Laparoscopic transabdominal extraperitoneal repair of lumbar hernia

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.

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.

Grynfeltt hernia repair using a Kugel patch

PURPOSE

To introduce a surgical technique for repairing Grynfeltt hernia using a Bard Kugel patch mesh.

METHOD

After incision and dissection, hernia was found behind the latissimus dorsi muscle. The retroperitoneal fat or sac was isolated from surrounding tissues and the retro muscular preperitoneal space was developed using blunt dissection at least 5 cm beyond the margins of defect in all directions. A proper size Kugel patch was placed into the place at least 3 cm beyond the muscular or rib edges. The defect was reduced and the mesh was fixed by interrupted sutures. Then the fibers of the latissimus dorsi muscle were reapproximated by loose absorbable suture. The skin was closed by continuous absorbable suture without any drainage.

RESULTS

The patients had a mean hospital stay of 3.22 days. The follow-up ranged from 4 months to 2 years and there were no recurrences or any other significant postoperative complications.

CONCLUSION

Repairing Grynfeltt hernias using a Kugel patch can be successfully performed with the posterior approach. This method of repair is easy, safe, and effective.

Preperitoneal onlay mesh repair for ventral abdominal wall and incisional hernia: a novel technique

INTRODUCTION

Intraperitoneal onlay mesh repair is a current technique for laparoscopic repair of ventral and incisional hernias. However, the placement of synthetic mesh intraperitoneally may potentially lead to mesh-induced complications such as adhesive intestinal obstruction, enterocutaneous fistula, or even mesh erosion into organs. Inspired by the concept of laparoscopic inguinal hernia repair, we developed a novel technique: preperitoneal onlay mesh repair (PPOM). This involves placing the mesh in the preperitoneal plane to help eliminate mesh-induced complications.

MATERIAL AND SURGICAL TECHNIQUE

Our first case of PPOM was performed on a 54-year-old woman who developed a complex incisional hernia after multiple abdominal operations. The total size of the hernia defect was 8 × 13 cm. The peritoneal flap was carefully created with synthetic mesh placed on the preperitoneal plane, and then it was completely closed with sutures. The patient had an uneventful recovery except for a small seroma.

DISCUSSION

We herein report the first case of incisional hernia successfully treated by this novel technique, PPOM. We explain the reasons to perform PPOM, the advantages it offers, and why we named this novel technique "PPOM."

Implementation of the trans-abdominal partial extra-peritoneal (TAPE) technique in laparoscopic lumbar hernia repair

Background

There is still not any standardized operative strategy that is well-accepted all over the world for lumbarhernia. We are here to investigate the feasibility of the trans-abdominal partial extra-peritoneal (TAPE) technique in lumbar hernia repair.

Methods

The TAPE technique was applied to 14 patients with lumbar hernia from May 2009 until January 2014. The surgical technique was described in details and follow-ups were performed for further evaluation.

Results

The mean age of the 14 patients was 68 ± 8 years, with the average BMI 25.5 ± 2.1 kg/m². The etiology study showed that 13 cases after surgical operations and one case after trauma. The average size of the hernia defect was 86.8 ± 46.4 cm², while the mean size of the mesh implanted was 275 ± 61.2 cm². The mean operative time was 59.2 ± 8.2 min. There was no intra-operative visceral injury in this serial of cases. There was no conversion case and all patients accepted the TAPE technique successfully. The VAS was 3.8 ± 1.9 and 2.2 ± 1.6 on POD1 and POD3, respectively. The mean post-operative hospital stay was 4.0 ± 1.3 days. The median follow-up time was 33 months. All patients returned to unrestricted movement within 2 weeks after surgery. During the follow-ups, no complication as bulge, seroma, hematoma, wound infection, abscess in surgical area and chronic pain, nor recurrence was observed.

Conclusions

According to our experience in this series of investigations, the TAPE could be a feasible and easy-to-learn technique which can be applied to most of the lumbar hernia repairs.

