Grynfelt hernia

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

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

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.

Surgical approach towards Grynfelt hernia: A single center experience

Due to the rarity of Grynfelt hernia, there is no standardized surgical technique.From April 2010 to September 2017, 12 cases of primary superior lumbar hernia (Grynfelt hernia) were identified through medical records reviewing and included in our study. Perioperative data, surgical outcomes, and long-term follow-up results were retrospectively analysed.Male/female ratio of patients was 1:1, with age 69.5 (62, 74.5) [median (25 percentile, 75 percentile)] years old. Right/left side ratio of lumbar hernia was 9/3. The in-hospital duration was 7 (5, 8) days. The surgical duration was 35 (30, 50) minutes. The defect size was 2.1 (1.5, 3) cm in diameter. The discharge of the patient was on 3 (2, 4) post-operative day (POD). The meshes used were: MK5816 (10), MK5810 (1), and UHS (1). There was only 1 case of postoperative complication where the patient was admitted in intensive care unit (ICU) due to hypoxemia. Morbidity, mortality, and recurrence cases were null.Our study indicates that open surgery with mesh implantation is a reliable way for the management of primary superior lumbar hernia.

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.