Open vs laparoscopic repair of secondary lumbar hernias: a prospective nonrandomized study

A case of idiopathic superior lumbar hernia repaired using a transabdominal laparoscopic approach

The patient is a 78-year-old woman who presented to our hospital with left lumbar back pain as her chief complaint. She was diagnosed with superior lumbar hernia. There was no history of abdominal or lumbar surgery, or trauma, so the condition was considered idiopathic. Mesh was placed laparoscopically to repair the hernia. She was discharged on the second postoperative day. One year has passed since the surgery, and there has been no recurrence of the hernia, nor have there been any complications such as neuropathic pain. Superior lumbar hernia is a type of abdominal wall hernia that protrudes through the superior lumbar triangle and is a relatively rare condition. Due to the lack of an established standard surgical procedure, various surgical techniques have been employed depending on the facility. Laparoscopic surgery was considered a minimally invasive and reliable method for hernia repair, providing good visualization in cases without intra-abdominal adhesions.

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.

Identifying the Hernial Orifice in Superior Lumbar Hernia Repair by Utilizing Anatomical Landmarks on Preoperative CT

Superior lumbar hernias are extremely rare, and surgical repair is essential for their treatment. However, the direct observation of the hernial orifice is frequently difficult because the hernia disappears in prone or lateral positions, which is an issue when using the open approach. Therefore, using anatomical landmarks to detect the hernial orifice on preoperative CT scans may be useful for correct identification and visualization. Here, we report two cases of superior lumbar hernias successfully treated using the abovementioned method.

Primary upper lumbar hernia repaired by transabdominal preperitoneal approach technique using a self-expanding mesh with a memory-recoil ring, report of a case

BACKGROUND

Upper lumber hernia is a rare entity which can cause obstruction and strangulation. Laparoscopic technique has been considered effective for such hernia repairs; however, there is no report of use of the self-expanding mesh.

CASE PRESENTATION

A 77-year-old woman visited to our hospital complaining of a bulge of about 5 cm in the left lumbar dorsal region while standing. Abdominal CT and MRI scans showed a fascial defect in the left lumbar abdominal wall and confirmed the presence of a hernia, in which retroperitoneal fatty tissue and the descending colon protruded. Transabdominal preperitoneal repair (TAPP) was performed and the operative findings revealed the hernia orifice, 3 × 2.5 cm in diameter, between two intercostal nerves. To avoid nerve injury or entrapment, the number of mesh fixation was desirable minimum; therefore, a self-expanding mesh with a memory-recoil ring was used. The mesh, 9.5 × 13 cm in diameter, was placed and tacked to the abdominal wall at two points, 1 cm ventral and dorsal to the hernia orifice. The postoperative course was uneventful and no pain or recurrence was observed with follow-up of 6 months.

CONCLUSION

We herein present a case of upper lumber hernia successfully repaired by TAPP with a self-expanding mesh.

Transabdominal Partial Extraperitoneal Repair of Lateral Hernias of the Abdomen and Flank

Background: Lateral hernia (LH) repair is a challenging and debated topic in abdominal wall surgery because of the anatomical location and mesh placement and fixation. Large LHs should be managed with an open procedure; however, there is no consensus regarding the repair of small- to medium-sized LHs. We report our treatment of this type of LH using the transabdominal partial extraperitoneal (TAPE) technique. Methods: After retrospective review of the prospective hernia database at two hernia centers, patients with small- to medium-sized LHs who underwent the TAPE technique were identified and analyzed. The key components of our technique include wide dissection of peritoneum off the defect and use of that peritoneum to cover the lower and medial part of the mesh as much as possible. The parameters studied included patient demographics, intraoperative data, and postoperative outcome. Results: We studied 19 patients with small- to medium-sized LHs repaired using the TAPE procedure between 2017 and 2020. LH etiologies were primary hernia (n = 3), incisional hernia (n = 15), and traumatic hernia (n = 1). Mean defect size was 5.8 ± 2.1 cm (range 2.5-10 cm), mean operative time 118.1 ± 41.7 minutes (range 65-240 minutes), and mean postoperative stay 6.4 ± 2.0 days (range 6-9 days). There were no perioperative complications. At a mean follow-up of 20 months, no patient had recurrence of LH. Discussion: For small- to medium-sized LHs, the laparoscopic TAPE technique is minimally invasive and safe; the procedure is associated with minimal postoperative complications.

