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Richter’s Hernia: Clinical Aspects and Management
151
CONCLUSION
Richter’s hernia remains a diagnostic challenge, and delays in diagnosis and treatment
continue to contribute to adverse outcomes. While Richter’s hernias commonly occur
naturally in femoral, inguinal and other hernia sites, the common use of minimally-invasive
abdominal surgery techniques presents the risk of formation of these hernias as a
complication. Awareness of this helps modify surgical technique to reduce the risk of this
complication. While most Richter’s hernias are still diagnosed at the time of surgery,
presentation of patients with chronic pain or discomfort at port hernia sites should raise
clinical suspicion. Imaging by CT may help in the pre-op diagnosis of a Richter’s hernia,
although operative exploration – open or laparoscopic - may be required for definitive
diagnosis and treatment in some cases. It is vital to keep in mind that a patient with a
Richter’s hernia may present with obstructive signs and symptoms, or in an insidious manner
lacking any physical or radiological findings.
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In: Hernias ISBN: 978-1-62948-441-9
Editor: Mark A. Suckow © 2014 Nova Science Publishers, Inc.
Chapter 11
LUMBAR HERNIA:
SIGNS, SYMPTOMS AND TREATMENT
Junsheng Li and Zhenling Ji
Center of Hernia Repair, Department of General Surgery,
Affiliated Zhongda Hospital, Southeast University, Nanjing, P. R., China
ABSTRACT
Lumbar hernias are quite uncommon as compared to other ventral abdominal wall
hernias, and without standard method of repair. Lumber hernias may be congenital or
acquired, and anatomically categorized into superior lumbar hernias and inferior hernias.
Lumbar hernias need to be repaired due to the risk of incarceration and strangulation.
Further, they can be misdiagnosed, with subsequent failure of inappropriate treatment.
Various repair techniques have been proposed, such as simple anatomical repair,
rotational musculofascial pedicle flap grafts, free grafts, fascial strip repair, and various
synthetic mesh repairs. With advancements in laparoscopic techniques, successful lumbar
herniorrhaphy can be achieved invasively by the creation of a completely extraperitoneal
working space and secure fixation of a wide posterior mesh, including both totally
extraperitoneal hernioplasty (TEP) and trans-abdominal preperitoneal (TAPP)
procedures. In this chapter, the anatomy of lumbar hernia is reviewed, the signs and
symptoms are described, and commonly used techniques of repair are introduced.
Keywords: Lumbar hernia, laparoscopic repair, tension free
INTRODUCTION
Lumbar hernia is a rare defect of the dorsolateral abdominal wall. It is defined as a
protrusion of extraperitoneal fat, with or without peritoneum and visceral contents.
According to the etiology, lumbar hernias may be congenital (about 20% of cases),
primary (spontaneous) or secondary (acquired), with primary hernias accounting for
approximately 55% of cases (Zhou et al., 2004). Congenital lumbar hernia appears during
Junsheng Li and Zhenling Ji
156
infancy and may be associated with other malformations; they are frequently diffuse and are
thought to result from an arrested or abnormal development of both the costovertebral skeletal
and abdominal musculature. Thus, lumbar hernia is sometimes referred to as,
“lumbocostovertebral syndrome” (Somuncu et al., 1997). Acquired lumbar hernia accounts
for 25–30% of all lumbar hernias (Lichtenstein et al. 1986; Heniford et al. 1997; Zamir et
al.,1998).
According to Orcutt (1971), all congenital hernias in the lumbar region perforate through
the inferior lumbar triangle. Conversely, acquired hernias that are of a traumatic nature
constitute 80% of reported lumbar hernias (Ng et al., 2006) and are predominantly associated
with the superior lumbar triangle due to the frequency of surgical interventions in this area
and because it is the thinnest site in the posterolateral abdominal wall (Skrekas et al., 2005).