Lumbar hernia after breast reconstruction

INTRODUCTION

Lumbar hernia is a rare complication that can occur after breast reconstruction using a latissimus dorsi flap. The defect occurs within the superior lumbar triangle and may result in visceral incarceration.

PRESENTATION OF CASE

We report a 61-year-old female who presented with a left sided lumbar bulge and pain 7 years following a modified radical mastectomy and latissimus dorsi flap reconstruction. Computed tomography demonstrated a lumbar hernia with incarcerated colon. The patient underwent a successful laparoscopic repair with prosthetic mesh underlay.

DISCUSSION

Lumbar hernias may be congenital, secondary to trauma or prior surgery. Imaging studies assist in excluding soft tissue tumors, infections, hematoma or abdominal wall denervation atrophy, which may also present as a lumbar bulge. Repair may be performed in an open, laparoscopic or retroperitoneoscopic approach.

CONCLUSION

Laparoscopic lumbar hernia repair with mesh is a safe and feasible way to manage an uncommon complication after breast reconstruction with a latissimus flap.

Bleichner's hernia - lumbar hernia

BACKGROUND

We present a case of a lumbar hernia and a review of the literature of this rare hernia type.

CASE REPORT

The case and the review will discuss the unusual presentations reported, common etiologies, the importance of early operative repair based on the high rate of incarceration and the recent recommendations regarding repair techniques.

CONCLUSIONS

Lumbar hernias are rare cases, but should be pursued in diagnosis and treated aggressively because of the high rate of incarceration. Repair can be accomplished with a minimally invasive technique.

Laparoscopic transabdominal preperitoneal repair of ventral hernia: a step towards physiological repair

The laparoscopic ventral hernia repair with preperitoneal placement of mesh minimizes the complications related to the intraperitoneal position of mesh and fixating devices. It allows safe use of conventional and less expensive polypropylene mesh. The prospectively collected data of 68 patients who underwent laparoscopic transabdominal preperitoneal mesh hernioplasty, for different types of ventral hernias between January 2005 and December 2009 was retrospectively reviewed. The study included 68 patients, 16 males and 52 females with a mean age 51.1 ± 11.1 years (range 23-74 years). Most of the hernias (67.6%) were in the midline position. The mean size of the defect was 30.8 ± 24.4 cm2 (range, 4-144 cm2) and the mean mesh size was 237.8 ± 66.8 cm2 (range, 144-484 cm2). The mean operating time was 96.7 ± 16.7 min (range 70-150 min). All repairs were done with polypropylene mesh. The mean postoperative hospital stay was 1.5 ± 0.6 days (range, 1-4 days). Nineteen patients (27.9%) suffered from postoperative complications. Four patients (5.8%) were detected to have seroma formation. There were two recurrences (2.9%). The mean follow up was 22.7 ± 13.4 months (range, 6-48 months). The laparoscopic preperitoneal ventral hernia repair with polypropylene mesh is cheaper and has acceptable postoperative outcomes. Peritoneal coverage of the mesh not only acts as a barrier between mesh and bowel and thereby prevents adhesions, it also provides an additional security of fixation. This is a safe and feasible option of ventral hernia repair in expert hands. However, for proper validation of these conclusions a long term prospective clinical trial is required.

Sutureless Meshplasty in Lumbar Hernia

Background. Lumbar hernia is a rare hernia arising through posterolateral abdominal wall defects. Different techniques of repair are reported in the literature. Methods. The authors present their experience of 4 lumbar hernias during a short span of 9 months. All surgical repairs were performed using synthetic mesh placed in the extraperitoneal space, below the muscular layers, using a sutureless tension-free technique. Results. The patients were 3 children and 1 adult, all males. All hernias were through superior triangle. Duration of surgery ranged between 60 and 80 minutes. There were no surgical complications. The mean hospital stay was 2.5 days. All patients are well on follow-up till date. Conclusions. Sutureless tension-free meshplasty of these rare hernias can be successfully performed with the posterior approach. This method of repair is easy, safe, and effective.