Transabdominal Preperitoneal (TAPP) for the Treatment of Spigelian hernias

Background And Objectives:

Spigelian hernias (SH) are a rare variant of abdominal wall defects that require prompt surgical intervention. With the advancement of abdominal wall surgery capabilities, there are several possible approaches of repairing SH. The aim of the study was to present our experience in performing laparoscopic or robotic transabdominal preperitoneal (TAPP) repairs of SH and discuss the advantages of TAPP in such hernias.

Methods:

Retrospective review of a prospectively maintained database of SH TAPP repairs between February 1, 2015 and February 29, 2020. Data included clinical details, size and location of fascial defect, presence of concomitant hernias, surgery duration, length of stay (LOS), mesh type, mesh size, and fixation method. Follow up visits at 1 month postoperative and telephone survey for pain assessment and subsequent hernia-related treatment.

Results:

During the study period 16 patients underwent TAPP SH repairs, 13 laparoscopically and 3 robotic. Seven (44%) patients had a concomitant inguinal hernia with 1 patient having bilateral inguinal defects. Mean surgery duration and mean LOS were 78 (range 41 – 120) minutes & 1.6 (range 1 – 3) days, respectively. Immediate postoperative complications included 2 seromas and 1 port-site hematoma. Mean telephone survey follow up was 17 months (range 3 – 49). Mean visual analogue scale scores were significantly lower at follow-up compared to discharge (1.9 vs 0.5, P = 0.0015).

Conclusion:

Advantages of TAPP SH repair include low postoperative chronic pain, potential low wound complications, intra-abdominal visualization of hernia contents, and repairing of concomitant inguinal hernias simultaneously.

Lumbar and para-iliac hernias: an alternative technique

Lumbar and para-iliac hernias are rare and occur after removal of an iliac bone graft, nephrectomies, retroperitoneal aortic surgery, or after blunt trauma to the abdomen. The incidence of hernia after the removal of these grafts ranges from 0.5 to 10%. These hernias are a problem that surgeons will face, since bone grafts from the iliac crest are being used more routinely. The goal of this article was to report the technique to correct these complex hernias, using the technique of fixing the propylene mesh to the iliac bone and the result of this approach. In the period of 5 years, 165 patients were treated at the complex hernia service, 10 (6%) with hernia in the supra-iliac and lumbar region, managed with the technique of fixing the mesh to the iliac bone with correction of the failure. During the mean follow-up of 33 months (minimum of 2 and maximum of 48 months), there was no recurrence of the hernias.

Flank incisional hernia after lateral approach spine operations: presentation and outcomes after repair

BACKGROUND

The flank approach to lumbar spine surgery is considered a new minimally invasive alternative to the anterior abdominal approach. Flank incisional hernia is one complication, but it has been poorly studied.

METHODS

Retrospective review of patients referred for evaluation of abdominal bulging after Lateral Interbody Fusion (LIF), 2013-2020.

RESULTS

Seventeen patients were evaluated for abdominal bulging after LIF: 14 were diagnosed with incisional hernias. Three with denervation injury without hernia defect were excluded.

CONCLUSIONS

This is the largest study addressing incisional flank hernias after LIF, an under-represented complication in the spine literature. We show that the patients present early, within months of their operation, and yet most hernias are not diagnosed for over a year. Although LIF is considered a minimally invasive procedure, the morbidity from hernia complications cannot be overlooked. These flank hernias are difficult to repair with suboptimal outcomes. We prefer robotic approach with primary closure of the defect and extraperitoneal sublay mesh, whenever possible. Prevention is key. To help reduce risk of hernia, we recommend closure of all muscle layers with slowly absorbable suture; this is different than was originally described in the spine literature.

