Primary lumbar hernia repair: the open approach

BACKGROUND: Lumbar hernias arise through posterolateral abdominal wall defects, named inferior triangle (Petit) and superior triangle (Grynfelt). Most of the lumbar hernias are secondary to trauma or previous surgery, while primary lumbar hernias are rare. There are two possible surgical approaches: the anterior approach with lumbar incision and the laparoscopic (transabdominal or totally extraperitoneal) approach. METHODS: We present a series of nine surgical procedures for primary lumbar hernia in 7 adult patients (2 affected by bilateral hernias). Seven were Grynfelt hernias, and two were Petit hernias. All surgical repairs were performed using synthetic mesh placed in the extraperitoneal space, below the muscular layers, using a tension-free technique. RESULTS: There was no surgical complication, except for 1 case with a subcutaneous haematoma. The mean hospital stay was 2.3 days. All patients returned to normal daily activities within 15 days after surgery. After a median follow-up period of 25 months, there was no case of recurrence or postsurgical sequelae, such as pain or muscular weakness. CONCLUSIONS: Primary lumbar hernias are rare congenital defects of the abdominal wall. Repair of these rare hernias can be successfully performed via the anterior approach with the use of synthetic mesh - this method of repair is easy, safe, and effective.     

Grynfelt hernia: case report and literature review

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.     

Grynfeltt's hernia

Summary The aim of this study is to report a case and review the relevant literature. The patient was a 64-year-old male with a right lumbar mass of 5 × 6 cm, which protruded when abdominal pressure was increased. Surgery revealed a defect of 3 × 2 cm in the transversalis fascia in the superior lumbar triangle; prosthetic material was used in the preperitoneal space. Lumbar hernias are rare defects of the abdominal wall (2% of wall hernias); fewer than 300 cases have been reported in the literature. All lumbar hernias can be corrected with surgical treatment. A tension-free mesh repair is almost always necessary, and gives satisfactory results.     

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

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.     

局麻下同时性双侧腹股沟无张力疝修补术

目的探讨局麻下同时施行双侧腹股沟疝无张力修补术治疗的可行性和安全性。摸索适合我国国情的双侧腹股沟疝的外科处理方式。方法回顾性分析2002年5月至2008年4月在局麻下施行无张力疝修补术的235例患者,其中同时性双侧疝修补96例,分期双侧疝修补27例和单侧疝修补112例。结果所有手术均在局麻下完成,手术方式均为疝环填充式（mesh-plug）无张力疝修补。96例同时性双侧疝修补均由同一医师序列完成双侧修补;同时性双侧修补术平均手术时间（92±23）min,单侧疝修补术平均手术时间（56±21）min,二者比较差异有统计学意义（P〈0.05）。平均住院时间,阴囊积液或血肿,切口感染,尿潴留,术后疼痛,术后6个月内腹股沟区疼痛或不适和术后复发差异无统计学意义（P〉0.05）。结论双侧腹股沟疝可以在局麻下施行同时性无张力疝修补,安全可行,避免了患者行分期手术的痛苦。     

Hernia repair in elderly patients

Background This study evaluates a 5-year experience of the management of the most frequent abdominal wall hernias in an elderly population. Methods From April 1990 to December 1995, 231 inguinal, 12 femoral and seven umbilical hernias were repaired in 221 patients (mean age 74 (range 66–93) years). Concomitant diseases were present in 157 patients, A mesh repair was performed with ‘tension-free’ or ‘plug’ techniques in all but 23 inguinal and two femora! hernia repairs, in which the Bassini or Shouldice procedures were adopted. Ten emergency hernia repairs were performed for strangulation. A total of 232 operations, including four emergency hernia repairs, were carried out under local anaesthesia. Results There was no perioperative mortality. Acute intestinal bleeding occurred 2 days after surgery in a patient with colonic diverticular disease. Urinary retention occurred once following emergency hernia repair under general anaesthesia and twice after elective hernia repair under local anaesthesia. Local complications included four scrotl haematomas (2 per cent), three wound infections (1 per cent) and one case of orchitis with atrophy after repair of a recurrent hernia. There was one recurrence after a Bassini repair and one after Shouldice inguinal herniorrhaphy. No recurrence was observed after mesh repair. Conclusion Local anaesthetic mesh hernia repair is safe and effective in elderly patients. Age should be no bar to elective hernia repair. This policy should avoid the complications of emergency operation.     

Feasibility of local infiltration anaesthesia for recurrent groin hernia repair.

