IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 5, May 201 3. ISSN – [0976-31 98]

IJCRI 201 3;4(5):243–247.www.ijcasereportsandimages.com

Sandwich technique of closure of lumbar hernia: A noveltechniqueManash Ranjan Sahoo, Anil Kumar T

ABSTRACTBackground: Lumbar hernia is a rare herniawhich accounts for less than 1.5% of total herniaincidence. Only about 300 cases have beenreported in literature. Lumbar hernia herniatesthrough the superior or inferior lumbartriangle. Herniation through inferior triangle ismore common, probably due to variableattachment of external oblique and latissimusdorsi to iliac crest. If they are closely attachedthen this triangle is not present and no herniaoccurs. Case Series: We present our experienceof four cases of lumbar hernias over a period oftwo years. All patients presented with graduallyenlarging swelling in the loin which enlarged insize on coughing and straining. Two of thempresented with multiple small ulceration overthe swelling. Examination revealed swelling inthe lumbar region with positive cough impulse,incomplete reducibility, and bowel sounds onauscultation. Ultrasound and computedtomography (CT) scan revealed hernia in rightlumbar region in all cases. Transverse skinincision was given over the hernia. Afterdissection in layers, the sac was separated and

contents were reduced. Around 15x15 cmprolene mesh was placed extraperitoneally andfixed around the defect. Another overlay of15x15 cm prolene mesh was placed, thussandwiching prolene mesh in between layers ofabdomen. Negative suction drain was given inall cases. 10 months of mean follow­up revealedno recurrence. Conclusion: Sandwich techniqueof closure of lumbar hernias is safe, feasible,acceptable and associated with no short­termrecurrence rates. However, long­term follow­upis needed to prove the efficacy of this technique.Keywords: Lumbar hernia, Sandwich technique,Superior lumbar triangle, Inferior lumbartriangle

*********Sahoo MR, Anil Kumar T. Sandwich technique ofclosure of lumbar hernia: A novel technique.International Journal of Case Reports and Images2013;4(5):243–247.

*********doi:10.5348/ijcri­2013­05­304­CS­1

INTRODUCTIONLumbar hernias are rare defects of posteriorabdominal wall. Lumbar region is bordered by 12th ribsuperiorly, iliac crest inferiorly, erector spinae musclesposteriorly and vertical line between anterior tip of 12thrib and iliac crest [1]. The two main areas of lumbarherniation are superior lumbar triangle (Grynfelt­Lesshaft) and inferior lumbar triangle (Petit). Herniathrough the inferior triangle is more common butsuperior triangle is larger in size [2]. Lumbar hernia canbe classified as congenital or acquired. Congenital

CASE SERIES OPEN ACCESS

Manash Ranjan Sahoo1 , Anil Kumar T2

Affi l iations: 1MS, Associate Professor, Department ofSurgery, S.C.B. Medical College, Cuttack, Odisha, India;2Post Graduate, Department of Surgery, S.C.B. MedicalCollege, Cuttack, Odisha, India.Corresponding Author: Dr. Manash Ranjan Sahoo, Mail ingAddress: Orissa Nursing Home, Medical road, Ranihat,Cuttack, Odisha, India. Postal Code - 753007; Phone:+91 9937025779; Fax Number: 0671 -241 4034; Email :manash67@gmail .com

Received: 30 October 201 2Accepted: 08 December 201 2Published: 01 May 201 3

Sahoo et al. 243

IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 5, May 201 3. ISSN – [0976-31 98]

IJCRI 201 3;4(5):243–247.www.ijcasereportsandimages.com Sahoo et al. 244

hernias are rare but case reports can be found inliterature. The acquired type may be secondary totrauma or surgical operation. Most incisional lumbarhernias occur after flank surgery (nephrectomy, aorticaneurysm repair, iliac bone graft harvest or latissimusdorsi myocutaneous flap) [3].