Reoperation with laparoscopic mesh repair for recurrent lumbar hernia due to iliac crest bone harvest

Previous reports have described laparoscopic mesh repair for lumbar hernia due to iliac crest bone harvest, but there have been no reports of reoperation with laparoscopic mesh repair for recurrent cases after laparoscopic mesh repair. Here, we describe the case of a 72-year-old Japanese woman with lumbar hernia recurrence 6 years after laparoscopic mesh repair for lumbar hernia due to iliac crest bone harvest. We performed a successful reoperation with laparoscopic mesh repair. Laparoscopic surgery should be considered to elucidate the mechanism of recurrence, previous mesh position, and the area that must be covered to prevent recurrence again.

Hybrid laparoscopic and open repair of post-nephrectomy flank hernia

Surgical repair of flank hernia is not routinely performed, due to perceived technical difficulties with the surgery and risk of recurrence, or the misconception that flank hernia is solely due to a denervation injury. Due to the rareness of flank hernia in the literature, there is no general consensus on the best method of surgical repair. We present the case of a patient with a symptomatic large flank hernia following open nephrectomy, in which a hybrid technique of open and laparoscopic flank hernia repair with sublay mesh and bone anchor fixation was successfully performed with good outcome. This case highlights the benefits of the hybrid approach, which allowed a laparoscopic assessment of the defect and adhesiolysis, followed by the open repair which enabled adequate mesh overlap, fixation to surrounding tissues and bone anchor fixation.

Incisional lumbar hernia after the use of a lumbar artery perforator flap for breast reconstruction

Autologous breast reconstruction with a perforator flap has become increasingly popular. The free lumbar artery perforator (LAP) flap has been described as a good alternative for autologous breast reconstruction. The LAP flap is a perforator flap based on a single pedicle. This flap is easy to harvest, with minimal donor-site morbidity. We present a case of a lumbar incisional hernia after LAP flap breast reconstruction in a 53-year-old patient. The patient had been treated with a bilateral mastectomy for cancer. Secondary breast reconstruction was performed with a bilateral DIEP flap. Reoperation was necessary because of a failed DIEP flap at the left side. Reconstruction was performed with a free LAP flap. The patient was referred for a right lumbar incisional hernia at the donor-site of the LAP flap. Open repair was performed with a retroperitoneal mesh. The thoracolumbar fascia was closed in with a running suture. Lumbar artery perforator is a perforator flap based on a single pedicle. Although it does not sacrifice any muscle and seems to be associated with minimal donor-site morbidity, we present the first report of a lumbar incisional hernia repair after LAP flap breast reconstruction treated using an open retroperitoneal mesh repair.

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.

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.

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.

Lumbar Incisional Hernia Repair: Complete Reconstruction of the Deficient Myofascial Component Using Christmas Tree Bone Anchors

Lumbar incisional hernias are difficult to repair because one of the hernia margins is bone, namely, the iliac crest. Previous studies have described the use of orthopedic bone anchors that fix a mesh onto the iliac crest. We present a novel technique for open repair of large lumbar incisional hernias using a double-mesh technique in combination with suture-loaded bone anchors to reattach the abdominal wall musculature onto the iliac crest. The surgical technique involves creating a preperitoneal plane behind the transversus abdominus and above the iliac crest and iliacus, below the iliac crest, with application of a Prolene mesh in this layer. This is followed by the drilling of suture-loaded Christmas Tree bone anchors™ along the rim of the iliac crest. The preloaded sutures are used to attach the myofascial component on the iliac crest, followed by the placement of a second Prolene mesh in an on-lay fashion. Drains are left in the preperitoneal and subcutaneous spaces. Unlike other reported techniques in the literature which only fix mesh onto the iliac crest, our technique with the use of Christmas Tree bone anchors™ allows for complete reconstruction of the lumbar abdominal wall defect and its myofascial components.

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.

