Lumbar hernias are rare hernias. Hafner et al1 stated that a general surgeon will get only one opportunity to repair a lumbar hernia during his life time. Lumbar hernia was first reported by P. Barbette in 1672. Since then, only about 300 cases have been reported2.
The lumbar region is bounded superiorly by the 12th rib, inferiorly by the iliac crest, medially by the erector spinae muscles and laterally by the external oblique muscle. Lumbar hernias occur through superior and inferior lumbar triangles in the lumbar region. Inferior lumbar triangle is bounded by the iliac crest inferiorly, external oblique muscle laterally, latismus dorsi muscle medially. Superior lumbar triangle which is the larger one, is an inverted triangle, the base is formed by 12th rib and the lower edge of the serrratus posterior inferior muscle, anterior boundary is formed by the internal oblique muscle and the roof is formed by external oblique and latissimus dorsi2.
Lumbar hernias can be congenital (20%) or acquired (80%). An acquired hernia may be primary or secondary. Secondary hernias can be spontanoues or secondary to trauma, surgery and infection. Several risk factors have been described for spontaneous hernias, including age, obesity, extreme thinness, intense wasting, chronic debilitating disease, muscular atrophy, chronic bronchitis, infected wound, and postoperative sepsis3.
Elective surgery remains the mainstay of treatment. Despite the different techniques recommended, the open approach is most affordable in our setup. We report a case of primary spontaneous lumbar hernia which was repaired by an open approach.
Case Report
50 year old female patient came with complaints of swelling and discomfort in left lumbar region for few weeks. She had no bowel or bladder disturbances. There was no history of previous surgery or trauma. On examination there was a globular, soft, non-tender, reducible, non-pulsatile swelling of size 6×6 cm located in the left lumbar region with an expansile cough impulse (Figure 1). The swelling was more prominent with straining and disappeared with prone position. Examination of rest of the abdomen, right flank, back & other hernial orifices was normal.
CT revealed evidence of a focal defect on posterior abdominal wall in the left paravertebral tranversalis fascia at L2 vertebral level, measuring 10×9 mm, with thinning of left latismus dorsi muscle and herniation of omental fat. Sac measured 65×32×34 mm (Figure 2).
Patient was taken up for surgery after routine pre operative investigations. Under spinal anesthesia, the patient was placed in right lateral position. Longitudinal incision was placed over the lumbar region. The hernia sac was identified and opened. The content being the extra peritoneal fat, was completely reduced (Figure 3). The size of the defect was about 1×1 cm which was primarily repaired with (1-0) polypropylene interrupted suture and then an onlay polypropylene mesh was placed over the defect (Figure 4). Overlying muscle was closed using polypropylene continuous sutures. The skin was closed with staplers. The postoperative period was uneventful and the patient was discharged on 1st postoperative day.
Discussion
Lumbar hernias present as a swelling on one or both sides over the back which increases in size on coughing and reduces on lying down. Patients may present with discomfort or nonspecific abdominal pain or back pain. Complications are rare but may occur in the form of bowel obstruction and sometimes hydronephrosis. The most common differential diagnosis is lipoma.
USG may not be helpful in diagnosis and CT scan remains the gold standard for detection of lumbar hernia and also for planning the surgical treatment.
91% of the patients present as non emergency cases and only 9% present as surgical emergencies to the hospitals4. Surgical treatment is the only option and it should be considered early to avoid complications.
Conclusion
Lumbar hernias are rare. USG may not be helpful in diagnosis of lumbar hernia, CT scan is the investigation of choice. Laparoscopy / open repair are the options for lumbar hernia mesh repair. Elective repair is recommended to avoid complication due to hernia.
References
- Hafner C., Wylie J., Jr., Brush B.E. Petit's lumbar hernia: repair with Marlex mesh. Arch Surg. 1963;86:180–186.
- Moreno-Egea A., Baena E.G., Calle M.C., Martínez J.A., Albasini J.L. Controversies in the current management of lumbar hernias. Arch Surg. 2007;1:82–88.
- Rajasekar M, Kumar KV. A rare case of lumbar hernia: a case report with review of literature, IOSR, 2015; 14(3): 10–13
- Alfredo M.-E., Enrique G.B., Miquel C.C., José Antonio T.M., José L.A. Controversies in the current management of lumbar hernias. Arch Surg. 2007;142:82–88.