hernias are very uncommon. Few cases have been reported.

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

Grynfeltt-Leschaft hernia is a type of lumbar hernia occurring in the superior lumbar triangle. Because of its rarity and non-specific presentation, lumbar hernia often poses a diagnostic challenge, and it can be easily misdiagnosed as a lipoma. If the correct diagnosis is missed, there is a significant risk of complications including hernia incarceration or strangulation. Here, we present a case of Grynfeltt-Lesshaft hernia which was repeatedly misdiagnosed as a lipoma and presented acutely with large bowel obstruction. A definite diagnosis was made by a computed tomography scan and the patient had emergency laparotomy and successful mesh repair of the hernia defect.