Management Criteria of Grynfeltt's Lumbar Hernia: A Case Report and Review of Literature

Grynfeltt's lumbar hernia is a rare abdominal wall pathology with around 300 cases described in the literature. Recently, a therapeutically aimed classification was proposed analysing the size, location, contents, muscular atrophy, origin, and existence of the previous recurrence. Surgical repair is the only definitive treatment option through either an open or laparoscopic approach. An 87-year-old female came to consult for swelling in the right lumbar area without traumatic history. A smooth, reducible, and tender mass of 4 x 3 cm was described. The suspicion of a Grynfeltt's hernia was confirmed by lumbar ultrasound with evidence of a 10 mm abdominal wall defect with the diameter increasing to 15 mm during a Valsalva maneuver. The patient had a primary type A lumbar hernia; therefore, open hernioplasty was performed. The patient was discharged from the hospital on the third postoperative day in optimal clinical condition. Her 12-month follow-up examination was uneventful.

A lumbar hernia diagnosis can be challenging. Preoperative imaging has an important role in assessing the size, location, and hernia contents. The use of a therapeutically aimed classification could be useful for optimal patient management and improvement of surgical outcomes.

Traumatic lumbar hernia: clinical features and management

Purpose

Traumatic lumbar hernia is rare, thus making diagnosis and proper treatment challenging. Accordingly, we aimed to investigate the clinical manifestations and proper management strategies of traumatic lumbar hernias.

Methods

The medical records of patients with traumatic lumbar hernia treated at Gachon University Gil Hospital from March 2006 to February 2015, were retrospectively reviewed.

Results

We included 5 men and 4 women (mean age, 55 years; range, 23–71 years). In 8 patients, most injuries were caused by motor vehicle collisions, including those wherein a pedestrian was struck (5 cases of car accidents, 2 falls, and 1 involving penetrating materials); in 1 patient, the probable cause was severe cough. Eight patients underwent hernia repair surgery (5 open and 3 laparoscopic), and a prosthetic mesh was used in 7 patients. Hernia repairs were elective in 7 patients; emergency hernia repair was performed with right hemicolectomy in 1 patient. No severe complication or recurrence was observed. Only 2 patients had mild complications, such as postoperative seroma.

Conclusion

Traumatic lumbar hernia is a relatively rare injury of the posteriolateral abdominal wall. Lumbar hernia should be suspected in patients with high-energy injuries of the torso, and all such patients should undergo abdominopelvic computed tomography. After diagnosis, hernia repair can be electively performed without complications in most cases.

Training System for Endoscopic Surgery Aiming to Provide the Sensation of Forceps Operation

In Japan, a rising number of endoscopic surgery operations have boosted an expectation for the development of a training environment for qualified surgeons. The endoscopic surgery operation requires the operator to operate forceps by hand based on two-dimensional operative field information displayed on the monitor. The characteristics of the operation include a lack of stereoscopic visual field information and movement of the tip of the forceps, which is symmetric about the trocar. These are issues that require an empirical solution from the operator. It is desirable that these issues have already been overcome before the operator starts practicing as an operating surgeon. To this end, it is effective to train the operator in the sensation of forceps operation, which associates the operative field vision with the forceps operation by hand. Therefore, this study includes digitizing the forceps operation by qualified surgeons and providing it to the trainee as visual and force information in order to build a training device that facilitates the cultivation of the sensation of forceps operation.

Delayed laparoscopic repair of a traumatic flank hernia: A case report and review of the literature

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Not all traumatic abdominal wall hernias require laparotomy at time of injury.

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Observation is considered to be safe when there is no other indication for surgery.

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Many patients managed non-operatively remain asymptomatic.

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Delayed laparoscopic repair with mesh reserved for hernias that become symptomatic.

Introduction

The traumatic abdominal wall hernia is a rare injury typically due to a high-energy blunt trauma mechanism. There is a lack of consensus on the appropriate management of these patients.

Presentation of the case

A 43-year-old male was evaluated for a left flank bulge eight months after a motorcycle collision. He was diagnosed with a traumatic abdominal wall hernia at time of injury that was managed non-operatively. He noticed a left flank bulge two months after his collision that progressively worsened in size and in discomfort. The patient underwent laparoscopic repair of the traumatic flank hernia. His postoperative course was uneventful and there was no recurrence at 3 years.

