Background: Primary hernias in the triangle of Grynfeltt are very rare and therefore pose a difficulty in diagnosis and treatment. Due to the lack of systematic studies, the surgical approach must be chosen individually for each patient. Here, we describe an easy and safe surgical approach. Case presentation: We report the case of a 53-year-old male patient with a history of mental disability and pronounced scoliosis, who presented with a Grynfeltt-Lesshaft hernia with protrusion of the ascending colon and the right ureter. The hernia was repaired via a dorsal, extraperitoneal approach. The hernia gap with a diameter of approximately 1 cm was closed with insertion of a 6.4 × 6.4 cm PROCEED™ VENTRAL PATCH (Ethicon, Norderstedt, Germany). The operating time was 33 min and the patient was discharged the next day and showed no signs of recurrence at 1-year follow up. Conclusion: The technique described here is favorable because it requires very little dissection of the surrounding tissue and no trans-/intraabdominal dissection. The technique was chosen in this particular case to guarantee a fast postoperative recovery and prompt hospital discharge. Keywords: Grynfeltt-Lesshaft hernia, Lumbar hernia, PROCEED™ VENTRAL PATCH Background incarceration and a right lumbar protrusion with the Lumbar hernias are a very rare cause of abdominal com- clinical appearance of a soft tissue mass. After several plaints, and there is no standardized surgical strategy. episodes of abdominal complaints, a computed tomog- Here, we present the case of a mentally disabled patient raphy of the abdomen was conducted, which revealed a with a primary Grynfeltt-Lesshaft hernia with herniation large herniation in the upper lumbar triangle with pro- of the ascending colon causing constipation and abdom- trusion of the ascending colon and the right ureter with inal pain. Due to the mental disability and the severe consecutive dilatation of the proximal ureter and the symptoms of the hernia, a safe surgical approach with renal pelvis (Fig. 1). The lumbar hernia was reduced at fast postoperative recovery was required. the bedside, and the patient was admitted for early surgi- cal hernia repair. After routine medical check-up and informed consent Case presentation of the legal guardian, the patient was operated under The 53-year-old patient with a history of mental disabil- general anesthesia. The patient was placed in a left ity and pronounced scoliosis presented repeatedly to our lateral position. A dorsal transverse incision of 6 cm be- emergency department with intermittent episodes of tween the 12th rib and iliac crest was made. The super- constipation and abdominal pain. Physical examination ior lumbar triangle with the bordering structures was revealed a double-sided inguinal hernia without signs of visualized. The triangle is inverted with the top pointing towards the iliac crest and is partially covered by the * Correspondence: Torben.Glatz@uniklinik-freiburg.de Department of General and Visceral Surgery, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg im Breisgau, Germany © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Glatz et al. Surgical Case Reports (2018) 4:50 Page 2 of 3 Fig. 1 Preoperative CT revealed a large Grynfeltt hernia with prolapse of the ascending colon and the right ureter with consecutive dilatation of the renal pelvis Fig. 3 Schematic display of the superior lumbar triangle. The triangle is inverted and partially covered by the latissimus dorsi. The base is latissimus dorsi. The base is formed by the lower border formed by the lower border of the 12th rib the triangle is anteriorly of the 12th rib and the posterior inferior serratus muscle bounded by the internal oblique muscle and posteriorly by the (cranial); the triangle is anteriorly bounded by the in- quadratus lumborum and erector spinae muscles ternal oblique muscle and posteriorly by the quadratus lumborum and erector spinae muscles (the anatomy of the superior lumbar triangle is described in Figs. 2 and 3). The transversalis fascia forms the floor, which was weak- the herniating colon, the internal oblique muscle was ened in our patient and contained the hernia gap with a notched. The retroperitoneal fat was easily separated from diameter of approximately 1 cm. The hernia sack was dis- the lower surface of the transversalis fascia by digital sected and reduced. To do so without risking any injury of adhesiolysis. The gap was closed with insertion of a 6.4 × 6.4 cm PROCEED™ VENTRAL PATCH (Ethicon, Norderstedt, Germany) in sublay technique with an over- lap of 3 cm to all sides. The lower part of the patch was laid out flat and tension free between the transversalis fascia and the retroperitoneal fat (Fig. 4). The straps were pulled to ensure the correct position of the patch and were then sutured to the fascia with non-absorbable sutures, after which the overlaps were resected. The mus- cles and fascia were adapted with absorbable sutures and the wound was closed. Drain placement was not neces- sary. The operating time was 33 min, and the patient was discharged the next day and showed no signs of recur- rence at 1-year follow up. Discussion and conclusion A review of the literature reveals only a handful of case reports, describing various open and laparoscopic tech- niques for the closure of lumbar hernias. Due to