ANATOMY
In applied surgical anatomy, the term “lumbar region” refers to a particularly weak area
of the dorsolateral abdominal wall. This area is bounded above by the 12
th
rib, below by the
iliac crest, behind by the erector spinae, and in front by the posterior border of the external
oblique (a line passing from the tip of the 12
th
rib to the iliac crest) (Moreno-Egea et al.,
2007). This area contains the superior triangle (Grynfeltt’s) and inferior lumbar triangle
(Petit’s).
The superior lumbar triangle, the Grynfeltt–Lesshaft region, is an inverted triangle, and is
the most common site of spontaneous herniation. This region is bordered by the lower aspect
of the 12
th
rib and the serratus posterior inferior muscle superiorly; the sacrospinal muscle
posteriorly; the inferior oblique muscle anteriorly. The roof is formed by the external oblique
and latissimus dorsi muscles, and the floor is formed by the transversalis fascia and
aponeurosis (Walsh and Springfield, 2004; Moreno-Egea et al., 2007). Figure 1 demonstrates
this anatomical area.
Figure 1. The inferior and superior lumbar triangles.
Lumbar Hernia: Signs, Symptoms and Treatment
157
The T12 and L1 nerves both cross the superior lumbar triangle. The abdominal wall
musculature (rectus abdominis, external and internal oblique, and transversus abdominis) and
overlying skin are supplied by the 7
th
through 11
th
intercostal nerves and subcostal nerve. If a
nerve is injured proximal to its division, motor innervation for entire segment of the muscle
would be comprised.
Minimal overlap exists between adjacent motor nerves. Segments of each abdominal
muscle are innervated by a single intercostal nerve. Thus, the loss of a single spinal level of
motor nerve results in paralysis of a full-thickness segment of the abdominal musculature, and
leads to bulging of the postoperative flank and lumbar herniation.
The inferior lumbar triangle was first described by Petit in 1783. It is upright, smaller,
more lateral and less constant than its superior homologue. The inferior triangle is superficial
and bordered inferiorly by the iliac crest, laterally by the external oblique and medially by the
latissimus dorsi, with the superficial fascia superficially and the lumbar fascia and internal
oblique aponeurosis deeply (Burick and Parascandola, 1996). The inferior lumbar triangle is
not covered by muscle and is not penetrated by any neurovascular structures (Moreno-Egea
and Aguayo, 2002; Jankovic et al., 2009).
Although hernias of the inferior lumbar triangle of Petit were described first (Petit, 1774),
the superior lumbar triangle is currently postulated as being the predominant area of weakness
(Heniford et al., 1997), though it is covered posteriorly by latissimus dorsi, or at least by its
thick and strong aponeurosis, which is attached to the thoracolumbar fascia. The superior
lumbar triangle, therefore, constitutes only a relatively weak area. In contrast, no muscular or
aponeurotic structures cover the inferior lumbar triangle; hence it represents a superficial area
of weakness. According to their contents, lumbar hernias may be extraperitoneal,
paraperitoneal or intraperitoneal.
RISK FACTORS FOR LUMBAR HERNIA
Factors believed to predispose to primary lumbar hernias include increasing age,
extremes of weight, chronic debilitating disease, wound infection and post-operative sepsis,
and increased intra-abdominal pressure (Moreno-Egea et al., 2007). Crush injury, iliac crest
fracture and local surgery can weaken the posterior abdominal wall and lead to secondary
lumbar hernia (Armstrong et al., 2008). Factors that may predispose to inferior lumbar hernias
include larger triangle base secondary to a more medial latissimus dorsi, tapered internal
oblique muscle, altered position of external oblique muscle and the existence of Hartmann
fissure at the triangle vertex (Moreno-Egea et al., 2007).
Loukas et al. (2007; 2008) classified the surface area of the triangles of Petit and
Grynfeltt in order to assess potential anatomic risk factors for inferior lumbar herniations.
They classified this variable anatomical triangle of Petit into four types based on the size of
surface area [Type I (43.7%), small triangles <8 cm
2
; Type II (26.2%), intermediate triangles
8–12 cm
2
; Type III (12.5%), large triangles >12 cm
2
; Type 0 (17.5%), absent triangle].