CASE SERIESFour patients, three male and one female, with ageranging from 30–50 years (mean age 40 years),presented with a gradually enlarging swelling in the loin(Figure 1). Three had swelling on the right side and oneon the left side. The swelling enlarged in size oncoughing and straining and was reduced in supineposition. Dragging pain was present in all cases at thesite of the swelling. Two patients had multiple smallulceration over the swelling at the time of presentation.There were no associated co­morbid conditions in anypatient (Table 1). There was no notable etiology liketrauma or surgery in any patient. On examinationimpulse on cough was positive with incompletereducibility in all patients. Mild tenderness was presentin the abdomen. Auscultation revealed bowel soundsover the swelling. Ultrasound and CT scan revealedhernia in right lumbar region containing small bowel(Figure 2).

During surgery a transverse incision was given overthe hernia. After dissection in layers, the hernial sac wasseparated and contents were reduced. First a prolenemesh of 15x15 cm was placed extraperitoneally and fixedaround the defect (Figure 3, 4). Another overlay of 15x15 cmprolene mesh was placed and fixed (Figure 5, 6). Skinand subcutaneous tissue was closed after giving negative

Figure 1: Preoperative photo of one of the patients showinghernia in the lumbar region.

Table 1: Clinical characteristics of the patients.

Figure 2: Computed tomography scan showing lumbar herniawith bowel as contents of hernia in all four patients.

Figure 3: Peroperative photograph showing inlay mesh placedextraperitoneally.

IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 5, May 201 3. ISSN – [0976-31 98]

IJCRI 201 3;4(5):243–247.www.ijcasereportsandimages.com Sahoo et al. 245

suction drain. Same procedure was followed for allcases. Postoperative period was uneventful. There are nopostoperative complications like wound infection ordehiscence in any case. Mean postoperative hospital staywas three and half days (range 2–5 days). Sandwichtechnique was used to provide strength to the repairbecause of lack of sufficient fascia for repair of thehernia. Ten months of mean follow up revealed no signsand symptoms of recurrence (Figure 7).

Figure 4: Peroperative photograph showing inlay mesh fixed toiliac crest and abdominal wall.

Figure 5: Peroperative photograph showing onlay mesh placedin position.

Figure 6: Peroperative photograph showing fixation of onlaymesh.

Figure 7: Postoperative photograph of a patient showinghealed surgical scan site. Inset shows the preoperative photo ofthe same patient.

DISCUSSIONLumbar hernia is a rare hernia which account for lessthan 1.5% of total hernia incidence [4]. It was firstdescribed by Barbette in 1672. Till date, less than 300cases have been reported in literature.Among the two lumbar triangles superior triangle islarger, more constant and safe than inferior triangle.About 20% of lumbar hernias are congenital and 80%are acquired [5]. Most commonly patient presents withreducible flank bulge associated with pain anddiscomfort. Lumbar hernias are associated with 25%risk of incarceration and 80% chance of strangulation[6] because two of the three boundaries for hernia defectare soft and muscular in origin. Computed tomographyscan is the diagnostic modality of choice [7]. It canprovide detailed information about the anatomy of the

IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 5, May 201 3. ISSN – [0976-31 98]

