Concurrent Spigelian and Grynfeltt-Lesshaft Hernias

Only 0.12% to 2% of diagnosed hernias are Spigelian type. Even less frequently encountered—Grynfeltt-Lesshaft hernias—hernias have unknown incidence. A Spigelian hernia is encountered along the Spigelian fascia and Grynfeltt-Lesshaft hernias are bounded by the superior lumbar triangle. These unique hernias can both be intermuscular, given their anatomical borders which allow concealment and preclusion of accurate diagnosis. Here, an 86-year-old male presented with symptoms consistent with small bowel obstruction. On physical exam, a right lower quadrant hernia and right posterior flank mass were appreciated. Computed tomography revealed obstruction secondary to bowel incarceration within Spigelian hernia and additional Grynfeltt-Lesshaft hernia. The patient underwent reduction and repair of Spigelian hernia with synthetic mesh, while repair of asymptomatic hernia was deferred. These unusual hernias are difficult to distinguish, given their negligible occurrence and unreliable exam findings. Clinicians must remain cognizant of their features to aid in diagnosis and mitigate potential sequelae.

LUMBAR HERNIA -POST TRAUMATIC SEQUALAE-TWO LAYER MESHPLASTY– A CASE REPORT

Lumbar hernia arises through posterolateral abdominal wall defects either through superior lumbar triangle [Grynfeltt-Lesshaft] or inferior lumbar triangle [Petit]. Most of the lumbar hernias are secondary to trauma or previous surgery. Few cases have been reported in literature. We report a case of post traumatic right Inferior triangle hernia of Petit in a 29-year-old healthy male. The hernial defect was closed with 2 layered procedure - sublay and onlay with polypropylene mesh, owing to a big defect and thin abdominal wall muscles. Patient recovered well. Our two layered open meshplasty have been effective, safe and presents with good post-operative recovery. The patient was followed up regularly and there was no recurrence even after 1 year.

Bilateral Lumbar Hernias Following Spine Surgery: A Case Report and Laparoscopic Transabdominal Repair

Lumbar hernias are rare abdominal wall defects. Fewer than 400 cases have been reported in the literature and account for 2% of all abdominal wall hernias. Lumbar hernias are divided into Grynfelt-Lesshaft or Petit hernias. The former are hernia defects through the superior lumbar triangle, while the latter are defects of the inferior lumbar triangle. Primary lumbar hernias are further subdivided into congenital or acquired hernias and can further be classified as either primary or secondary. Secondary hernias occur after previous flank surgeries, iatrogenic muscular disruption, infection, or trauma. We review a rare presentation of metachronous symptomatic bilateral secondary acquired lumbar hernia following spine surgery. A successful laparoscopic transabdominal lumbar hernia repair with extraperitoneal mesh placement was performed, with resolution of the hernia symptoms. An extensive literature review regarding lumbar hernia and different types of repairs was performed.

Management of incidental lumboiliac hernia during spinal cord stimulator implant: a case report

Lumboiliac or lumbar hernia is a rare defect in the posterolateral abdominal wall that may be inadvertently misidentified and interfere with the implantable pulse generator (IPG) portion of spinal cord stimulator (SCS) implants. We report the case of a 54-year-old Caucasian man with an incidental finding of a lumboiliac hernia in the inferior lumbar triangle of Petit with placement of an IPG in a SCS implant. With the assistance of surgical colleagues, the correct diagnosis was made intraoperatively. We describe the operative repair of the lumboiliac hernia with a synthetic mesh. A new IPG pocket was created above the mesh prior to proceeding with IPG placement. No recurrence of the hernia defect was observed on 2-month follow-up. It is important that pain physicians and neurosurgeons who perform SCS implants are aware of lumboiliac hernias to avoid potential diagnostic or management errors. Lumboiliac hernias should be included on the differential diagnosis of lumbar or flank masses. Confirmation with imaging may be necessary and definitive surgical treatment should be pursued.

ESTUDIO ANATÓMICO DE LOS PUNTOS DÉBILES DE LA PARED POSTERIOR DEL ABDOMEN. Anatomical study of the weak points of the abdominal posterior wall.

