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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 55  |  Issue : 6  |  Page : 234-237

The lumbar hernia: A clinical conundrum


Department of General Surgery, SGT Medical College and Hospital and Research Institute, Gurugram, Haryana, India

Date of Submission20-Apr-2022
Date of Decision26-Jul-2022
Date of Acceptance23-Aug-2022
Date of Web Publication22-Nov-2022

Correspondence Address:
Manjit Tanwar
Department of General Surgery, SGT Medical College and Hospital and Research Institute, Badli Road, Near Sultanpur Bird Sanctuary, Gurugram - 122 505, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_91_22

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  Abstract 


Lumbar hernias are rarely encountered as compared to other ventral abdominal wall hernias and are often misdiagnosed and overlooked. They account for less than 1.5% of all abdominal hernias. Fewer than 300 cases have been reported over the past 300 years. A lumbar hernia is defined as a protrusion of intra-abdominal contents through a weakness or rupture in the posterior abdominal wall. It must be distinguished from a lipoma, cold (tuberculous) abscess or a pseudo-hernia due to local muscular paralysis. Presenting a case of 65-year-old female who came to surgery OPD with complaint of a swelling in the right lumbar area since 5 years. On examination, a smooth and non-tender swelling measuring approximately 4 x 3 cm was evident in right lumbar region. We proceeded with a lumbar ultrasound which confirmed the presence of the hernia in posterior abdominal wall. Later, the patient was admitted for surgery under spinal anaesthesia. An open approach was performed and intraoperative findings revealed retroperitoneal fat, intermuscular lipoma and a small hernia sac as contents of swelling. It is very unusual to find lumbar hernias presenting with a lipoma, as in our case, the clinical findings alone can be very confusing and increase the chances of incorrect diagnosis and subsequent treatment. Inability of clinical examination and ultrasonography alone in making an adequate diagnosis of lumbar hernia in preoperative setting mandates a routine CT/MRI for all such patients, to ensure surgeons have a correct diagnosis before proceeding for surgery. Ideal management is just like other hernias, i.e., with mesh hernioplasty either laparoscopically or through an open approach.

Keywords: Lipoma, lumbar hernia, rare


How to cite this article:
Dagar A, Hurria N, Chandrakar S, Tanwar M, Gupta S, Sinha A. The lumbar hernia: A clinical conundrum. Formos J Surg 2022;55:234-7

How to cite this URL:
Dagar A, Hurria N, Chandrakar S, Tanwar M, Gupta S, Sinha A. The lumbar hernia: A clinical conundrum. Formos J Surg [serial online] 2022 [cited 2022 Nov 26];55:234-7. Available from: https://www.e-fjs.org/text.asp?2022/55/6/234/361707




  Introduction Top


Lumbar hernias are rarely encountered hernias and are often misdiagnosed and overlooked. A lumbar hernia is defined as a protrusion of intra-abdominal contents through a weakness or rupture in the posterior abdominal wall. Lumbar hernias can emerge through the superior lumbar triangle (Grynfeltt-Lesshaft triangle) which is surrounded by the 12th rib, paraspinal muscles, and internal oblique muscle.[1],[2]

A lumbar hernia can also present itself through the inferior lumbar triangle (Petit triangle), which is surrounded by the iliac crest, latissimus dorsi muscle, and external oblique muscle. Weakness of the lumbodorsal fascia through either of these areas results in progressive protrusion of extraperitoneal fat and a hernia sac. Lumbar hernias are not prone to incarceration. Small lumbar hernias are frequently asymptomatic. Back pain may be associated to larger hernias.[2]

A lumbar hernia must be distinguished from a lipoma, cold (tuberculous) abscess, or a pseudohernia due to local muscular paralysis. Lumbar pseudohernia can result from any interference with the nerve supply of the affected muscles, the most common cause being injury to the subcostal nerve during a renal operation.[3]


  Case Report Top


A 65-year-old female came to the surgery outpatient department with complaint of a swelling in the right lumbar area for the past 5 years. A smooth and nontender swelling measuring approximately 4 cm × 3 cm was evident in the right lumbar region [Figure 1] with positive slip sign and a cough impulse. The lumbar swelling was only partially reducible in the left lateral position. We proceeded with a lumbar ultrasound which confirmed the presence of the hernia in posterior abdominal wall measuring 10.6 mm. Omental fat was seen herniating in the right lumbar region through the superior lumbar triangle; hence, the patient was provisionally diagnosed with Grynfeltt hernia. After taking an informed and written consent regarding inclusion of patient's physical and clinical details as well as preoperative and intraoperative photos into the current study, the patient was admitted for surgery under spinal anaesthesia. An open approach was performed. A lumbar transverse incision was made over the swelling. Intraoperative findings revealed retroperitoneal fat, intermuscular lipoma, and a small hernia sac as contents of swelling [Figure 2] and [Figure 3]. After removal of the intermuscular lipoma, a 3 cm × 1.5 cm-sized hernial defect was observed in the superior lumbar triangle [Figure 4]. Grynfeltt hernial sac was dissected and redeposited into the cavity. Polypropylene mesh was placed under the muscular layer [Figure 5], and the defect was closed with vicryl sutures. Postoperative period was uneventful, and the patient was discharged on day 2 postprocedure. Follow-up consultations with the patient took place at the 1-week, 4-week, and 3-month mark, from the date of the procedure, with no new issues reported and a normal physical examination.
Figure 1: Pre operative picture of swelling in right lumbar region

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Figure 2: Intra operative findings