Discussion

Historically, exploratory laparotomy was considered necessary in patients diagnosed with a traumatic abdominal wall hernia at time of injury due to the high-percentage of concomitant intra-abdominal injuries. More recent studies suggest that some patients with a traumatic abdominal wall hernia may be safely managed non-operatively. A minority of these patients will require surgery for symptoms or complications related to the hernia and laparoscopic repair performed in a delayed fashion appears to have improved outcomes when compared to those that undergo repair at time of injury.

Conclusion

There is growing evidence supporting a non-operative management strategy in patients with a traumatic abdominal wall hernia who do not have a clear indication for abdominal surgery. These patients may be safely observed with delayed laparoscopic repair using synthetic mesh reserved for traumatic abdominal wall hernias that become symptomatic.

Repair of a Grynfeltt-Lesshaft hernia with the PROCEED™ VENTRAL PATCH: a case report

Background

Primary hernias in the triangle of Grynfeltt are very rare and therefore pose a difficulty in diagnosis and treatment. Due to the lack of systematic studies, the surgical approach must be chosen individually for each patient. Here, we describe an easy and safe surgical approach.

Case presentation

We report the case of a 53-year-old male patient with a history of mental disability and pronounced scoliosis, who presented with a Grynfeltt-Lesshaft hernia with protrusion of the ascending colon and the right ureter.

The hernia was repaired via a dorsal, extraperitoneal approach. The hernia gap with a diameter of approximately 1 cm was closed with insertion of a 6.4 × 6.4 cm PROCEED™ VENTRAL PATCH (Ethicon, Norderstedt, Germany). The operating time was 33 min and the patient was discharged the next day and showed no signs of recurrence at 1-year follow up.

Conclusion

The technique described here is favorable because it requires very little dissection of the surrounding tissue and no trans-/intraabdominal dissection. The technique was chosen in this particular case to guarantee a fast postoperative recovery and prompt hospital discharge.

LAPAROSCOPIC REPAIR OF LUMBAR HERNIA (GRYNFELT): TECHNICAL DESCRIPTION

Background:

Lumbar hernias are rare. Usually manifest with reducible volume increase in the post-lateral region of the abdomen and may occur in two specific anatomic defects: the triangles of Grynfelt (upper) and Petit (lower). Despite controversies with better repair, laparoscopic approach, following the same principle of the treatment of inguinal hernias, seems to present significant advantages compared to conventional/open surgeries. However, some technical and anatomical details of the region, non usual to general surgeons, are fundamental for proper repair.

Aim:

To present systematization of laparoscopic transabdominal technique for repair of lumbar hernias with emphasis on anatomical details.

Method

: Patient is placed in the lateral decubitus. Laparoscopic access to abdominal cavity is performed by open technique on the left flank, 1.5 cm incision, followed by introduction of 11 mm trocar for a 30º scope. Two other 5 mm trocars, in the left anterior axillary line, are inserted into the abdominal cavity. The peritoneum of the left paracolic gutter is incised from the 10^th rib to the iliac crest. Peritoneum and retroperitoneal is dissected. Reduction of all hernia contents is performed to demonstrate the hernia and its size. A 10x10 cm polypropylene mesh is introduced into the retroperitoneal space and fixed with absorbable staples covering the defect with at least 3-4 cm overlap. Subsequently, is carried out the closure of the peritoneum of paracolic gutter.

Results:

This technique was used in one patient with painful increased volume in the left lower back and bulging on the left lumbar region. CT scan was performed and revealed left superior lumbar hernia. Operative time was 45 min and there were no complications and hospitalization time of 24 h.

Conclusion:

As in inguinal hernia repair, laparoscopic approach is safe and effective for the repair of lumbar hernias, especially if the anatomical details are adequately respected.

A rare case of a superior lumbar hernia secondary to penetrating injury

Lumbar hernias are rare occurrences, with only 300 cases reported in the literature. We present a unique case of a superior lumbar hernia secondary to penetrating trauma to the right flank. We performed a herniorrhaphy using porcine mesh, and provided additional support by mobilizing the external oblique and latissimus dorsi into the defect. At follow up three months after repair, the patient was asymptomatic and exam revealed an intact lumbar abdominal wall with normal contour. Although literature displays a consensus on the need for lumbar hernia repair, specific repair techniques must be tailored to defect etiology, size, location, and contents.