IJCRI 201 3;4(5):243–247.www.ijcasereportsandimages.com Sahoo et al. 246

lumbar area, extent of the defect, presence of herniatedintra­abdominal viscera and also differentiates herniafrom muscle atrophy with no fascial defect, for which nosurgical intervention is required. The predominantcause for the postoperative bulge is intercostal nerveinjury which results in subsequent paralysis ofabdominal wall musculature. This injury can be reducedby avoiding extending the incision into the 11thintercostal space [8].Surgical repair is the treatment of choice and shouldbe considered in all cases if medically feasible. Varioussurgical approachs have been described includingprimary repair, tissue flaps and mesh repair includinglaparoscopic trans­abdominal and retroperitoneoscopicapproaches [9]. Comparative studies have showncertain advantages of laparoscopic approach over theconventional open repair [10]. In intraperitoneallaparoscopic repair, lateral peritoneal reflection of colonis taken down to facilitate exposure of hernia defect. Inretroperitoneal approach lateral retroperitoneal space isentered and insufflated. Now has days laparoscopicrepair become the procedure of choice for lumbarhernia [3].Regarding open approaches to surgery no procedurehas been shown to have a definite advantages overothers, especially in view of the relatively rarity of thesecases. Surgical repair is sometimes difficult andchallenging for the surgeons. The difficulty in definingthe margins of the fascial defect, the weakness of theinvolved structures, the involvement of a bone elementand lack of surgical experience are all taken intoconsideration during surgical planning. Bleichrodt et al.used omentum polypropylene sandwich in presence ofinfection with good results [11]. Very less literature isavailable on using sandwich technique for repair oflumbar hernia. In our study we used a novel techniqueof sandwiching two prolene meshes in between layers ofabdomen to provide strength to the defect repair withvery good results.

CONCLUSIONSandwich technique repair of lumbar hernia is safe,easy and a novel idea to strengthen the weak abdominalwall. It provides better results in short­term follow­upwithout recurrences, however, long­term follow­up isneeded to prove its efficacy.

*********Author ContributionsManash Ranjan Sahoo – Conception and design,Acquisition of data, Analysis and interpretation of data,Drafting the article, Final approval of the version to bepublishedAnil Kumar T – Conception and design, Acquisition ofdata, Analysis and interpretation of data, Drafting thearticle, Critical revision of the article, Final approval ofthe version to be published

GuarantorThe corresponding author is the guarantor ofsubmission.Conflict of InterestAuthors declare no conflict of interest.Copyright© Manash Ranjan Sahoo et al. 2013; This article isdistributed under the terms of Creative CommonsAttribution 3.0 License which permits unrestricted use,distribution and reproduction in any means providedthe original authors and original publisher are properlycredited. (Please see www.ijcasereportsandimages.com/copyright­policy.php for more information.)

REFERENCES1. Maingot’s abdominal operation 10th edition page131–2.2. Orcutt TW. Hernia of the superior lumbar triangle.Ann Surg 1971;173(2):294–7.3. Salamesh JR, Salloum EJ. Lumbar incisional herniasdiagnostic and management dilemma. JSLS2004;8(4):391–4.4. Jak Abraham hernias: Maingot’s abdominaloperations 9th edition page 271.5. Shackelford surgery of alimentary tract 6th editionpage 688–9.6. Heniford BT, Lannitti DA, Gagner M. Laparoscopicinferior and superior lumbar hernia repair. ArchSurg 1997;132(10):1141–4.7. Baker ME, Weinerth JL, Andriani RT, Cohan RH,Dunnick NR. Lumbar hernia: Diagnosis by CT. AJRAm J Roentgenol 1987;148(3):565–7.8. Gardner GP, Joseph LG, Rosca M, Rich J, WoodsonJ, Menzoian JO. The retroperitoneal incision. Anevaluation of postoperative flank ‘bulge’. Arch Surg1994;129(7):753–6.9. Carbonell AM, Kercher KW, Sigmon L, et al. A noveltechnique of lumbar hernia repair using bone anchorfixation. Hernia 2005;9(1):22–5.10. Moreno­Eega A, Torralba­Martinez JA, Morales G,Fernandez T, Girela E, Aguayo­Albasini JL. Open vslaparoscopic repair of secondary lumbar hernias: aprospective nonrandomized study. Surg Endoscopy2005;19(2):184–7.11. Bleichrodt RP, Malyar AW, de Vries Reilingh TS,Buyne O, Bonenkamp JJ, van Goor H, Theomentum­polypropylene sandwich technique: anattractive method to repair large abdominal­walldefects in the presence of contamination orinfection. Hernia 2007 Feb;11(1):71–4.

IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 5, May 201 3. ISSN – [0976-31 98]

IJCRI 201 3;4(5):243–247.www.ijcasereportsandimages.com Sahoo et al. 247

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