the rare appearance, there is hardly any evidence supporting one or the other technique . Fig. 2 The hernia sack prolapsed in the superior lumbar triangle Considering the general condition of our patient and between the M. Erector Spinae, the internal oblique and the 12th rip the need for an urgent operation, we decided against Glatz et al. Surgical Case Reports (2018) 4:50 Page 3 of 3 Our approach is favorable; hence, it requires almost no dissection of the surrounding tissue and muscles and no (laparoscopic) intraabdominal dissection. It can also be performed by any surgeon familiar with more com- mon hernias (e.g., umbilical) even with limited experi- ence with lumbar hernias in a very short time and therefore is very safe. Due to the position and size of the incision and the limited need for dissection, postopera- tive recovery is fast and incisional pain is acceptable. The overlap of the mesh was about 3 cm to all sides. Due to the small gap and the strong tissue around the hernia, we refrained from further preparation to insert a larger mesh with a wider overlap. We were able to dis- charge the patient who had a mental disability the next day. A mentally and physically healthy patient could have been presumably treated in an outpatient setting. Our operative technique is certainly a feasible alternative to the laparoscopic approach. In this particular case, it Fig. 4 Surgical repair of the hernia was performed with the patient was our chosen approach due to the need for an urgent in a lateral position via a dorsal approach and insertion of a 6.4 × 6.4 cm PROCEED™ VENTRAL PATCH (Ethicon, Norderstedt, Germany) operation and to guarantee a fast postoperative recovery and prompt hospital discharge. Availability of data and materials laparoscopy, but instead for an open, extraperitoneal, The datasets used during the current study are available from the dorsal approach with insertion of a self-expanding, par- corresponding author on reasonable request. tially absorbable, flexible laminate mesh device, very Authors’ contributions similar to the approach described by Solaini et al. . TG and OT performed the operation and wrote the manuscript. HN was in The effective use of the PROCEED™ VENTRAL PATCH charge of the patient’s follow-up and graphical design of the figures. PH and SF reviewed the manuscript and figures and assisted in writing the manuscript. has been demonstrated for umbilical hernias and like- All authors read and approved the final manuscript. wise small incisional hernias. We could demonstrate that the patch can be also effectively used for closure of her- Ethics approval and consent to participate We describe an urgent procedure, carried out with informend consent of the nias in the Grynfellt-Triangle via a dorsal approach. patient and legal guardian, there was no ethics comitee involvement. Up to now, there is no retrospective study or random- ized controlled trial analyzing the results of the different Consent for publication The patient’s legal guardian gave informed consent for the publication of surgical techniques for closure of a primary lumbar her- the case. nia, and due to the rare appearance, there will probably never be one. Therefore, the surgical approach has been Competing interests The authors declare that they have no competing interests. chosen individually for each patient with consideration of the particular situation. Publisher’sNote In 2013, Suarez et al. recommended a laparoscopic ap- Springer Nature remains neutral with regard to jurisdictional claims in proach to hernias in the triangle of Grynfellt with the published maps and institutional affiliations. main argument of faster postoperative recovery and less Received: 8 March 2018 Accepted: 8 May 2018 postoperative pain and consumption of pain medication . This recommendation is based mostly on the result of a randomized controlled trial comparing open and References 1. Moreno-Egea A, Baena EG, Calle MC, Martinez JAT, Albasini JLA. laparoscopic repair of secondary lumbar hernias, which Controversies in the current management of lumbar hernias. Arch Surg. reveals beneficial results of the laparoscopic approach 2007;142:82–8. . However, this study was carried out with patients 2. Solaini L, Di Francesco F, Gourgiotis S, Solaini L. A very simple technique to repair Grynfeltt-Lesshaft hernia. Hernia. 2010;14:439–41. suffering from incisional hernias and is therefore not 3. Zarmpis N, Wassenberg D, Ambe PC. Repair of small and medium size comparable with our case of a primary Grynfeltt- umbilical hernias with the “Proceed Ventral patch” in the preperitoneal Lesshaft hernia. The trial reports a mean operating time position. Am Surg. 2015;81:1144–8. 4. Suarez S, Hernandez JD. Laparoscopic repair of a lumbar hernia: report of a of 71 min, a postoperative morbidity of 86%, and a mean case and extensive review of the literature. Surg Endosc. 2013;27:3421–9. hospital stay of 7 days for the open approach. These 5. Moreno-Egea A, Torralba-Martinez JA, Morales G, Fernandez T, Girela E, figures certainly do not compare to the technique Aguayo-Albasini JL. Open vs laparoscopic repair of secondary lumbar hernias: a prospective nonrandomized study. Surg Endosc. 2005;19:184–7. described here.
Surgical Case Reports – Springer Journals
Published: May 30, 2018
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