Open Approach to Primary Lumbar Hernia Repair: A Lucid Option

Background

Lumbar hernia is a rare type of hernia. Awareness of the anatomical basis of this hernia is important for proper diagnosis and treatment.

Introduction

Lumbar hernia is a protrusion of either extraperitoneal fat or intraperitoneal contents through either of the lumbar triangles. Primary lumbar hernias are extremely rare thereby rendering such a case reportable, to create an awareness about this condition to upcoming surgeons.

Case Report

A case of primary lumbar hernia treated successfully by open mesh repair is presented.

Discussion

The anatomical aspects underlying this condition along with diagnostic tests, their pitfalls, and surgical approaches are discussed.

Conclusion

Awareness of this condition is essential for arriving at a clinical diagnosis. CT scan provides a road map for deciding the approach. Both the traditional open and the newer laparoscopic approaches are described. However open meshplasty is still a very safe and effective method of treatment.

Open Approach to Primary Lumbar Hernia Repair: A Lucid Option

BACKGROUND

Lumbar hernia is a rare type of hernia. Awareness of the anatomical basis of this hernia is important for proper diagnosis and treatment.

INTRODUCTION

Lumbar hernia is a protrusion of either extraperitoneal fat or intraperitoneal contents through either of the lumbar triangles. Primary lumbar hernias are extremely rare thereby rendering such a case reportable, to create an awareness about this condition to upcoming surgeons.

CASE REPORT

A case of primary lumbar hernia treated successfully by open mesh repair is presented.

DISCUSSION

The anatomical aspects underlying this condition along with diagnostic tests, their pitfalls, and surgical approaches are discussed.

CONCLUSION

Awareness of this condition is essential for arriving at a clinical diagnosis. CT scan provides a road map for deciding the approach. Both the traditional open and the newer laparoscopic approaches are described. However open meshplasty is still a very safe and effective method of treatment.

Grynfelt-Lesshaft hernia a case report and review of the literature

INTRODUCTION

Lumbar hernia account for less than 2% of al abdominal hernias, been the Grynfelt-Lesshaft's hernia (GLH) more frequent than the others. With approximately 300 cases published in the literature, the general surgeon may have the chance of treat it ones in their professional life.

CASE REPORT

A 42-years old male with human immunodeficiency virus and Diabetes Mellitus presented to the outpatient clinic with a GLH. Preoperative classified as a type "A" lumbar hernia an open approach was scheduled. We performed a Sandwich technique with a sublay and onlay ULTRAPRO(®) mesh fixed with PDS(®) II suture without complications and discharged the patient 24-h after. After six months, the patient denied any complication.

DISCUSSION

Primary (spontaneous) lumbar hernias represent 50-60% of all GLH. The preoperative classification of a lumbar hernia is mandatory to propose the best surgical approach. According to the classification of Moreno-Egea A et al., the best technique for our patient was an open approach. The Sandwich technique has demonstrated good outcomes in the management of the GLH.

CONCLUSION

The surgical approach should be according to the classification proposed and to the experience of the surgeon. The Sandwich technique has good outcomes.

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

The Grynfeltt-Lesshaft hernia is a rare posterior abdominal wall defect that allows for the herniation of retro- and intraperitoneal structures through the upper lumbar triangle. While this hernia may initially present as a small asymptomatic bulge, the defect typically enlarges over time and can become symptomatic with potentially serious complications. In order to avoid that outcome, it is advisable to electively repair Grynfeltt hernias in patients without significant contraindications to surgery. Due to the limited number of lumbar hernioplasties performed, there has not been a large study that definitively identifies the best repair technique. It is generally accepted that abdominal hernias such as these should be repaired by tension-free methods. Both laparoscopic and open techniques are described in modern literature with unique advantages and complications for each. We present the case of an unexpected Grynfeltt hernia diagnosed following an attempted lipoma resection. We chose to perform an open repair involving a combination of fascial approximation and dual-layer polypropylene mesh placement. The patient's recovery was uneventful and there has been no evidence of recurrence at over six months. Our goal herein is to increase awareness of upper lumbar hernias and to discuss approaches to their surgical management.

