Traumatic lumbar hernia: clinical features and management

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.

Abdominal hernias secondary to non-penetrating trauma. A systematic review

Traumatic abdominal wall hernia (TAWH) is a protrusion of contents through a defect in the abdominal wall as a consequence of a blunt injury. The objective of this review was to describe demographic and clinical aspects of this rare pathology, identifying the optimal moment for surgical intervention, evaluating the need to use mesh, and analyzing the effectiveness of surgical treatment. Thus, a systematic review using PubMed, Embase, and Scopus databases was carried out between January 2004 and March 2024. Computed tomography is the gold-standard imaging test for diagnosis. Open surgery is generally the preferred approach, particularly in emergencies. Acute TAWH can be treated by primary suture or mesh repair, depending on local conditions, while late cases usually require mesh.

Pediatric Traumatic Lumbar Hernias and Associated Injuries: A Case Series

OBJECTIVE

Traumatic lumbar hernias are a rare entity mostly seen with high-impact, blunt abdominal trauma. This injury occurs when there is disruption of the posterior musculature along with bony structures, allowing for herniation of abdominal contents. There are minimal cases of this entity reported in adults, but even fewer in the pediatric population.

METHODS

We describe 3 cases of traumatic lumbar hernia at our institution as well as provide a review of the literature to elucidate the most common mechanisms, severity of injury, and associated injuries.

RESULTS

Traumatic lumbar hernia is most commonly seen in restrained passengers involved in motor vehicle collisions. A majority of cases are diagnosed using computed tomography imaging and less frequently during primary surgical exploration. The most common associated injuries were mesenteric and bowel injuries, followed by spinal and chest trauma. Traumatic lumbar hernia often leads to prolonged hospital stays and increased need for posthospital rehabilitation because of associated traumatic comorbidities.

CONCLUSIONS

Traumatic lumbar hernia is a rare entity in children, and early suspicion and identification of associated injuries is necessary in the management of these patients.

Traumatic lumbar hernia: A systematic review of the literature

PURPOSE

Traumatic lumbar hernia (TLH) constitutes a protrusion of content through a defect in the posterior abdominal wall, as a result of injury. This rare entity has been described in limited number of cases.

METHODS

A systematic review of the literature was performed according to the meta-analysis of observational studies in epidemiology guidelines. The English literature from 1990 until 2021 was reviewed, using PubMed, EMBASE and Google Scholar bibliographic databases, to identify case reports and case series with patients that were diagnosed with TLH. For each eligible study, demographics, clinical presentation, hernia characteristics, preoperative imaging investigations, operation details, and postoperative data were extracted for assessment. Statistical analysis was performed on SPSS, version 20.0.

RESULTS

A total of 62 studies were included for review, with 164 patients with TLH. Mean age was (42.6 ± 14.3) years (47.6% males, 31.1% females, gender not specified in 35 cases). Mean diameter of hernia neck was (6.3 ± 3.1) cm, while the triangles of Petit and Grynfeltt were affected in 74.5% and 14.6%, respectively. Patients diagnosed in the emergency setting account for 54.2%, with CT scan establishing diagnosis in all but one case (97.7%). A delayed diagnosis was made in 45.8%, at a mean 1 year following trauma. Flank bulging (82.8%) and chronic back pain (34.3%) were the most frequent symptoms. In both delayed and acute group, open surgery (63.6% and 92.3%, respectively) was the preferred surgical approach. Postoperative complications were reported in 11.4% of acute and 15.0% of delayed patients. Hernia recurrence was 7%.

CONCLUSIONS

TLH is uncommon with 164 cases described since 1990. CT scan is the gold standard in diagnosis. Open surgery is generally the preferred approach, particularly in the emergency setting. Acute TLH can be treated either by primary suture repair or mesh, depending on the local conditions, whereas delayed cases usually require a mesh.

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.