Introducción: Las hernias lumbares, se desarrollan en el área comprendida entre la costilla XII y la cresta iliaca, lateral a los músculos erectores de la espina. Se producen a través de los puntos donde los pedículos vásculo-nerviosos atraviesan los planos músculo-aponeuróticos, siendo crucial la existencia de intersticios entre dichos planos. Se reconocen dos zonas anatómicamente débiles: el triángulo lumbar inferior y el cuadrilátero lumbar. Materiales y método: 24 cadáveres adultos, ambos sexos, formolados. Se disecó la pared posterior del abdomen por planos, registrando la existencia o no de áreas débiles, su forma, dimensiones y áreas. Resultados: Triángulo lumbar inferior; encontrado en 28 casos (58,3%), 13 derechos y 15 izquierdos. Se encontró un caso con forma de hendidura. Las dimensiones medias de los lados fueron 19,96mm la base, 33,62mm anterior y 27,42mm posterior. El área promedio de la zona débil fue de 25,66 mm2 (17,8 mm2-59,38 mm2). Cuadrilátero lumbar; encontrado en 29 casos (60,4%) 15 derechos y 14 izquierdos. Se encontraron 9 casos a forma de triángulo (18,7%), 4 derechos y 5 izquierdos. Se encontró un caso a forma de hendidura. La media de los lados fue 28,40mm posterosuperior, 24,19mm posteroinferior, 19,46mm anterosuperior y 31,52mm anteroinferior. . El área promedio del cuadrilátero lumbar fue de 55,6 mm2 (16,6 mm2-167,3 mm2). Conclusión: Es más constante la presencia, como área anatómicamente débil, el cuadrilátero lumbar y su variante triangular. El triángulo lumbar inferior predomina a izquierda mientras que el cuadrilátero lumbar y su variante triangular presentaron igual distribución a ambos lados.Introduction: Lumbar hernias develop in the area between the XII rib and the iliac crest, lateral to the erector muscles of the spine. They occur through the points where the neurovascular bundles cross the muscle planes, being crucial the existence of interstices between these planes. Two anatomically weak areas are recognized: the lower lumbar triangle and the lumbar quadrilateral. Materials and method: 24 adult cadavers, both sexes. The posterior wall of the abdomen was dissected by planes, recording the existence or not of weak areas, their shape, dimensions and areas. Results: Lower lumbar triangle; found in 28 cases (58.3%), 13 rights and 15 left. One case as slit shape was found. The average dimensions of the sides were 19.96mm the base, 33.62mm anterior and 27.42mm posterior. The average area of the weak zone was 25.66 mm2 (17.8 mm2-59.38 mm2). Lumbar quadrilateral; found in 29 cases (60.4%) 15 rights and 14 left. We found 9 cases with triangle shape (18.7%), 4 right and 5 left. One case as slit shape was found. The average of the sides was 28,40 mm posterior superior, 24,19 mm posterior inferior, 19,46 mm anterior superior and 31,52 mm anterior inferior. . The average area of the lumbar quadrilateral was 55.6 mm2 (16.6 mm2-167.3 mm2). Conclusion: The presence of the quadrilateral lumbar and its triangular variant is more constant, as an anatomically weak area. The lower lumbar triangle predominates on the left while the lumbar quadrilateral and its triangular variant presented the same distribution on both sides.

Unusual Locations of Pancreatic Pseudocysts in Lumbar Triangle, Psoas Muscle and Intercostal Space, and Obturator Externus

Pancreatic pseudocyst develops as a complication of both acute and chronic pancreatitis. Although the common location of pseudocyst is lesser sac, extension of pseudocyst can occur into mesentery, retroperitoneum, inguinal region, scrotum, liver, spleen, mediastinum, pleura, and lung. Extension of pseudocyst into psoas muscle and lumbar triangle is extremely rare. The development of pseudocyst in lumbar triangle is radiologically equivalent and further extension of Grey Turner's sign seen clinically in acute pancreatitis. This extension occurs due to the destructive nature of pancreatic enzymes. The lumbar triangle is the site of anatomic weakness in the lateral abdominal wall in the lumbar region. We report the case of a 35-year-old alcoholic male patient who presented with abdominal pain followed by distension and swelling in the right lumbar region for 1 week. On computed tomography scan of the abdomen, acute-on-chronic pancreatitis with multiple pseudocysts in the right posterior pararenal space, extending through the right lumbar triangle in the right lateral abdominal wall, right posterior paraspinal muscles, right iliopsoas, right obturator externus, and medial aspect of the right upper thigh, beneath anterior abdominal wall in the upper abdomen and in the right lateral thoracic wall through the right 11th intercostal space, was detected.

Correction of complications portal hypertension syndrome

The results a new approach of simultaneous correction of complications of portal hypertension with endovideosurgical method are considered. Surgeries of 4 patients, suffering from portal hypertension, were performed by laparoscopic access and included gastric devascularization with ligation and the transection of the left gastric and short gastric veins; ligation of the splenic artery; resection of the parietal peritoneum, retroperitoneal tissue, and lumbar muscles in the lumbar triangle. Average duration of one surgery was 120±22 minutes. The highest volume of blood loss was 150±35 ml. There were no intraoperative complications. The average time spent in the IC unit was 14±4,2 hours. On the day following the surgery, all patients were able to get out of the bed, walked on their own and were allowed to have liquid food. Each patient had one session of endoscopic ligation with an overlay of 5 to 8 Cook ligatures to eradicate varicose veins of the esophagus. The postoperative period of hospital treatment was 10±2,3 days, treatment responses were favorable in all patients. The total time of inpatient stay was 22±3 days. All patients underwent two sessions of reinfusion of externally modified ascitic fluid. The postoperative spiral computer tomographies and subtraction digital angiographies showed effectiveness of disconnection of vessels in the gastroesophageal system. Blood flow in the splenic artery is not detected, ultrasound shows shrinkage of spleen. The maximum follow-up after the operation was 10 months. There were no episodes of bleeding recurrence and no signs of ascites. All patients are socially adapted and able to work, and do not present any complaints during follow-up examinations.