OBJECTIVE: To describe the the feasibility of and patients' satisfaction with day case repair of recurrent inguinal hernias under unmonitored local anaesthesia. DESIGN: Prospective study. SETTING: Public service university hospital, Denmark. SUBJECTS: All patients with a reducible recurrent inguinal or femoral hernia unselectedly referred for elective repair during the 4-year period 1 September 1994 to 31 August 1998. INTERVENTIONS: Data were collected prospectively and consecutively from standardised, detailed files, a questionnaire 4 weeks postoperatively, and the Copenhagen Hospitals electronic patient data management system. MAIN OUTCOME MEASURES: Feasibility of local anaesthesia in the day case setting, patient satisfaction and morbidity. RESULTS: 215 consecutive operations for recurrent hernias were performed under unmonitored local anaesthesia. No conversion to general anaesthesia took place and no patients developed urinary retention. After 207 operations, the patients were discharged on the day of operation (96%), and the median time from the end of operation to discharge was 90 minutes (IQR 75-140). After 6 operations (3%), patients had complications that required surgical intervention. The 4-week questionnaire was returned after 208 operations (97%). 30 patients were dissatisfied, mainly because of intraoperative pain (17 patients, 8%). No mortality or cardiopulmonary morbidity was recorded during the first 30 days postoperatively. CONCLUSIONS: Open day-case repair of recurrent inguinal hernias can safely be conducted under unmonitored local anaesthesia with minimal morbidity. Intraoperative pain is the main topic that requires improvement.     

Regional anaesthesia in the outpatient treatment of bilateral inguinal hernias using totally extraperitoneal laparoscopy

The treatment of bilateral inguinal hernias using totally extraperitoneal laparoscopy is usually done with general anaesthesia. The objective of this article is to evaluate the regional anaesthesia technique in extraperitoneal laparoscopic surgery for treating bilateral inguinal hernias in an outpatient surgery unit. Prospective clinical study of 30 patients with uncomplicated bilateral inguinal hernia undergoing surgery using extraperitoneal laparoscopy. The anaesthesic technique used were spinal regional anaesthesia. We analysed clinical data (age, sex, associated diseases, prior abdominal surgery, site and hernia type), intra-operative complications (bleeding, peritoneal rupture, subcutaneous emphysema, reconversion rate, haemodynamic stability, respiratory problems and degree of satisfaction), postoperative complications (haematomas, urinary retention, post lumbar puncture headaches, nausea, vomiting and postoperative pain) and recurrence rate. All the patients undergoing surgery under-spinal anaesthesia in any case was necessary to reconvert it to general anaesthesia. In conclusion, regional anaesthesia is safe and efficient in an outpatient surgery unit in the treatment of bilateral inguinal hernias.     

Repair of lumbar incisional hernia using polypropylene mesh strip sutures – A case report

IntroductionLumbar hernias are considered rare and they constitute less than 1.5% of all abdominal wall hernias.Case reportHere we present a case of a 72-year-old female with a left flank swelling since 2-years diagnosed as a lumbar incisional hernia. This lumbar incisional hernia¹ was repaired successfully using polypropylene mesh strip sutures.²DiscussionMany surgical techniques have been described for repair of LIH. Suture repair, mesh repair and myofascial flaps have been described for lumbar hernias. Repairing a lumbar hernia can be surgically challenging because of its proximity to bony structures, which can limit proper dissection and mesh overlap. We performed defect closure with PMSS. Patient has no recurrence after 2 years of follow up.ConclusionIn our case of left lumbar incisional hernia, defect closure with PMSS was an effective operation. This technique may also be effective in potentially contaminated settings due to reduced implant load. Further studies are required to understand its biomechanics and long-term outcomes.     

Spigelian Hernia

We report on the evolution in concept and techniques that allowed us to improve the treatment of spigelian hernia, operable in day surgery in 90% of cases and through a preperitoneal and recently a preperitoneal and subfascial prosthetic repair (PHS). Background data. We propose an innovative use of the PHS mesh for spigelian hernia repair. With this new implementation, we confront the standard surgical technique and its postoperative period. Methods. From January 1992 to March 2004, we performed 2,500 hernia surgical operations, including 32 spigelian hernia repairs (1.3% of total case series). The first surgical approach used for 20 of these 32 patients (62.5% of total spigelian hernias), all electively operated on, was a classical preperitoneal repair (Wantz), performed when possible by size of defect and weight (Body Mass Index) of the patient, under local anesthesia and on a day-surgery basis. Our new modified technique takes place through the insertion of a PHS large-type mesh, whose bottom underlay portion lies flat in the preperitoneal space with the connector obliterating the hernial orifice and with the overlay portion lying on the internal oblique muscle, covered by the aponeurosis of the external oblique muscle. Results. Our modification to the classical technique consisted only in the application of a product, such as the PHS, in a hernia defect, which presented with an orifice of the size of the connector and, therefore, was easily repairable with the use of the PHS device. This approach is easier than the preperitoneal approach, its always suitable for local anaesthesia, and it gives a more comfortable postoperative period. The surgical approach may be performed completely in day surgery. Conclusions. We believe that spigelian hernia surgical repair should always be performed by means of a preperitoneal prosthesis under local anaesthesia when the patients clinical and physical conditions allow for it, always in day surgery, and using the PHS mesh when the hernia defect size fits with the connector diameter. This last possibility seems to be easier and more comfortable for the patient in the postoperative period.     

