Lumbar hernia

lumbar hernia repair
superior triangle,inferior triangle
grynfeltt ,jean louis petit

1. Lumbar hernia Georges KHALIFEH FFI GHPSO Chirurgie Digestive et Viserale

2. History J Grynfeltt   and  P Lesshaft   independently described superior lumbar hernias in 1866  8  and 1870  9 , respectively . The first description of the inferior or superficial lumbar hernia by French surgeon  Jean-Louis Petit  (1672-1750) in 1738

3. Epidemiology R are defect of the posterior abdominal wall with approximately 300 cases reported in the literature. The proportion of lumbar hernias to all abdominal hernias is less than 1.5%, and most of them are unilateral. Most common in patients aged between 50 and 70 years with a male predominance

4. Clinical presentation Patients with lumbar hernias can present with a variety of symptoms, including : posterolateral mass back pain bowel obstruction (if contents contain bowel) urinary obstruction (if contents are kidney/ureter).

5. Pathology Lumbar hernias occur through defects in the lumbar muscles or the posterior fascia, below the 12 th  rib and above the iliac crest.  Two types are described, according to the anatomical location of the hernial neck : superior lumbar hernia  ( Grynfeltt-Lesshaft hernia) ​ occurs through the  superior lumbar triangle inferior lumbar hernia  ( Petit hernia ) occurs through the  inferior lumbar triangle

6. S uperior triangle I nverted Deeper more constant most common B oundaries : posterior border of internal oblique ( anterior) anterior border of sacrospinalis ( posterior) 12th rib and the serratus posterior inferior muscle (base ) external oblique and latissimus muscle (roof ) aponeurosis of the transversus abdominis (floor). For all practical purposes it is an avascular space.

7. I nferior triangle Upright L ess constant M ore vascular boundaries are : posterior border of the external oblique muscle ( anterior) Anterior border of the latissimus dorsi muscle ( posterior) I liac crest (base ) S uperficial fascia (roof ) I nternal oblique (floor ) The inferior triangle is commonly referred to as the lumbar triangle being more superficial in location and easily demonstrable .

8. Contents Lumbar hernias may contain a number of intra- or retro-peritoneal structures including: stomach small  or  large bowel mesentery omentum ovary spleen kidney

9. LH diagnosis and treatment can be challenging

10. Etiology Congenital (20%) / Acquired (80%) There are three broad etiologies for lumbar hernias: C ongenital hernias  (20%) discovered in infancy and are due to defects in the musculoskeletal system may be associated with other malformations(renal agenesis, lumbo - costo -vertebral syndrome) P rimary acquired lumbar hernias  (55%) spontaneous, withou t a causal factor such as surgery, infection, or trauma risk factors include age, extremes of body habitus, quick weight loss, chronic disease, muscular atrophy, chronic bronchitis, wound infection, postoperative sepsis, and strenuous physical activity S econdary acquired lumbar hernias  (25%) blunt , penetrating, or crushing trauma fractures of the iliac crest surgical lesions hepatic abscesses infections in pelvic bones, ribs, or lumbodorsal fascia infected retroperitoneal hematomas

11. Patients usually present with nonspecific complaints. It has been observed to be more common in males and on the left side. Complications like incarceration, intestinal obstruction, strangulation and volvulus may occur.

12. Managment Surgical treatment of lumbar hernias is always recommended because of the risks of entrapment and strangulation. There is still ongoing discussion regarding which is the best surgical technique to be employed. It has been described that approximation of the limits of the hernia may be sufficient for small hernias, while in most cases the use of mesh is recommended. The growth in laparoscopic repair of abdominal wall hernias has brought on the use of the preperitoneal space ( sublay )

13. ( a) Large hernia sac after dissection of the subcutaneous tissue. ( b) Scheme representing a transverse anatomical view of the hernia sac protruding through the Petit’s triangle. T, transversum abdominis muscle; IO, internal oblique muscle; E, external oblique muscle ; LD, latissimus dorsi muscle

14. Moreno- Egea et al T herapeutically classification system : four types of LH based on six criteria: Size Location Contents muscular atrophy Origin existence of previous recurrence The presence of at least two criteria is necessary for defining the LH type

15. Classification of LH according to Moreno- Egea et al. EP: extraperitoneal ; IP: intraperitoneal ; LH: lumbar hernia; LPS: laparoscopy; TEP: total extraperitoneal

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