Primary lumbar hernia: A rarely encountered hernia

INTRODUCTION

Lumbar hernia is an uncommon abdominal wall hernia, making its diagnosis and management a challenge to the treating surgeon. Presentation may be misleading and diagnosis often missed. An imaging study forms an indispensable aid in the diagnosis and surgery is the only treatment option.

PRESENTATION OF CASE

A 42 year old male presented with history of pain in lower back of 4 years duration and was being treated symptomatically over 4 years with analgesics and physiotherapy. He had noticed a swelling over the left side of his mid-back and consequently on examination was found to have a primary acquired lumbar hernia arising from the deep superior lumbar triangle of Grynfelt. Diagnosis was confirmed by Computed Tomographic imaging.

DISCUSSION

A lumbar hernia may be primary or secondary with only about 300 cases of primary lumbar hernia reported in literature. Lumbar hernias manifest through two possible defects in the posterior abdominal wall, the superior being more common. Management remains surgical with various techniques emerging over the years. The patient at our center underwent an open sublay mesh repair with excellent outcome.

CONCLUSION

A surgeon may encounter a primary lumbar hernia perhaps once in his lifetime making it an interesting surgical challenge. Sound anatomical knowledge and adequate imaging are indispensable. Inspite of advances in minimally invasive surgery, it cannot be universally applied to patients with lumbar hernia and management requires a more tailored approach.

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.

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.

Laparoscopic ventral incisional hernia repair: evidence-based guidelines of the first Italian Consensus Conference

PURPOSE

The laparoscopic treatment of ventral incisional hernias is the object of constant attention and is becoming increasingly widespread in the international scientific-surgical community; however, there is ample debate on its technical details and indications. In order to establish a common approach on laparoscopic ventral incisional hernia repair, the first Italian Consensus Conference was organized in Naples (Italy) on 14-15 January 2010.

METHODS

The format of the Consensus Conference was freely adapted from the standards of the National Institute of Health and the Italian Health Institute. The parties involved included the followings: a Promotional Committee, a Scientific Committee, a group of Experts, the Jury Panel and a Scientific Secretariat.

RESULTS

Eleven statements, regarding three large chapters on the indications, the technical details and the management of complications were drafted on the basis of literature references collected by the Scientific Committee, documents developed by the Experts, reports presented and discussed during the Consensus Conference, and discussion among the members of the Jury.

CONCLUSIONS

The laparoscopic approach is safe and effective for defects larger than 3 cm in diameter; old age, obesity, previous abdominal operations, recurrence and strangulation are not absolute contraindications. Ensuring an adequate overlap, careful adhesiolysis and correct fixing of the prosthesis are among the technical details recommended. Complications and recurrences are comparable to, and in some cases, less numerous than with the open approach.

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.

Successful laparoscopic repair of a lumbar hernia occurring after iliac bone harvest

INTRODUCTION

Many techniques have been described for the surgical repair of lumbar hernias, including primary repair, local tissue flaps, and conventional mesh repair. All these open techniques require a large incision plus extensive dissection to expose the hernia ring. This report presents a case of a recurrent lumbar hernia, which was successfully repaired using a laparoscopic approach.

CASE REPORT

A 75-year-old female presented with a symptomatic right lumbar hernia, 1-year after an iliac bone harvest for knee surgery. Under general anesthesia, the patient was placed in a lateral decubitus position. A 3 trocar technique was used to do adhesiolysis of the surrounding tissues, to provide an ample working space to identify the hernia. A composix dual mesh (bard) was tailored so that it would overlap the defect with intermittent fixation by a spiral tacker (protac). No hernia recurrence occurred over 2 years after surgery.

CONCLUSION

The laparoscopic approach has significant advantages for the repair a lumbar hernia: it enables the exact localization of the anatomic defect, and the mesh can be placed deep into the defect, thus allowing the intraabdominal pressure to hold it in position.

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.