A Grynfeltt hernia: Report of a case

Superior lumbar hernia (Grynfeltt hernia) is an uncommon variety of abdominal wall defect. There are three types of lumbar hernia: congenital, acquired, and incisional hernias. Diagnosis depends largely on the capacity for clinical suspicion, and confirmation is based on imaging tests. We report a case of an acquired lumbar hernia diagnosed by computed tomography (CT), which was treated successfully at our institution.     

A different type of congenital lumbar hernia associated with the lumbocostovertebral syndrome

Congenital lumbar hernia is rare in infancy and childhood, and its association with the lumbocostovertebral syndrome is even more unusual. Only 20 cases have been reported in the English literature. We present the case of a child with multiple costovertebral anomalies, undescended testis, and lateral abdominal wall hernia that is not within the anatomical boundaries of traditional lumbar hernias.     

Petit Lumbar Hernia—a Double-Layer Technique for Tension-Free Repair

This report describes an alternative technique for Petit hernia repair. The treatment of lumbar hernias should follow the concept of tension-free surgery, and the preperitoneal space can be the best place for prosthesis placement. An obese patient had a bulge in the right lumbar region, which gradually grew and became symptomatic, limiting her daily activities and jeopardizing her quality of life. She had previously undergone 2 surgical procedures with different incisions. We created a preperitoneal space and attached a mesh in this position. Another prosthesis was placed on the muscles, with a suitable edge beyond the limits of the defect. There were no complications. It has been described as a safe and tension-free repair for Petit hernia. In larger defects, a second mesh can be used to prevent further enlargement of the triangle and also to provide additional protection beyond the bone limits.Key words: Hernia, Lumbar hernia, Open repair, Prosthetic mesh repairDorsal or lumbar hernias are found in the posterior abdominal wall at the level of the lumbar region. This condition is uncommon, and there are no major series of such cases reported in the literature. They can be classified as congenital or acquired conditions. Acquired hernias are almost always unilateral and have etiopathogenic factors such as obesity, coughing, repeated physical activity, and parietal weakening.^1–3The most common site for the occurrence of lumbar hernias is in the superior lumbar triangle (Grynfeltt) and less commonly in the inferior lumbar triangle (Petit).¹ Surgical treatment of lumbar hernias is always recommended because of the risks of entrapment and strangulation.⁴ 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). In this site, using mesh requires skill and experience in order to create sufficient space and to ensure proper placement of the mesh beyond the limit of the bones in the Petit‘s triangle. We present an alternative technique for tension-free repair of lumbar hernias when the use of laparoscopy is not recommended.     

Over a thousand ambulatory hernia repairs in a primary care setting

INTRODUCTION

This paper outlines the development and feasibility of a dedicated ambulatory primary care hernia service and examines the outcomes achieved during the period 1 March 2005 to 31 December 2008.

PATIENTS AND METHODS

A prospective analysis of 1164 patients who underwent abdominal wall hernia repair at Probus Surgical Centre during the study period. The operations were carried out by two GPs with a special interest (GPwSI) and one retired surgeon. The techniques used were a Lichtenstein mesh repair or modified Shouldice repair for inguinal hernias and a primary sutured repair for ventral hernias. All procedures were performed as day-cases under local anaesthesia without sedation. All patients were reviewed routinely at 6 weeks. The primary outcomes of the study were recurrence and patient satisfaction levels, and complications such as infection, haematoma and chronic pain.

RESULTS

No patient required conversion to general anaesthesia. There were three (0.3%) recurrences. Complication rates were low and similar to those obtained in other specialist hernia units. More than 90% of patients were satisfied with the service and would recommend it to a friend.

CONCLUSIONS

Routine elective abdominal wall hernia repairs can be performed in a primary care setting, safely and with excellent outcomes.     

