Lumbar incisional hernias: diagnostic and management dilemma.
BACKGROUND
Lumbar hernias occur infrequently and can be congenital, primary (inferior or Petit type, and superior or Grynfeltt type), posttraumatic, or incisional. They are bounded by the 12th rib, the iliac crest, the erector spinae, and the external oblique muscle. Most postoperative incisional hernias occur in nephrectomy or aortic aneurysm repair incisions.


METHODS
We present 2 patients who had undergone flank incisions and subsequently developed significant bulging of that area. The first patient had an atrophy of the abdominal wall musculature while the other had a large lumbar incisional hernia that was repaired laparoscopically.


CONCLUSIONS
Lumbar incisional hernias are often diffuse with fascial defects that are usually hard to appreciate. Computed tomography scan is the diagnostic modality of choice and allows differentiating them from abdominal wall musculature denervation atrophy complicating flank incisions. Repairing these hernias is difficult due to the surrounding structures. Principles of laparoscopic repair include lateral decubitus positioning with table flexed, adhesiolysis, and reduction of hernia contents, securing ePTFE mesh with spiral tacks and transfascial sutures to an intercostal space superiorly, iliac crest periosteum inferiorly, and rectus muscle anteriorly. Posteriorly, the mesh is secured to psoas major fascia with intracorporeal sutures to avoid nerve injury.


CONCLUSIONS
Lumbar incisional hernia must be differentiated from muscle atrophy with no fascial defect. The laparoscopic approach provides an attractive option for this often challenging problem.
Salameh
Jihad R
JR
University of Mississippi Medical Center, Jackson, Mississippi 39216, USA. Jsalameh@surgery.umsmed.edu
Salloum
Ellis J
EJ
D000368:Aged; D001672:Biocompatible Materials / Q000627:therapeutic use; D006555:Hernia, Ventral / Q000000981:diagnostic imaging* / Q000209:etiology / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008161:Lumbosacral Region; D008297:Male; D008875:Middle Aged; D011138:Polytetrafluoroethylene / Q000627:therapeutic use; D013526:Surgical Mesh; D013514:Surgical Procedures, Operative / Q000009:adverse effects; D013536:Suture Techniques; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
D001672:Biocompatible Materials; D011138:Polytetrafluoroethylene