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CASE REPORT
Year : 2017  |  Volume : 5  |  Issue : 2  |  Page : 84-86

A traumatic lumbar hernia: Case report and review of the literature


1 Department of Surgery, King Khalid Hospital, Hail, Saudi Arabia
2 Department of Medical, King Khalid Hospital, Hail, Saudi Arabia

Date of Web Publication26-Jul-2017

Correspondence Address:
Alaa Mohamed Sedik
King Khalid Hospital, Hail
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_80_16

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  Abstract 

Acute lumbar hernia secondary to blunt trauma is a rare injury of the abdominal wall and, when encountered, is a difficult challenge for the trauma surgeon. Traumatic hernias occurred most commonly in the inferior lumbar triangle (70%) and were most frequently a result of a motor vehicle collision (71%). Delayed diagnosis is not uncommon, as nearly a quarter of these are missed at initial presentation. These hernias are best managed by operative intervention; however, there is no well-defined treatment strategy regarding either the timing or the type of repair. Several approaches, including laparoscopy, have been described to repair these defects. We reported a case of traumatic inferior triangle hernia as a result of a motor traffic accident.

Keywords: Blunt abdominal trauma, lumbar hernia, traumatic abdominal hernia


How to cite this article:
Sedik AM, Fathi A, Maali M, Hussein A, Elhoushy S. A traumatic lumbar hernia: Case report and review of the literature. Saudi Surg J 2017;5:84-6

How to cite this URL:
Sedik AM, Fathi A, Maali M, Hussein A, Elhoushy S. A traumatic lumbar hernia: Case report and review of the literature. Saudi Surg J [serial online] 2017 [cited 2019 Aug 25];5:84-6. Available from: http://www.saudisurgj.org/text.asp?2017/5/2/84/211614


  Introduction Top


Lumbar hernias are located in the thoracolumbar region and are classified as either congenital or acquired. It accounts for <1.5% of all abdominal hernias most of these hernias are the acquired form and are categorized into two groups: Spontaneous (primary) hernias, and postoperative incisional or traumatic (secondary) hernias. Traumatic lumbar hernia is a rare entity with only fewer than 310 cases reported so far in the world.[1],[2] This paper details a case of secondary lumbar hernia that occurred after blunt abdominal injury.


  Case Report Top


A 47-year-old Saudi male not known to have any medical problem before was admitted 6 months ago through the emergency room (ER) as a victim of road traffic accident. He was conscious, alert, oriented, with stable vital signs. He was spontaneously breathing and was complaining mainly of painful left flank swelling with skin discoloration. Advanced trauma life support protocol was followed. Clinically, he was generally looking otherwise healthy with no pallor or cyanosis. Not in pain with stable vital signs and a normal oxygen saturation. Head and neck examination was normal. Chest shows normal expansions and no external trauma signs and normal breath sounds.

Locally, the abdomen is not distended with ecchymosis and swollen left flank region, no tenderness or rigidity. And bowel sounds were normal [Figure 1].
Figure 1: (a) Acute left flank ecchymosis with bulge, while (b and c) computerized abdominal scan showed left lumbar hernia at the triangle of Petit

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Initial blood works and focused assessment with sonography for trauma ultrasound examination were normal; the patient was prepared for computed tomography (CT) abdomen and pelvis that came to be negative for any other intra-abdominal associated injuries yet a left traumatic inferior lumbar hernia was diagnosed it and was actually the first time to be diagnosed at our trauma center.

The situation is discussed with the patient that he was kept under observation and he would have a period of watchful expectancy as no need to go in during this acute phase as there were no other associated injuries requiring emergency laparotomy. Same time, emergency repair has its own risks due to associated edema and ecchymosis of the acutely injured tissues. The patient agreed about the plan with regular follow-up in outpatient department (OPD). Moreover, he will be admitted for mesh hernioplasty after 6 weeks to avoid complications like incarceration or strangulation if repair not done. He came to OPD for follow-up after 4 weeks and was doing well but, he wants to postpone the surgery for few months due to some personal issue. Finally, he agreed about surgery in the past OPD visit and actually admitted 4 weeks ago. Unfortunately, he changed his mind again and refused any surgical treatment despite the discussion about the risks of incarceration and strangulation that could happen in the future. He was offered OPD follow-up with advice to come to ER if pain, vomiting, should occur. A picture was taken during the last admission showing a noncomplicated hernia swelling with normal skin covering was present [Figure 2]. I believe that I have to report that case as it is a very rare entity that requires reporting in the literature, even if the patient refused surgery.
Figure 2: Late presentation of the patient with left lumber hernia with normal skin cover

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  Discussion Top


Lumbar hernias are classified as congenital, generally associated with other malformations, or acquired, manifesting in adults spontaneously or secondary to trauma or surgical incision. Most lumbar hernias occur in the superior lumbar triangle of Grynfeltt. However, most traumatic hernias occur in the inferior lumbar triangle of Petit.[1],[2],[3] The lower abdomen is an anatomically weaker area, especially the inferior lumbar triangle. The superior lumbar triangle is covered posteriorly by latissimus dorsi, or at least by its thick and strong aponeurosis. In contrast, no muscular or aponeurotic structures cover the inferior lumbar triangle [Figure 3].[4] Small hernias may be asymptomatic except for a palpable mass. In <10% of cases, the onset is acute with bowel obstruction.[5],[6],[7]
Figure 3: Anatomy of the superior and inferior lumbar triangles; Grynfeltt and Petit, respectively. all boundaries are shown

