This document discusses lumbar hernias, which are rare defects in the posterior abdominal wall. It describes the history and epidemiology of lumbar hernias, noting they affect around 300 people and are more common in males aged 50-70. Clinical presentations can include back pain or a mass, as well as bowel or organ obstruction if contents protrude. There are two types - superior occurring through the superior lumbar triangle, and inferior through the inferior triangle. Surgical repair is usually recommended due to risk of incarceration or strangulation, though techniques like mesh placement versus direct repair are debated.

1. Lumbar hernia
Georges KHALIFEH FFI
GHPSO
Chirurgie Digestive et Viserale

2. History
 J Grynfeltt and P Lesshaft independently described superior lumbar hernias
in 1866 8 and 1870 9, respectively.
 The first description of the inferior or superficial lumbar hernia by French
surgeon Jean-Louis Petit (1672-1750) in 1738

3. Epidemiology
 Rare defect of the posterior abdominal wall with approximately 300 cases
reported in the literature.
 The proportion of lumbar hernias to all abdominal hernias is less than 1.5%,
and most of them are unilateral.
 Most common in patients aged between 50 and 70 years with a male
predominance

4. Clinical presentation
Patients with lumbar hernias can present with a variety of symptoms, including :
 posterolateral mass
 back pain
 bowel obstruction (if contents contain bowel)
 urinary obstruction (if contents are kidney/ureter).

5. Pathology
Lumbar hernias occur through defects in the lumbar muscles or
the posterior fascia, below the 12th rib and above the iliac
crest.
Two types are described, according to the anatomical location
of the hernial neck:
 superior lumbar hernia (Grynfeltt-Lesshaft hernia)
 occurs through the superior lumbar triangle
 inferior lumbar hernia (Petit hernia)
 occurs through the inferior lumbar triangle

6. Superior triangle
Inverted
Deeper
more constant
most common
 Boundaries :
 posterior border of internal oblique (anterior)
 anterior border of sacrospinalis (posterior)
 12th rib and the serratus posterior inferior muscle (base)
 external oblique and latissimus muscle (roof)
 aponeurosis of the transversus abdominis (floor).
For all practical purposes it is an avascular space.

7. Inferior triangle
Upright
Less constant
More vascular
 boundaries are:
 posterior border of the external oblique muscle (anterior)
 Anterior border of the latissimus dorsi muscle (posterior)
 Iliac crest (base)
 Superficial fascia (roof)
 Internal oblique (floor)
The inferior triangle is commonly referred to as the lumbar triangle
being more superficial in location and easily demonstrable .

8. Contents
Lumbar hernias may contain a number of intra- or retro-peritoneal structures
including:
 stomach
 small or large bowel
 mesentery
 omentum
 ovary
 spleen
 kidney

9.  LH diagnosis and treatment can be challenging

10. Etiology
Congenital (20%) / Acquired (80%)
 There are three broad etiologies for lumbar hernias:
 Congenital hernias (20%)
 discovered in infancy and are due to defects in the musculoskeletal system
 may be associated with other malformations(renal agenesis, lumbo-costo-vertebral syndrome)
 Primary acquired lumbar hernias (55%)
 spontaneous, without a causal factor such as surgery, infection, or trauma
 risk factors include age, extremes of body habitus, quick weight loss, chronic disease, muscular atrophy,
chronic bronchitis, wound infection, postoperative sepsis, and strenuous physical activity
 Secondary acquired lumbar hernias (25%)
 blunt, penetrating, or crushing trauma
 fractures of the iliac crest
 surgical lesions
 hepatic abscesses
 infections in pelvic bones, ribs, or lumbodorsal fascia
 infected retroperitoneal hematomas

11.  Patients usually present with nonspecific complaints.
 It has been observed to be more common in males and on the left side.
 Complications like incarceration, intestinal obstruction, strangulation and
volvulus may occur.

12. Managment
 Surgical treatment of lumbar hernias is always recommended because of the
risks of entrapment and strangulation.
 There is still ongoing discussion regarding which is the best surgical technique
to be employed.
 It has been described that approximation of the limits of the hernia may be
sufficient for small hernias, while in most cases the use of mesh is
recommended.
 The growth in laparoscopic repair of abdominal wall hernias has brought on
the use of the preperitoneal space (sublay)

13. (a) Large hernia sac after dissection of the subcutaneous tissue.
(b) Scheme representing a transverse anatomical view of the hernia sac protruding through the Petit’s triangle. T, transversum
abdominis muscle; IO, internal oblique muscle; E, external oblique muscle; LD, latissimus dorsi muscle

18. Moreno-Egea et al
Therapeutically classification system :
 four types of LH based on six criteria:
1. Size
2. Location
3. Contents
4. muscular atrophy
5. Origin
6. existence of previous recurrence
The presence of at least two criteria is necessary for defining the LH type

19. Classification of LH according to Moreno-Egea et al.
EP: extraperitoneal; IP: intraperitoneal; LH: lumbar hernia; LPS: laparoscopy; TEP: total extraperitoneal

22.  THANK YOU . . .