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Single-incision laparoscopic total extraperitoneal repair for a Grynfeltt hernia: a case report
© Wei et al.; licensee BioMed Central Ltd. 2014
Received: 23 June 2013
Accepted: 25 November 2013
Published: 15 January 2014
A superior lumbar hernia, which is also known as a Grynfeltt hernia, is a rare abdominal wall defect that can be primary or secondary to trauma or orthopedic surgery. The anatomic location of a lumbar hernia makes diagnosis and repair challenging. We successfully repaired a lumbar hernia using a single-incision laparoscopic total extraperitoneal approach. To the best of our knowledge, this is the first report of the use of this surgical technique in the treatment of a primary Grynfeltt hernia.
A 76-year-old Taiwanese man presented to our hospital with a left lower bulging mass noted for over three months. Abdominal computed tomography revealed a left Grynfeltt hernia. We performed a single-incision laparoscopic total extraperitoneal repair. Our patient was discharged uneventfully on the fourth day after the operation. There was no evidence of recurrence after six months of follow-up.
A laparoscopic total extraperitoneal repair for a lumbar hernia provides an excellent operative view and minimal invasiveness. The single-incision technique also provides better cosmetic outcomes. Our experience suggests that the single-incision laparoscopic total extraperitoneal approach may be a feasible and safe alterative to conventional approaches in lumbar hernia repair.
A lumbar hernia is a rare type of abdominal wall defect over the lumbar triangles that can be categorized into superior (Grynfeltt) and inferior (Petit) by anatomic location. The four borders of Grynfeltt or superior lumbar hernia are the 12th rib superiorly, quadratus lumborum muscle medially, iliac crest inferiorly, and internal oblique muscle laterally. The external oblique and latissimus dorsi muscles form its roof, and its floor comprises the transversalis fascia and the aponeurosis of the transversus abdominis muscle. Because of the anatomic location, the diagnosis and repair of a lumbar hernia are challenging. With the improvements in laparoscopic techniques, minimally invasive surgery has emerged as an increasingly popular therapeutic option in hernia repair in comparison to the conventional open approach. To the best of our knowledge, this report is the first description in the world of the use of single-incision laparoscopic total extraperitoneal approach in the repair of primary Grynfeltt hernia.
Lumbar hernias account for only 2% of all abdominal hernias . There are only about 300 cases reported in the English literature since its first description by Barbette in 1672. The anatomy of the inferior and superior lumbar triangle was reported by Petit and Grynfeltt in 1783 and 1866, respectively . Lumbar hernias can be categorized into congenital (20%) or acquired, which have been further classified into two types: primary (55%) and secondary (25%). Whereas primary lumbar hernias have no apparent provoking cause, the etiologies of secondary lumbar hernias include trauma, infection, orthopedic surgery and kidney surgery. A superior lumbar hernia, which is also known as a Grynfeltt hernia, is a primary lumbar hernia that is more common, larger and deeper compared to the inferior lumbar hernia .
Lumbar hernias mostly present as an asymptomatic protruding mass over the lower back or flank area. Differential diagnoses including lipoma, local abscess and postoperative hematoma; even neoplasms should first be ruled out. The diagnosis is based on the clinical history and physical findings. Computed tomography is a good tool not only for definite diagnosis but also for preoperative planning [4, 5].
Currently, there are three approaches to lumber hernia repair: open, intraperitoneal and extraperitoneal laparoscopic. Open primary repair for a lumbar hernia was first described by Owen in 1888, followed by closure of the fascia defect with the tensor fascia latae flap by Dowd in 1907  and repair using prosthetic mesh by Alves et al. in 1996 . The defect may be closed directly for smaller lumbar hernias, whereas a muscular flap or prosthetic mesh should be considered for achieving tension-free closure in the management of larger hernia defects. A laparoscopic intraperitoneal approach for traumatic lumbar hernias was first reported by Burick and Parascandola in 1996, and for a primary lumbar hernia by Heniford et al. in 1997 [2, 8]. This intraperitoneal access provides more accurate localization, better fascia reconstruction, less wound pain, and superior cosmetic results compared to the open approach . However, intraperitoneal access with manipulation of intra-abdominal organs may contribute to subsequent intra-abdominal adhesions. Laparoscopic extraperitoneal repair, the most recently developed technique first described by Meinke in 2003 , not only allows precise anatomic localization of the hernia defect and minimal wound discomfort , but also avoids unnecessary manipulation of visceral organs and reduces the possibility of subsequent intra-abdominal adhesions. Therefore, it may be the ideal method for lumbar hernia repair.
In our case, the right decubitus position was adopted because of the protruding mass. The reason for making the incision over the left anterior axillary line between our patient’s 12th rib and iliac crest was to facilitate instrument manipulation for the management of the prolapsed mass and also for hernia repair. Due to his poor self-care ability and intolerance to wound pain, our patient’s hospital stay was longer than average (one to two days after the surgery).
Compared with the open and intraperitoneal laparoscopic approaches, laparoscopic total extraperitoneal repair for a lumbar hernia provides an excellent operative view and minimal invasiveness. The single-incision technique also provides better cosmetic outcomes. Our experience suggests that the single-incision laparoscopic total extraperitoneal approach may be a feasible and safe alternative to the conventional approaches in lumbar hernia repair.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The author would like to thank E-Da hospital operation room colleagues for their great help and reviewers for their valuable comments and suggestions.
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