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.

Lumbar hernias can be superior (Grynfelt) and inferior (Petit). Inferior lumbar hernias are extremely rare and, therefore, are associated with diagnostic difficulty. We present a case of a primary spontaneous inferior lumbar hernia in a 79-year-old woman that was initially diagnosed as a large lipoma on ultrasound. The first operation was abandoned and an open mesh repair was conducted. Lumbar hernias can be primary acquired (55%), secondary acquired (25%) or congenital (20%). Cross-sectional imaging by CT or MRI appears to be the gold standard in diagnosis as ultrasound may lead to misdiagnosis. Strangulation, incarceration and obstruction are recognised complications, requiring prompt surgical intervention. There are currently no guidelines for surgical managements, although laparoscopic surgery may give the best results. In view of the scarcity of published cases, we aim to add to the literature to raise the index of suspicion and to promote prompt surgical management of lumbar hernias.

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A primary inferior lumbar hernia misdiagnosed as a lipoma.

BACKGROUND/AIM Lumbar hernia is caused by a defect in the abdominal wall. Due to its rarity, there is no established consensus on optimal treatment for lumbar hernia yet. Thus, we here investigated the clinical, surgical characteristics and outcomes of lumbar hernia by collecting 28 such patients from our hospital. METHODS Patients diagnosed with lumbar hernia from our institution between April 2011 and August 2020 were retrospectively collected in this study. Demographics, clinical characteristics and surgical information were recorded. RESULTS A consecutive series of 28 patients with lumbar hernia were retrospectively collected, including 13 males (46%) and 15 females (54%). The ages of the patients ranged from 5 to 79 years (median: 55 years), with a mean age of 55.6 ± 14.9 years. A total of 7 cases had a history of previous lumbar trauma or surgery. There were 11 (39%), 15 (54%) and 2 (7.1%) cases had right, left and bilateral lumbar hernia, respectively. Superior and inferior lumbar hernia were found in 25 (89%) and 3 (11%) patients. General anesthesia was adopted in 16 cases (group A), whereas 12 patients received local anesthesia (group B). Patients in the group B had a shorter hospital stay than that of the group A (3.5 ± 1.3 days vs. 7.1 ± 3.2 days, p = 0.001), as well as total hospitalization expenses between the two groups (2989 ± 1269 dollars vs. 1299 ± 229 dollars, p < 0.001). With a median follow-up duration of 45.9 months (range: 1-113 months), only 1 (3%) lumbar hernias recurred for the entire cohort. CONCLUSIONS Lumbar hernia is a relatively rare entity, and inferior lumbar hernia is rarer. It is feasible to repair lumbar hernia under local anesthesia.

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Clinical, surgical characteristics and long-term outcomes of lumbar hernia.

Background A superior lumbar hernia is a posterior ventral hernia that is rarely encountered in the clinical setting. However, no standard operative strategy exists for superior lumbar hernia repair at present. Methods Twelve patients with primary superior lumbar hernia who underwent sublay repair via the retroperitoneal space with the Kugel patch between December 2008 and June 2019 were included in this study. The demographic, peri-operative and post-operative data of the patients were collected to analyse the effectiveness of this technique. Results All patients underwent an uneventful operation. The median operative time was 60 min, and the median blood loss was 35 mL. The median hernia defect area was 16 cm2 . Five medium-sized Kugel patches (11 cm × 14 cm) and seven large-sized Kugel patches (14 cm × 17 cm) were used for the repairs. The median visual analogue scale score on post-operative day 1 was 3. The median time to removal of drainage was 3 days. The median duration of the hospital stay was 3 days. No serious post-operative complications, including seroma, haematoma, incision or mesh infection, recurrence and chronic pain, occurred during the follow-up period. Conclusion Sublay repair for primary superior lumbar hernia with the Kugel patch shows benefits including a reliable repair, minimal invasiveness and few post-operative complications.

https://www.onlinelibrary.wiley.com/doi/pdf/10.1111/ans.15866

Sublay repair for primary superior lumbar hernia with the Kugel patch.

Lumbar hernias were proposed in 1672 by Barbette but the first case was not published until 1731 wherein Garangeot reduced a lumbar hernia during autopsy1; the first repair was conducted 19 years later by Ravaton.2 The lumbar region, formed by the twelfth rib, iliac crest, erector spinae, and external oblique denotes the site for herniation. Lumbar hernias are most commonly categorised anatomically, as superior lumbar hernia (Grynfeltt-Lesshaft triangle), inferior lumbar hernia (Petit triangle), or diffuse involvement. Other classifications include aetiology (primary or secondary) and sac content (extra-, paraor intra-peritoneal); however, none of these categorisations have any treatment value. In 2007, Moreno-Egea et al2 proposed a preoperative classification with surgical implications (hernia size, location, content, aetiology, muscle atrophy and recurrence), but this has yet to be universally applied. Owing to the rarity of lumbar hernia, a surgeon may only come across one case throughout their career.3 With only 300 cases reported, they comprise less than 2% of all abdominal hernias.3 Bilateral occurrences are even less frequently documented, with the first primary and secondary cases published in 2002 by Karmani et al4 and in 2006 by Bhasin et al5, respectively. Tung Wah Hospital performs an average of 500 hernia repairs annually, the majority of which are inguinal hernias; repair of lumbar hernias is uncommon, owing to their low incidence. Our most recent experience was in March 2017 when a 66-year-old man was referred to our centre for incidental finding of painless swellings over bilateral flanks which spontaneously reduced when the patient was supine; cough impulses were present. Aside from injuring his right lower ribs 2 months prior to presentation (treated conservatively), there was no trauma or surgical history. His past health includes hyperlipidaemia, benign prostatic hyperplasia, and obstructive sleep apnoea. His body mass index was 23 kg/m2. A clinical diagnosis of bilateral reducible superior lumbar hernias (within the Grynfeltt-Lesshaft triangle) was made (Fig 1). Prior to consulting us, the patient underwent computed tomography imaging with findings compatible with our diagnosis. Open repair was performed under general anaesthesia with the patient lying prone. Dissection of the latissimus dorsi muscle via a linear incision revealed the hernias bounded superiorly by Hong Kong Med J 2019;25:78–80 https://doi.org/10.12809/hkmj187410

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Bilateral lumbar hernia.

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.

L.G. Castañeda-González

Papers

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