Laparoscopic versus open surgical techniques for ventral or incisional hernia repair

BACKGROUND

There are many different techniques currently in use for ventral and incisional hernia repair. Laparoscopic techniques have become more common in recent years, although the evidence is sparse.

OBJECTIVES

We compared laparoscopic with open repair in patients with (primary) ventral or incisional hernia.

SEARCH STRATEGY

We searched the following electronic databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, metaRegister of Controlled Trials. The last searches were conducted in July 2010. In addition, congress abstracts were searched by hand.

SELECTION CRITERIA

We selected randomised controlled studies (RCTs), which compared the two techniques in patients with ventral or incisional hernia. Studies were included irrespective of language, publication status, or sample size. We did not include quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted data independently. Meta-analytic results are expressed as relative risks (RR) or weighted mean difference (WMD).

MAIN RESULTS

We included 10 RCTs with a total number of 880 patients suffering primarily from primary ventral or incisional hernia. No trials were identified on umbilical or parastomal hernia. The recurrence rate was not different between laparoscopic and open surgery (RR 1.22; 95% CI 0.62 to 2.38; I(2) = 0%), but patients were followed up for less than two years in half of the trials. Results on operative time were too heterogeneous to be pooled. The risk of intraoperative enterotomy was slightly higher in laparoscopic hernia repair (Peto OR 2.33; 95% CI 0.53 to 10.35), but this result stems from only 7 cases with bowel lesion (5 vs. 2). The most clear and consistent result was that laparoscopic surgery reduced the risk of wound infection (RR = 0.26; 95% CI 0.15 to 0.46; I(2)= 0%). Laparoscopic surgery shortened hospital stay significantly in 6 out of 9 trials, but again data were heterogeneous. Based on a small number of trials, it was not possible to detect any difference in pain intensity, both in the short- and long-term evaluation. Laparoscopic repair apparently led to much higher in-hospital costs.

AUTHORS' CONCLUSIONS

The short-term results of laparoscopic repair in ventral hernia are promising. In spite of the risks of adhesiolysis, the technique is safe. Nevertheless, long-term follow-up is needed in order to elucidate whether laparoscopic repair of ventral/incisional hernia is efficacious.

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.

Lumbar hernia misdiagnosed as a subcutaneous lipoma: a case report

Introduction

Lumbar hernia is a rare abdominal wall defect and clinical suspicion is necessary for diagnosis.

Case presentation

We report the case of a 40-year-old Caucasian woman with a superior lumbar hernia (Grynfeltt hernia) initially misdiagnosed as a recurrent lipoma. The correct diagnosis was made intra-operatively and the hernia was repaired using synthetic mesh. The patient was free of recurrence at 4 months after the operation.

Conclusion

A lumbar or flank mass should always raise suspicion of a lumbar hernia. Ultrasound and computed tomography may confirm the diagnosis. Adequate surgical treatment should be planned on the basis of etiology and hernia size. Both open and laparoscopic techniques can be used with good results.

Anatomical and Surgical Considerations on Lumbar Hernias

Lumbar hernias, which are rare hernias of the posterolateral abdominal wall, can be divided into two groups: primary lumbar hernias, often the expression of a congenital defect, which typically arise in two areas of weakness, the superior triangle and inferior triangle and acquired (or diffuse) lumbar hernias which are usually due to previous lumbar trauma or surgery. Clinical examination may be adjuvated by ultrasound or CT scan, which can reveal the abdominal wall defect with the hernia content (viscera or extraperitoneal tissue). Surgical repair of lumbar hernias, both primary and acquired, has rapidly developed through recent years, similarly to the treatment of more frequent kinds of hernia (groin, epigastric), evolving from direct repair to mini-invasive techniques, even if, since the rarity of these hernias, precise knowledge of this complex anatomic region is required. Nowadays there are two valid alternatives: open tension-free repair (with use of mesh), and mini-invasive repair. Both are safe and effective, even if smaller hernias can be treated by open approach, with loco-regional anesthesia and good cosmetic effect. Larger hernias, or hernias with suspected viscera involvement, should require larger incisions and viscera exploration. For this reason laparoscopic access would be preferable.