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Figure 3: Excision of Lipoma and separating sac from its attachments

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Figure 4: The hernial sac

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Figure 5: Mesh placement and closure

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  Discussion Top


Compared to other ventral abdominal wall hernias, lumbar hernias are rare. They account for <1.5% of all abdominal hernias. Fewer than 300 cases have been reported over the past 300 years.[4] Lumbar hernias have been categorized as congenital (20%) and acquired (80%). Acquired are further classified as primary if they occur spontaneously and secondary if there is a predisposing cause such as trauma, infection, or previous surgery.[5]

Clinically, spontaneous lumbar hernia presents as a swelling over lower back or flanks,[5] but a traumatic lumbar hernia, in addition, may be associated with flank pain and hematoma.[6]

Lumbar hernias need to be differentiated from lipomas, hematomas, fibromas, abscesses, and kidney tumors. Lipomas are usually soft and freely mobile masses. Fibromas are firm masses attached to fascia or muscle. Hematomas present with local ecchymosis. Abscesses present with pain, edema, cellulitis, fever, and leucocytosis. Kidney tumors are painless, firm to hard in consistency, and dull on percussion and may be associated with hematuria. None of these differential diagnoses exhibit demonstrable cough impulse or decrease in size in lateral position.[4],[7]

It is very unusual to find lumbar hernias presenting with a lipoma; as in our case, the clinical findings alone can be very confusing and increase the chances of incorrect diagnosis and subsequent treatment.[4],[7] Although many case reports and case series on lumbar hernia are available in the medical literature, only a handful of reports of lumbar hernia with intermuscular lipoma have been published.[8],[9] In our case, we were fortunate that the swelling in the lumbar region was partially reducible; hence, we could make a diagnosis of hernia preoperatively. To highlight the clinical dilemma, authors would like to quote here a case with confounding clinical findings, precluding a correct preoperative diagnosis of lumbar hernia, eventually leading to multiple surgeries of the patient.[8]

A very important observation was made by the authors while reviewing a landmark case series on lumbar hernia by Hsu et al. In 11 of 15 patients included in the study, a computed tomography (CT)/magnetic resonance imaging (MRI) was done which confirmed lumbar hernia preoperatively. Of the remaining four patients who did not have preoperative CT/MRI, three were taken up for surgery with a preoperative diagnosis of lipoma on the basis of clinical examination and ultrasonography. Howwever, during surgery, surgeons confirmed the swelling to be a lumbar hernia and not a lipoma.[6] This point highlights the inability of clinical examination and ultrasonography alone in making an adequate diagnosis of lumbar hernia in preoperative setting. Thus, mandating a routine CT/MRI for all such patients, to ensure surgeons have a correct diagnosis before proceeding for surgery.

Various surgical approaches can be used for repairing lumbar hernias. Although the conventional open approach is still the most popular choice of technique mainly due to its safety, effectiveness and affordability,[6] minimally invasive techniques such as the intraperitoneal and extraperitoneal approaches are also becoming increasingly popular.[10]


  Conclusion Top


It is very rare to witness a case of lumbar hernia presenting along with an intermuscular lipoma. Such cases are clinically difficult to diagnose. Radiological investigations help confirm the diagnosis. Ideal management is just like other hernias, i.e., with mesh hernioplasty either laparoscopically or through an open approach.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Piozzi GN, Cirelli R, Maino ME, Lenna G. Management criteria of Grynfeltt's lumbar hernia: A case report and review of literature. Cureus 2019;11:e3865.  Back to cited text no. 1
    
2.
Ahmed ST, Ranjan R, Saha SB, Singh B. Lumbar hernia: A diagnostic dilemma. BMJ Case Rep 2014;2014:bcr2013202085.  Back to cited text no. 2
    
3.
Nixon SJ, Tulloh B. Abdominal wall, hernia and umbilicus. In: Williams NS, Bulstrode C, O'Connell PR, editors. Bailey & Love's Short Practice of Surgery. 26th ed. Florida USA: CRC Press-Taylor & Francis Group; 2013. p. 966-7.  Back to cited text no. 3
    
4.
Sharma P. Lumbar hernia. Med J Armed Forces India 2009;65:178-9.  Back to cited text no. 4
    
5.
Wei CT, Chen YS, Sun CK, Hsieh KC. Single-incision laparoscopic total extraperitoneal repair for a Grynfeltt hernia: A case report. J Med Case Rep 2014;8:16.  Back to cited text no. 5
    
6.
Hsu S, Shen K, Liu H, Chen T, Yu J. Lumbar hernia: Clinical analysis of cases and review of the literature. Chir Gastroenterol 2008;24:221-4.  Back to cited text no. 6
    
7.
Goyal S, Singla S, Nakipuria DR. A spontaneous inferior lumbar hernia: Rare case report and review. MOJ Surg 2018;9:60-1.  Back to cited text no. 7
    
8.
Zadeh JR, Buicko JL, Patel C, Kozol R, Lopez-Viego MA. Grynfeltt hernia: A deceptive lumbar mass with a lipoma-like presentation. Case Rep Surg 2015;2015:954804.  Back to cited text no. 8
    
9.
Heo TG. Primary Grynfeltt's hernia combined with intermuscular lipoma: A case report. Int J Surg Case Rep 2021;84:106163.  Back to cited text no. 9
    
10.
Stamatiou D, Skandalakis JE, Skandalakis LJ, Mirilas P. Lumbar hernia: Surgical anatomy, embryology, and technique of repair. Am Surg 2009;75:202-7.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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