Laparoscopic tension-free hernioplasty for lumbar hernia

Lumbar hernia, a defect of the posterior abdominal wall, is a very rare condition. The repair of a posterior abdominal wall hernia by simply closing the hernia port with sutures may not be adequate, especially when the herniation is due to a weakness in the abdominal wall. Recently, a simple, logical method of tension-free repair has become a popular means for the treatment of various abdominal wall hernias. Previous studies have advocated the use of tension-free repair for lumbar hernia; the technique uses a mesh replacement and requires an extensive incision. Herein we present a case of superior lumbar hernia. Our technique consisted of a laparoscopic tension-free hernioplasty with the application of a Prolene mesh. This technique, which provides an excellent operative view, is safe, feasible, and minimally invasive. We conclude that laparoscopic tension-free repair should be the preferred option for the treatment of lumbar hernia.     

Laparoscopic repair of Morgagni hernia and paraesophageal hernia on the same patient

Morgagni hernias have been recognized with increasing frequency as a source of abdominal pain and dyspnea in adults. Morgagni hernias are rarely accompanied by paraesophageal hernias. We report a case of Morgagni hernia associated with paraosephageal hernia, both repaired laparoscopically. On the 65-year-old woman patient, diaphragmatic defect and paraesophageal hernia were closed with primary sutures, and Hill-type gastropexy was performed successfully. The procedure lasted 115 min. The patient was discharged 5 days after surgical treatment and there were no complications following the operation. Primary closure with direct sutures is rapid, simple, and effective and can be combined with other laparoscopic procedures, as in our case. It can be performed by surgeons trained in intracorporeal suturing and knotting in all kinds of hospitals. The laparoscopic approach to Morgagni hernias minimizes trauma and shortens postoperative hospital stay, and patients have a comfortable postoperative period.     

General vs regional anaesthesia in outpatient treatment for inguinal hernias using extraperitoneal laparoscopy

Summary The treatment of inguinal hernias using laparoscopy can be performed without violating the peritoneal cavity using the totally extraperitoneal technique (TEP). This procedure is usually done with general anaesthesia. The objective of this article is to evaluate the general and regional anaesthesia techniques in extraperitoneal laparoscopic surgery for treating inguinal hernias in an outpatient surgery unit. A prospective clinical study of 131 patients with uncomplicated inguinal hernia undergoing surgery using extraperitoneal laparoscopy was completed. Two study groups were established according to the anaesthesia technique used: general (n = 90) and regional (n = 41). We analyzed clinical data (age, sex, associated diseases, prior abdominal surgery, site and hernia type), intra-operative complications (bleeding, peritoneal rupture, subcutaneous emphysema, reconversion rate, haemodynamic stability, respiratory problems and degree of satisfaction), postoperative complications (haematomas, urinary retention, post lumbar puncture headaches, nausea, vomiting and postoperative pain) and recurrence rate. General anaesthesia was used significantly more in the cases of prior infra-umbilical surgery and bilateral hernias (p < 0.05). Statistically significant differences were not shown for intra- or post-operative complications. The rate of conversion was higher for general (5.5%) than for regional anaesthesia (2.4%). Recurrence was detected only in the regional anaesthesia group. In conclusion, general anaesthesia is not required for the performance of extraperitoneal laparoscopic inguinal hernia repair; regional anaesthesia is a safe and efficient alternative.     

Tension free perineal hernioplasty: report of a case

Summary Perineal hernias are extremely rare in clinical practice, most being secondary to radical pelvic surgery. Different surgical approaches have been described, with primary closure as well as with the use of flaps and mesh. We report the case of a 35 year old female with a primary anterior perineal hernia, that was repaired using a cone of polypropylene mesh through a perineal approach under regional anaesthesia. Two years later she remains asymptomatic without recurrence. We believe this is the first report of such repair for a primary perineal hernia.     

Intramesosigmoid hernia: a rare type of congenital internal hernia

Intestinal obstruction from congenital internal hernias is a rare and often unsuspected problem. We report the case of a 66-year-old male with a rare type of congenital internal hernia causing bowel obstruction. He underwent successful laparoscopy-assisted surgical repair without bowel resection. Symptomatic congenital internal hernias usually present with intermittent or acute small-bowel obstruction without any history of previous abdominal surgery. Laparoscopy or hand-assisted laparoscopy can be useful tools for locating the region of pathology and enable minimally invasive surgical treatment.     

A new method for inguinal hernia repair]

We report 60 operations for groin hernia which were performed with Artschvadze's new method. 45 operations were carried out under local anaesthesia, 15 under general anaesthesia. 46 primary and 14 recurrent hernias were included in the study. During a follow-up of 6-30 months no recurrences were seen.