Background Abdominal wall surgery has changed dramatically in recent years. The current management of lumbar hernias should reflect the development of modern imaging techniques and new forms of noninvasive treatment. Objective To review and update knowledge on lumbar hernias. Data Sources Literature review using MEDLINE with the key words “lumbar hernia” for the years 1950 through 2004. For an analysis prior to this date (1750-1950), we used cases reported by Thorek. Our own study of 28 patients was also included. Study Selection All articles reporting clinical cases on lumbar hernia. Data Extraction Two reviewers analyzed the epidemiological, clinical, and treatment data of the articles. Data Synthesis One hundred thirty-five clinical case articles and 8 studies with more than 5 patients, together with our personal experience of 28 cases, were analyzed. Nine percent of acquired lumbar hernia cases presented for emergency surgery, which means that a clinical diagnosis was completed with computed tomography in more than 90% of the cases. None of the published classifications has a therapeutic orientation. We present an original classification based on 6 categories and 4 types. In our study, there was a predominance of incisional hernias (79%), with no difference with regard to sex or location but with a predominance in the upper space (47%). Laparoscopic treatment accounts for 9% of the publications' cases and there is only 1 prospective comparative study. Conclusions The use of a complete classification and tomography must be standard practice in the preoperative protocol of patients with lumbar hernia. The laparoscopic approach seems to be the best option for treating small or moderate defects; open surgery can be reserved for large defects and to salvage failures with the laparoscopic approach.

https://jamanetwork.com/journals/jamasurgery/articlepdf/399652/srv50015_82_88.pdf

Controversies in the current management of lumbar hernias.

Lumbar hernias are a protrusion of intra-abdominal contents through a weakness or rupture in the posterior abdominal wall. They are considered to be a rare entity with approximately 300 cases reported in the literature since it was first described by Barbette in 1672. Petit described the inferior lumbar triangle in 1783 and Grynfeltt described the superior lumbar triangle in 1866; both are anatomical boundaries where 95% of lumbar hernias occur, whereas the other 5% are considered to be diffuse. Twenty percent of lumbar hernias are congenital and the other 80% are acquired; the acquired lumbar hernias can be further classified into either primary (spontaneous) or secondary. The typical presentation of lumbar hernias is a patient with a protruding semispherical bulge in the back with a slow growth. However, they may present with an incarcerated or strangulated bowel, so it is recommended that all lumbar hernias must be repaired as soon as they are diagnosed. The "gold standard" for diagnosing a lumbar hernia is a CT scan, because it is able to delineate muscular and fascial layers, detect a defect in one or more of these layers, evaluate the presence of herniated contents, differentiate muscle atrophy from a real hernia, and serve as a useful tool in the differential diagnosis, such as tumors. Recent studies have demonstrated the advantages of a laparoscopic repair instead of the classic open approach as the ideal treatment option for lumbar hernias. We report a case of a spontaneous lumbar hernia initially diagnosed as a lipoma and corrected with the open approach, but after relapsing 2 years later it was corrected using a laparoscopic approach. It is followed by an extensive review of lumbar hernias literature regarding history, anatomy, and surgical techniques.

Laparoscopic repair of a lumbar hernia: report of a case and extensive review of the literature.

Hernias through the triangle of Petit (TP) are uncommon. The anatomy of the TP is known to be variable, yet quantitative data are scant. The triangle was observed in 80 adult cadavers and its dimensions and surface area were measured. On the basis of surface area we classified the triangles into four types. Type I or small TP, with a surface area of 12 cm2. Finally, Type IV (17.5%) were not triangles. In these, the latissimus dorsi was covered by the external abdominal oblique muscle. We hope these data will help prediction of which patients are at greater risk of herniation through the TP.

The clinical anatomy of the triangle of Petit

Background: Lumbar hernias arise through posterolateral abdominal wall defects, named inferior triangle (Petit) and superior triangle (Grynfelt). Most of the lumbar hernias are seco

Primary Lumbar Hernia Repair: The Open Approach

The purpose of this study was to describe the anatomy of the two orifices of the abdominal posterior wall where lumbar hernias could appear. They may protrude through the superficial lumbar triangle (JL Petit) or the deepest superior orifice (Grynfeltt). The exact limits were precised by dissections in cadavers to explain the main differences of these two locations. We report two cases of spontaneous lumbar hernias discovered in outpatient clinic. Clinical diagnosis was difficult and both the patients were sent for lumbar lipoma but a meticulous examination gave us a clue. MRI was useful to confirm the defect in the posterior abdominal wall under the 12th rib. Only one patient was operated by a direct approach with a reinforcement of an unabsorbable mesh. No recurrence appeared during follow-up. Thanks to clinical and anatomical knowledge, these rare superior lumbar hernias were diagnosed and a correct surgical treatment permitted a quick recovery.

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Lumbar hernia: anatomical basis and clinical aspects

Background. Lumbar hernia is a relatively rare phenomenon. The aim of this study was to investigate the clinical manifestation, the diagnosis of lumbar hernia, and the outcome of the surgical procedure. Methods. Eleven cases of lumbar hernia were studied by clinical observation retrospectively from July 1998 to July 2000. Results. All the patients were diagnosed clinically and confirmed operatively. The typical manifestation was a semi-spherical painful mass in the superior or inferior triangle. If the gut was incarcerated, bowel obstruction may subsequently develop. Ten of the eleven patients were treated successfully. Conclusions. The clinical symptoms and signs usually allow for easy diagnosis. Excision of the sac and high ligation, followed by repair using either surrounding tissue or prosthetic material, provided satisfactory results.

J. O. Nve

Papers

Lumbar hernia: Clinical analysis of 11 cases