Further, it was noted that a Type III triangle of Petit may be more prone to herniation due to
its larger surface area. Similarly, the triangle of Grynfeltt was also classified into four types
based on the size of the surface area [Type I (50%), small triangles <5 cm
2
; Type II (22%),
Junsheng Li and Zhenling Ji
158
intermediate triangle 5–15 cm
2
; Type III (10%), large triangles >15 cm
2
; Type 0 (18%),
absent triangle].
Traumatic hernias are most likely to occur in the superior triangle (up to 95%), but
diffuse hernias not corresponding to the described anatomic landmarks may also be found.
Additionally, those injuries associated with the use and misuse of seatbelts may be more
likely to occur in the inferior triangle. These hernias may occur as a result of significant focal
blunt force that does not cause penetration or as a shearing force across the pelvis as seen in
some seatbelt injuries (Burick and Parascandola, 1996; McCarthy and Lemmon 1996; Zamir
et al., 1998). Motor vehicle accidents are responsible for a large number of these injuries,
although other mechanisms, including handlebar injuries, gore injuries and falls may also be
causative (Kubalak, 1994; McCarthy and Lemmon, 1996; Otero and Fallon, 1998).
It remains to be determined why primary lumbar hernias occur more frequently on the
left side than the right (Horovitz et al., 1998). Such a side predominance has also been
observed in traumatic hernias, but is thought to be related to the high frequency of seatbelt-
induced injuries in drivers (McCarthy and Lemmon, 1996; Zamir et al., 1998). To account for
the left-side predominance, it is postulated that the deep opening of the superior lumbar
triangle is, more or less, open depending on the position of the left kidney. The right kidney is
displaced inferiorly by the liver and is therefore more inferior than the left one. Dissection of
the superior lumbar triangle by both posterior and anterior approaches confirmed that the
peritoneum is separated from the abdominal wall by the kidney on the right side, whereas on
the left it is only partially separated by the kidney (Guillem et al., 2002).
CLINICAL FEATURES
The vast majority of lumbar hernias are unilateral, most often located on the left side, and
more originate in the superior lumbar triangle than in the inferior lumbar triangle (Thoreck,
1950; Swartz, 1978). Two-thirds have been documented in men (Heniford et al., 1997).
The majority of patients either remain asymptomatic or present with a posterior lump,
They appear as smooth, reducible, cough-impulsive, painless or uncomfortable bulges in the
flank. It may be asymptomatic or associated with varying amounts of pain (Walsh and
Springfield, 2004). Of lumber hernias that occur spontaneously, signs of intestinal obstruction
or bowel strangulation may also be present if the intestine becomes strangulated, and it was
reported that 9%-24% will actually be strangulated (Moreno-Egea et al., 2007).
The hernia contents are most frequently the colon; however, a variety of intraabdominal
organs (small intestine, stomach, spleen, kidney) may herniate into the lumbar space, even
become incarcerated (Horovitz et al., 1996; AstarcÂoflu et al., 2003; Teo et al., 2010).
DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
Lumbar hernias can be diagnosed by clinical symptomatology and physical examination.
In many cases, the differential diagnoses of lumbar hernias include a lipoma, sarcoma,
abscess, hematoma or renal tumor. Computed tomography (CT) is especially helpful in
assessing the anatomical relationships of the lumbar area, identifying the contents, and ruling
Lumbar Hernia: Signs, Symptoms and Treatment
159
out tumors or other pathologies (Baker et al., 1987) Figure 2 demonstrates a CT image of a
lumbar hernia.
Following lumbotomy, many patients exhibit mild bulging of the atrophic dorsolateral
abdominal wall, a normal postoperative finding that is hard to distinguish from a true
postoperative lumbar hernia. This has been termed pseudohernia (Moreno-Egea et al., 2007)
and may be readily characterized with CT. In addition, CT may prove useful for
characterizing other potential mimickers of lumbar hernias, such as intercostal hernias,
subcutaneous hematomas, long-standing degloving injuries, abscesses or soft-tissue tumors.
