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LUMBAR HERNIA

Satish R Ranka*, Ganesh Bakshi**,Mnanmohan Kamat***, J D Mohite****
*Medical Officer; **Fourth Year Resident; ***Lecturer; ****Unit Chief and Professor, Department of General Surgery, Seth GS Medical College and KEM Hospital,Mumbai, 400 012.

In this article we report a case of lumbar hernia. The patient underwent perperitoneal meshplasty. The patient is well on follow up with no recurrence. The relevant literature has been reviewed and management discussed in brief.

INTRODUCTION

Superior lumbar hernia is one of the rare hernias. It can occur individually or in associated with certain syndromes or following trauma. We report a case of Lumbar hernia which was treated successfully at our institution.

CASE REPORT

A 60 year old lady presented to the surgical OPD with complains of swelling in left lumbar region associated with dull aching pain since 5-6 months. The swelling used to appear on coughing and disappear on compressing it. There was no history suggestive of irreducibility. There was also no history of trauma, surgery done in past or localized muscular paralysis.

On examination there was a single oval swelling of 10 x 6 cms arising from the superior lumbar triangle with an expansile impulse on coughing. It was non tender and reducible with a gurgle. The opposite side lumbar region and other hernial orifices were normal. The abdominal muscle tone was good.

Patient was thoroughly investigated, Anaesthesia fitness and consent was taken.

Left lumbar preperitoneal meshplasty with few stabilization sutures with prolene was done.

The patient was well on follow up with no recurrence.

DISCUSSION

Lumbar hernia is a rare hernia which accounts for less than 1.5% of total hernia incidence. Only 200-300 cases have been reported in the literature. It herniates through superior/inferior lumbar triangle. Herniation through inferior triangle is more common, probably due to variable attachment of external oblique and latissimus dorsi to iliac crest. If they are closely attached then this triangle is not present and no hernia occurs.[1]

Fig. 1
Fig.1 : Left lumbar hernia - Anterior view.

Fig. 2
Fig.2 : Left lumbar hernia - Lateral view.

 

Anatomy

Superior Triangle of Grynfeltts and Lesshaft

It lies above and anterior to triangle of Petit.

Boundaries

Above : 12th rib and lower border of serratus posterior inferior.

Anteriorly : Posterior border of internal oblique.

Posteriorly : Quadratus lumborum and erector spinae.

Floor : Transversalis fascia.

Roof : Latissimus dorsi.

AETIOLOGY

1. Congenital : Individually or associated with 1) Other abdominal hernias[2] viz. epigastric, inguinal 2) Lumbocostovertebral syndrome[3] 3) Neurofibromatosis type 1.[4]

2. Acquired : Trauma, localised muscular paralysis (e.g. polio), post laparoscopic cholecystectomy.[5]

Lumbar hernia does not include hernia following an operation on kidney which is an incisional hernia.[6]

PRESENTATIONS

1. Lump

2. Backache with pain radiating to groin due to irritation of lateral cutaneous branch of 10,11,12th intercostal nerves.

3. Obstruction

COMPLICATIONS

1. Irreducibility

2. Incarceration[7]

3. Strangulation.

INVESTIGATION

It has been demonstrated on flow phase of a Te-99m MDP three phase bone scan.[8]

DIFFERENTIAL DIAGNOSIS

1. Lipoma

2. Cold abscess

TREATMENT

Before the era of meshplasty, Dowd repair[9] was practised. It involved closure of defect by a pedical flap of tensor fascia lata and gluteus maximus from below the iliac crest with side to side opposition of external oblique and latisimus dorsi for petits triangle hernia. For superior triangle flaps from adjacent structures were developed.

Presently if the defect is small and good, strong tissue around, then defect can be closed with continuous polypropylene suture.

For large defect, poor muscular tissue, preperitoneal meshplasty is the preferred treatment. Lately in the laparoscopic era, lumbar hernia are repaired laparoscopically with prosthetic mesh.[10]

ACKNOWLEDGEMENTS

We are grateful to the Dean of Seth GS Medical College and KEM Hospital for granting us permission to publish the case report.


REFERENCES

  1. Jack Abrahamson. Hernia’s : Maingot’s Abdominal Operations : 9th Edition, US. 271.
  2. Cocozza E, Pidoto RR, Ravera M. Bilateral lumbar hernia associated with lumbar hernias. Minerva Chirurgica 1999; 54 (6) : 421-3.
  3. Helderman-van der Enden AT, Bartelings MM, van Kamp IC, et al. Body wall defects in two sibs. American Journal of Medical Genetics 1997; 73 (1) : 15-8.
  4. Rimmelin A, Dias P, Salatino S, et al. Colonic lumbar hernias secondary to congenital bone anomalies in a case of neurofibromatosis type 1. Journal de Radiologie 1996; 77 (4) : 279-81.
  5. Kennedy RJ, Tulloh BR. Lumbar hernia : another rare complication of laparoscopic cholecystectomy. (Letter; Comment). Medical Journal of Australia 1997; 166 (4) : 222.
  6. Allan Clain. Hamilton Bailey’s Demonstration of Physical Signs. Oxford : Butterworth - Heinemman. 17th Edition. 1994; 272.
  7. Zamir G, Gross E, Simha M. Incarcerated lumbar hernia. Injury 1998; 29 (7) : 561-3.
  8. Gerard PS, Moallem A, Limani R. Demonstration of a lumbar hernia on the flow phase of a Te-99m MDP three phase bone scan. Clinical Nuclear Medicine 1996; 21 (11) : 877-8.
  9. Dowd CN. Congenital lumbar hernia at the triangle of Petit. Annals of Surgery 1907; 45 : 245.
  10. Bickel A, Haj M, Etian A. Laparoscopic management of lumbar hernias. Surgical Endoscopy 1997; 11 (11) : 1129-30.

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