Large Traumatic Lumbar Hernia: A Difficult and Uncommon Problem

Lumbar hernias are congenital or acquired posterolateral abdominal wall hernias and are located in the superior or inferior lumbar triangle. Traumatic lumbar hernias are rare, and the optimal method to repair these is not well-defined. We present the case of a 59-year-old obese female who presented after a motor vehicle collision with an 8.8 cm traumatic right-sided inferior lumbar hernia and overlying complex abdominal wall laceration. The patient underwent an open repair with retro rectus polypropylene mesh and biologic mesh underlay several months after the abdominal wall wound healed, and the patient lost 60 pounds. The patient recovered well without complications or recurrence at the one-year follow-up. This case demonstrates a complex, open surgical approach to repair a large traumatic lumbar hernia not amenable to laparoscopic repair.

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.

Life-Threatening and Non-Life-Threatening Complications Associated With Coughing: A Scoping Review

BACKGROUND

This is an update of the section on complications that are associated with coughing in the 2006 CHEST cough guidelines that addresses two aims: (1) to systematically identify and thematically categorize the diverse complications of cough by providing a guide for future studies and (2) to identify gaps in the literature for future research.

RESEARCH QUESTION

What are the potential complications that are associated with the act of coughing that have been reported in infants, children, adolescents, and adults?

STUDY DESIGN AND METHODS

A scoping review was performed with the use of PubMed and SCOPUS databases that were searched from their beginning until September 6, 2019.

RESULTS

Two hundred forty-seven publications met our inclusion criteria. To these, we added 38 articles from the 2006 complications paper that were not identified in the literature search plus the paper itself for a final total of 286 publications that formed the basis of this review. Since 2006, three new categories of complications have been reported: ear, nose and throat; disease transmission; and laboratory testing. Multiple additional complications that fall outside of these three categories have also been identified and included in the following categories: cardiovascular, constitutional symptoms, dermatologic, GI, genitourinary, musculoskeletal, neurologic, ophthalmologic, psychosocial/quality of life, and respiratory. Not previously highlighted is that some of the complications led to serious morbidity that included death, especially in patients with comorbid conditions, and potentially resulted in harm to others when cough resulted in a motor vehicle accident.

INTERPRETATION

Our work identified a large number of cough complications that we thematically categorized primarily by organ system so that future studies of each system or each complication can be conducted. The gap in the literature that future studies should address is to identify the frequency of the complications and the strength of their association with cough. Only then will one be able to describe the findings in a manner that allows specific recommendations for avoiding these complications. In the meantime, patients with cough should be evaluated and treated according to evidence-based guidelines to mitigate or prevent the myriad of potential complications that are associated with coughing.

Timing of repair and mesh use in traumatic abdominal wall defects: a systematic review and meta-analysis of current literature

Background

Traumatic abdominal wall hernias or defects (TAWDs) after blunt trauma are rare and comprehensive literature on this topic is scarce. Altogether, there is no consensus about optimal methods and timing of repair, resulting in a surgeon’s dilemma. The aim of this study was to analyze current literature, comparing (1) acute versus delayed repair and (2) mesh versus no mesh repair.

Methods

A broad and systematic search was conducted in PubMed, EMBASE, and the Cochrane Library. The selected articles were assessed on methodological quality using a modified version of the CONSORT 2010 Checklist and the Newcastle-Ottawa scale. Primary endpoint was hernia recurrence, diagnosed by clinical examination or CT. Random effects meta-analyses on hernia recurrence rates after acute versus delayed repair, and mesh versus no mesh repair, were conducted separately.

Results

In total, 19 studies were evaluated, of which 6 were used in our analysis. These studies reported a total of 229 patients who developed a TAWD, of whom a little more than half underwent surgical repair. Twenty-three of 172 patients (13%) who had their TAWD surgically repaired developed a recurrence. In these studies, nearly 70% of the patients who developed a recurrence had their TAWD repaired primarily without a mesh augmentation and mostly during the initial hospitalization. Pooled analysis did not show any statistically significant favor for either use of mesh augmentation or the timing of surgical repair.

Conclusion

Although 70% of the recurrences occurred in patients without mesh augmentation, pooled analysis did not show significant differences in either mesh versus no mesh repair, nor acute versus delayed repair for the management of traumatic abdominal wall defects. Therefore, a patient’s condition (e.g., concomitant injuries) should determine the timing of repair, preferably with the use of a mesh augmentation.