Magnetic resonance imaging (MRI) is reported to give precise delineation of the defect
(Armstrong et al., 2008).
TREATMENT
Treatment is surgical, unless precluded by severe co-morbidity, and early operative repair
at the time of diagnosis is recommended (Armstrong et al., 2008). However, there is no
consensus as to the optimal surgical approach.
Many techniques have been described for surgical repair of lumbar hernia, including
primary repair, local tissue flaps, and conventional mesh repair (Ponka,1980; AstarcÂoflu, et
al., 2003; Habib, 2003). More recently, treatment of lumbar hernia through trans-
abdominoretroperitoneal laparoscopy or through retroperitoneoscopy has been proposed
(Habib, 2003).
Repair needs to be individualized and depends on the size of the defect. For small defects
with good surrounding fascia, primary repair may be performed. As this is often not possible,
use of a number of muscle flaps have been described, but have been largely relegated to
historic interest by the availability of prosthetic mesh.
Figure 2. CT image of a right superior lumbar hernia.
Junsheng Li and Zhenling Ji
160
Open Procedure
Following incision directly over the hernia defect, the herniated fatty mass is excised or
the content of hernia is reduced, and the hernia sac is dissected free of the muscular rim and
ligated, if the defect is small and surrounded by strong tissue. The defect can be closed by
overlapping the adjacent fascia and muscle structure (primary closure) with interrupted
nonabsorbable sutures. For a larger lumbar defect, a mesh patch is placed to cover the defect.
The mesh should be placed such that it overlaps the defect at least by >2cm on all sides and
then fixed with nonreabsorbable sutures. Before the wound is closed a drain is inserted,
depending on the amount of tissue dissected. Another open preperitoneal procedure was
described (Witherspoon et al., 2012) in which the pre-peritoneal plane is widely developed
with blunt finger and gauze dissection and a Polysoft® Hernia Patch (Davol Inc., C.R. Bard
Inc., Crawley, UK) is deployed as an underlay patch with an overlap of approximately 3 cm.
Incarcerated Condition
In the presence of possible small bowel obstruction in an incarcerated hernia, an open
approach is most appropriate. Nonabsorbable mesh repair may not be preferred in patients
with strangulated hernia in which intestinal wall necrosis or perforation have occurred. In
such cases, intestinal resection would be needed, and contamination is unavoidable. In this
condition, if the hernia is of small or moderate size, primary repair with late closure of the
skin is reasonable. In large defects, muscle fascial rotational flaps of gluteus maximus (Dowd,
1907) and latissimus dorsi muscle (Rishmiller, 1917) could be used to repair the large defect
(Geis and Saletta, 1989). Imbrication of the transversalis fascia is an alternative for the
treatment of such conditions (Geis and Saletta, 1989).
Laparoscopic Procedure
Laparoscopic management provides excellent operative visualisation, preventing damage
to nearby structures, and is associated with lower pain scores, shortened hospital stay, early
return to routine activity, more favourable cosmesis and minimal morbidity (Grauls et al.,
2004; Ipek et al., 2005; Moreno-Egea et al., 2005).
Laparoscopic approach of lumbar hernia repair can be either retroperitoneal or trans-
abdominal.
Retroperitoneoscopy is undertaken with a 10-mm trocar placed into the retroperitoneal
space through an open technique, along the anterior axillary line, between the inferior border
of the chest wall and the anterior superior iliac spine (Postema & Bonjer, 2002; Woodward et
al., 1999). Even if the operating space is small, the retroperitoneal fat is detached at a distance
from the colon and the ureter, flush with the lumbar wall in a nonvascular plane, first with the
finger or with a balloon (Woodward et al., 1999; Postema and Bonjer, 2002) and then with
the up-and-down movements of a scope. In the space created, one or two 5-mm operating
trocars are placed along the anterior axillary line to achieve the dissection.