Abdominal wall injuries occur in nearly one of 10 patients coming to the emergency department after nonpenetrating trauma. Injuries range from minor, such as abdominal wall contusion, to severe, such as abdominal wall rupture with evisceration of abdominal contents. Examples of specific injuries that can be detected at cross-sectional imaging include abdominal muscle strain, tear, or hematoma, including rectus sheath hematoma (RSH); traumatic abdominal wall hernia (TAWH); and Morel-Lavallee lesion (MLL) (closed degloving injury). These injuries are often overlooked clinically because of (a) a lack of findings at physical examination or (b) distraction by more-severe associated injuries. However, these injuries are important to detect because they are highly associated with potentially grave visceral and vascular injuries, such as aortic injury, and because their detection can lead to the diagnosis of these more clinically important grave traumatic injuries. Failure to make a timely diagnosis can result in delayed complications, such as bowel hernia with potential for obstruction or strangulation, or misdiagnosis of an abdominal wall neoplasm. Groin injuries, such as athletic pubalgia, and inferior costochondral injuries should also be considered in patients with abdominal pain after nonpenetrating trauma, because these conditions may manifest with referred abdominal pain and are often included within the field of view at cross-sectional abdominal imaging. Radiologists must recognize and report acute abdominal wall injuries and their associated intra-abdominal pathologic conditions to allow appropriate and timely treatment. © RSNA, 2017.

Don't Forget the Abdominal Wall: Imaging Spectrum of Abdominal Wall Injuries after Nonpenetrating Trauma.

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.

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

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. 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. 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. 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.

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

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.

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

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 10th 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. Racional: As hernias lombares sao raras. Geralmente se manifestam com aumento de volume redutivel na regiao postero-lateral do abdome e podem ocorrer em dois defeitos anatomicos especificos: os triângulos de Grynfelt (superior) e Petit (inferior). Apesar de controversias com relacao a melhor forma de reparo, a abordagem laparoscopica, seguindo o mesmo principio do tratamento das hernias inguinais, parece apresentar vantagens significativas em relacao as operacoes convencionais/abertas. Entretanto, alguns detalhes tecnicos e anatomicos desta regiao, nao usual aos cirurgioes gerais, sao fundamentais para o adequado reparo. Objetivo: Apresentar sistematizacao da tecnica laparoscopica transabdominal para a correcao das hernias lombares com enfase nos detalhes anatomicos. Metodo: Paciente e colocado em decubito lateral. O acesso laparoscopico a cavidade abdominal e realizado pela tecnica aberta no flanco esquerdo, incisao de 1,5 cm, seguida pela introducao de trocarteres de 11 mm para otica de 30o. Dois outros trocarteres de 5 mm, na linha axilar anterior esquerda, sao inseridos na cavidade abdominal. O peritonio da goteira paracolica esquerda e incisado desde a 10a costela ate a crista iliaca. O peritonio e o retroperitoneal sao dissecados. A reducao de todo o conteudo de hernia e realizada para demonstrar a hernia e seu tamanho. Tela de polipropileno de 10x10 cm e introduzida no espaco retroperitoneal e fixada com grampos absorviveis cobrindo o defeito com pelo menos 3-4 cm de sobreposicao. Posteriormente, realiza-se o fechamento do peritonio da goteira paracolica. Resultados: Esta tecnica foi utilizada em um paciente com aumento doloroso de volume na regiao lombar esquerda e abaulamento na regiao lombar esquerda. Tomografia computadorizada foi realizada e revelou hernia lombar superior esquerda. O tempo operatorio foi de 45 min e nao houve complicacoes; o tempo de hospitalizacao de 24 h. Conclusoes: Assim como no reparo das hernias inguinais, a abordagem laparoscopica e segura e efetiva para as hernias lombares, especialmente se os detalhes anatomicos forem adequadamente respeitados.

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Laparoscopic repair of lumbar hernia (grynfelt): technical description

Back lumbar hernia is a rare abdominal wall defect that usually presents spontaneously after trauma or lumbar surgery or, less frequently, during infancy (congenital). Few reports have been published in the literature describing primary lumbar hernia. A general surgeon will have the opportunity to repair only one or a few lumbar hernia cases in his/her lifetime. We report a case of a healthy 50-year-old man, with no previous surgeries or history of trauma, who presented to the outpatient department with abdominal discomfort, pain, and a sensation of a growing mass on his lower left back for 4 years. CT scan of the abdomen showed a mass in the left posterolateral abdominal wall. Specifically, a herniation of retroperitoneal fat between the erector spinae muscle group and internal oblique muscles through aponeurosis of the transversalis muscle (Grynfeltt hernia). The patient underwent a small lumbotomy, polypropylene mesh was placed and he recovered well. Although many techniques have been described for the surgical management of such hernias, none of them can be recommended as the preferred method. Our impression, however, is that the open approach, with a small lumbotomy, seems to be easy, safe and presents good postoperative recovery.

D. Cesar

Papers

Grynfelt hernia: case report and literature review