Candidates for Hernia Repair
The patient presents with a “lump in the flank” associated with a dull, heavy, pulling feeling. Diagnosis is confirmed by the presence of reducible, often tympanic mass in the flank when the patient is erect.
History and physical examination axiomatically are the best means of diagnosing hernias. Associated conditions such as ascites, constipation, obstructive uropathy, chronic obstructive pulmonary disease, or cough are carefully sought in the review of systems.
The Hernia Repair Procedure
A wide variety of techniques have been described for repair of lumbar hernias. These include closure of the fascial defect with nonabsorbable sutures, overlapping of the aponeuroses, fascial rotation flaps and free fascia lata grafts. Hafner and colleagues have reinforced large defects of the inferior lumbar triangle using Marlex mesh. Laparoscopic approach has been used in the repair of uncomplicated lumbar hernias.
The surgical treatment of lumbar hernias is performed through an oblique incision. The preperitoneal fat adjacent to the hernia sac should be carefully inspected because it may represent mesocolon with associated blood supply. The paraperitoneal sliding component of the sac should be inverted and plicated avoiding the blood supply of the viscus. When a sac is present it should be opened and its contents identified. This helps in evaluating the anatomy of a sliding component and to identify a multilocular sac.
What is a lumbar hernia?
Lumbar hernia is a protrusion between the last rib and the iliac crest where the transverse muscle is covered by the latissimus dorsi. The lumbar hernia must be differentiated from abscesses, haematomas, soft tissue tumours, renal tumours and muscle strain. Lumbar hernias increase in size and should be repaired when found. Nearby fascia is mobilised and the hernial defect obliterated by precise fascia-to-fascia closure. The recurrence rate is low.
Where does lumbar hernia occur?
Lumbar herniae are through the posterior abdominal wall at some level in the lumbar region. The most common sites (95%) are:
- superiorly – Grynfeltt’s triangle
- inferiorly – Petit’s triangle
What might happen if lumbar hernia is not treated?
Lumbar hernias rarely result in strangulation and hence the prognosis is good. These hernias increase in size and eventually become symptomatic. The corrective surgical procedure becomes more complex as the hernial defect becomes larger. Reconstruction is the challenging aspect of lumbar hernia surgery.
What is Petit’s hernia?
Petit’s hernia is the one that protrudes through lumbar triangle. This triangle lies in the posterolateral abdominal wall bounded in front by free margin of external oblique muscle, behind by latissimus dorsi and below by iliac crest. The neck (place where a hernia protrudes into the opening) is large, so chances of strangulating are small.