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Clinical suspicion based on a flank pain, ecchymosis, or bulge is fundamental to guide imaging diagnosis because extraperitoneal fat herniated through a wall defect may mimic a lipoma. In the acute stage, only 30% of lumbar hernia patients had hernia evidence on physical examination.[8] CT scan is the best diagnostic tool for traumatic lumbar hernia. It can accurately show the anatomy of the disrupted musculature layers, show the presence of herniated intra-abdominal viscera or retroperitoneal fat, and show associated intra-abdominal injuries.[4],[9] Management of traumatic lumbar hernia is controversial. The main questions in the management are “when” and “how.” If there is suspicion of strangulation and/or associated intra-abdominal injury, emergent laparotomy or laparoscopy must be performed. However, if there is no suspicion of these, as in our case, a period of watchful expectancy with mesh repair to be done at a later date could be the treatment modality if agreed by the patient.

In general, for lumbar hernias, both open and laparoscopic techniques can be used with good results.[9] Anterior repair is appropriate for repairing recurrent or large defects with a double mesh (sublay and onlay) or a gluteus aponeurosis flap.[10] Laparoscopic repair has been used successfully in different reports with less pain, shortened hospital stay and good cosmetic and functional results.[11],[12],[13]


  Conclusion Top


Although a rare pathology, knowledge of lumbar hernia is important to avoid misdiagnosis. In particular, a lumbar or flank mass should always raise suspicion of a lumbar hernia. Ultrasound and CT may confirm the diagnosis. Appropriate surgical treatment should be planned on the basis of etiology and hernia size.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Le Neel JC, Sartre JY, Borde L, Guiberteau B, Bourseau JC. Lumbar hernias in adults. Apropos of 4 cases and review of the literature. J Chir (Paris) 1993;130:397-402.  Back to cited text no. 1
    
2.
Moreno-Egea A, Baena EG, Calle MC, Martínez JA, Albasini JL. Controversies in the current management of lumbar hernias. Arch Surg 2007;142:82-8.  Back to cited text no. 2
    
3.
Dennis RW, Marshall A, Deshmukh H, Bender JS, Kulvatunyou N, Lees JS, et al. Abdominal wall injuries occurring after blunt trauma: Incidence and grading system. Am J Surg 2009;197:413-7.  Back to cited text no. 3
    
4.
Guillem P, Czarnecki E, Duval G, Bounoua F, Fontaine C. Lumbar hernia: Anatomical route assessed by computed tomography. Surg Radiol Anat 2002;24:53-6.  Back to cited text no. 4
    
5.
Astarcioglu H, Sökmen S, Atila K, Karademir S. Incarcerated inferior lumbar (Petit's) hernia. Hernia 2003;7:158-60.  Back to cited text no. 5
    
6.
Losanoff JE, Kjossev KT. Diagnosis and treatment of primary incarcerated lumbar hernia. Eur J Surg 2002;168:193-5.  Back to cited text no. 6
    
7.
Bender JS, Dennis RW, Albrecht RM. Traumatic flank hernias: Acute and chronic management. Am J Surg 2008;195:414-7.  Back to cited text no. 7
    
8.
Netto FA, Hamilton P, Rizoli SB, Nascimento B Jr., Brenneman FD, Tien H, et al. Traumatic abdominal wall hernia: Epidemiology and clinical implications. J Trauma 2006;61:1058-61.  Back to cited text no. 8
    
9.
Killeen KL, Girard S, DeMeo JH, Shanmuganathan K, Mirvis SE. Using CT to diagnose traumatic lumbar hernia. AJR Am J Roentgenol 2000;174:1413-5.  Back to cited text no. 9
    
10.
Burt BM, Afifi HY, Wantz GE, Barie PS. Traumatic lumbar hernia: Report of cases and comprehensive review of the literature. J Trauma 2004;57:1361-70.  Back to cited text no. 10
    
11.
Moreno-Egea A, Torralba-Martinez JA, Morales G, Fernández T, Girela E, Aguayo-Albasini JL. Open vs. laparoscopic repair of secondary lumbar hernias: A prospective nonrandomized study. Surg Endosc 2005;19:184-7.  Back to cited text no. 11
    
12.
Moreno-Egea A, Guzmán P, Girela E, Corral M, Aguayo Albasini JL. Laparoscopic hernioplasty in secondary lumbar hernias. J Laparoendosc Adv Surg Tech A 2006;16:572-6.  Back to cited text no. 12
    
13.
Madan AK, Ternovits CA, Speck KE, Pritchard FE, Tichansky DS. Laparoscopic lumbar hernia repair. Am Surg 2006;72:318-21.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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