Lumbar Hernia

Section: Abdominal wall and retroperitoneum Sub-section: Hernias Curriculum: Curriculum, page 4

Definition

• Superior lumbar triangle (of Gryfelt)
  • More common for acquired
  • (e.g. Trauma)
• Inferior lumbar triangle (of Petit)
  • Usual site of congenital herniation

Incidence

• Very rare
• Seen in young, athletic women & middle-aged men

Anatomy

• See: Lumbar Triangle
• 2 triangles
  • Superior Lumbar Triangle of Gryfelt
    • Superior Lateral: 12th rib
    • Medial: Quadratus lumborum
    • Lateral: Internal oblique
  • Inferior Lumbar Triangle of Petit
    • Lateral: External Oblique (Lateral/free edge)
    • Medial: Latissimus dorsi (lateral border)
    • Inferior: Iliac Crest
    • Floor: Internal Oblique

Clinical

• Clinically present as “a lump in the flank”
• Tender mass → back ache +/- heavy pulling feeling
• Lumber bulge
• Appears on standing; disappears on lying down
• Ix: CT may be helpful

Management

• Repair if symptomatic or signs of strangulation
• Flank approach with patient in lateral position
  • Dissect through muscle layers, separate transversalis fascia from peritoneum up to 8th rib (sweep peritoneum off diaphragm, and to midline
  • Fix mesh to iliac crest and fascial layers between 9th/10th ribs and wrap forwards to midline
  • Close muscles in 2 layers over mesh and drain
• Or anterior retroperitoneal approach

Natural Hx:

• Incarceration / strangulation in 10%
• Giant lumbar hernias: unlikely to strangulate & have a high recurrence rate if operated on
• So usually don’t