Lumbar Hernia

Lumbar Herniation
Lumbar herniation is associate uncommon wall herniation, creating its designation and management a challenge to the treating MD. The presentation is also dishonorable designation usually lost. associate imaging study forms an essential aid within the designation and surgery is that the sole treatment choice.

Presentation of case
A forty-two-year previous male conferred with a history of pain in the lower back of four year period and was being treated symptomatically over four years with analgesics and physiatrics. He had noticed a swelling over the left facet of his mid-back and consequently on examination was found to own a primary nonheritable body part herniation arising from the deep superior body part triangle of Grynfelt. the designation was confirmed by Computed Tomographic imaging.

A body part herniation is also primary or secondary with solely regarding three hundred cases of the primary body part herniation reportable in literature. body parthernias manifest through 2 attainable defects within the posterior wall, the superior being additional common. Management remains surgical with numerous techniques rising over the years. The patient at our center underwent associate open subway mesh repair with a glorious outcome.

An MD might encounter a primary body part herniation maybe once in his lifespancreating it a motivating surgical challenge. Sound anatomical information and adequate imaging area unit indispensable. In spite of advances in minimally invasive surgery, it can not be universally applied to patients with body part herniation and management needs an additional tailored approach.

Keywords: body part herniation, Primary, Mesh repair
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1. Introduction
The anatomical existence of body part hernias has been best-known for four centuries with the primary suggestion by the mound in 1672. the primary case was reportable by Garangoet in 1731. Petit and Grynfelt portrayed the boundaries of the superior and also the inferior triangles, named when them severally, in 1783 and 1866 [1]. Over the last four centuries regarding three hundred cases of primary body part hernias are reportable creating it the rarest type of wall hernias general MD might be changed on a case maybe once in his career, inflicting a diagnostic perplexity within the absence of high suspicion.

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A forty-two-year previous male conferred with the history of pain within the lower back of four years period. He had no history of trauma or previous surgery. The patient noticed a

swelling over the left facet of mid-back that magnified on straining and disappeared on lying prone. He had approached multiple medical practitioners over the last four years however received solely symptomatic management within the type of analgesics and physiatrics.

On examination, there was swelling over the left body part region, deckle edged superiorly by the twelfth rib, medially by paraspinal muscles and laterally by external oblique muscle. Cough impulse was a gift with a sleek surface, soft consistency, and no inflammatory signs. it had been reducible in the prone position. the conditional designation was primary nonheritable body part herniationarising from the deep superior triangle of Grynfelt. Routine blood investigations unconcealed no abnormalities. On imaging, ultrasound didn’t acquire any wall defect. computed axial tomography was requested and reportable as body part herniation involving the left superior triangle with a defect and herniating peritoneum.

The herniation was approached through a transverse incision over the left body part region. Intraoperatively content of the herniation was found to be retroperitoneal fat. there have been 2 defects noted within the region of the superior triangle three with weakened out facia. A subway repair was dole out with plastic mesh placed within the preperitoneal house. A subway mesh repair was used as this could maintain the utmost overlap of healthy tissue with the deep-seated mesh material. The postoperative course was quiet. On two month follow up patient’s symptoms had resolved and there was no return of the herniation at one year follow up.

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Defects noted within the superior triangle with retroperitoneal fat as content.

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Subway mesh in situ.

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3. Discussion







Anatomically the posterior wall is created by one muscle, the quadratus lumborum. within the realm of treatment of retroperitoneal pathology and repair of body part hernias, one might speak of a “surgical” posterior wall. From outside to within the surgical posterior wall consists of the subsequent entities (1) skin (2) superficial facia (3) superficial layer (composed posterolaterally by the latissimus dorsi muscle and anterolaterally by the external oblique muscle) (4) thoracolumbar fascia(posterior, middle and anterior) (5) middle muscular layer (sacrospinalis, internal oblique and musculus serratus posterior inferior) (6) deep muscular layer (quadrates lumboruma and striated muscle muscle) (7) transversal facia (8) extraperitoneal membranous animal tissue and fat (9) serous membrane. The posterior and middle layers enwrap the sacrospinalis. the center and also the anterior layer enwrap the quadratus lumborum. the center layer continues laterally to the border of the transverses abdominis by fusion of all three layers [3].

Lumbar hernias manifest through 2 attainable defects within the posterior wall. The superior body part triangle of Grynfelt and also the inferior body part triangle of Petit  The larger superior triangle is inverted, deeper and additional constant. It’s boundaries area unit fashioned by posterior border of internal oblique (anterior), anterior border of sacrospinalis (posterior), twelfth rib and also the musculus serratus posterior inferior muscle (base), external oblique and latissimus muscle (roof), fascia of the ab (floor). For all sensible functions, it’s associated vascular house. The inferior triangle is upright, less constant and additional tube-shaped structure. Its boundaries are the posterior border of the external oblique muscle (anterior), anterior border of the latissimus dorsi muscle (posterior), bone crest (base), superficial fascia (roof), internal oblique (floor). The inferior triangle is usually remarked because the body part triangle being additional superficial in location and simply demonstrable [3]. The content of a body part herniation is alsoretroperitoneal fat, kidney, colon, or less normally tiny gut, omentum, ovary, spleen, appendix or ovary.

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Diagrammatic illustration of body part triangle anatomy.

Lumbar hernias are also inborn or nonheritable . associate nonheritable herniation is also primary or secondary. Secondary body part hernias area unit of traumatic or post-surgical flank incisions, excretory organ surgery, bone harvesting etiology comprising regarding twenty-fifth of nonheritable hernias. inborn hernias are noted to arise from the inferior triangle and area unit usually seen with different anomalies like excretory organ agenesia, lumbocostovertebral syndrome.

Patients typically gift with nonspecific complaints. it’s been determined to be additional common in males and on the left facet. Complications like immurement, blockage, strangulation, and pathology might occur. Physical examination plays an awfully necessary role in the designation. There are reportable cases of body part hernias misdiagnosed as lipomas or maybe a skeletal muscle symptom. The patient might gift with a low backache or a particular purpose of pain over the region of the herniation. An examination finding of swelling with cough impulse that reduces in prone position clinches the designation. A challenge for clinical designation is seen with fat patients. Confirmation of this condition ofttimes need imaging studies, a CT scan being the study of an alternative. an in-depth discussion with the specialist relating to the anatomy and content of the herniation is found to be useful because it could be a seldom encountered entity.

Surgical repair of the herniation is that the solely definitive treatment choice. associate open or laparoscopic technique is also utilized. the primary open repair was wiped. The Down technique was introduced using musculoaponeurotic rotation flaps mistreatment the gluteus muscle major and medius muscles. Later latissimus dorsi flap, free grafts, fascial strip repair, and numerous mesh repairs are used. presently artificial mentoplasty is that the most well-liked among open repairs combined with muscle flaps looking on the character of the defect. Failure of those repairs is also because of restricted fascial strength, weakness of the encircling tissues and stitching the bony portion of the herniation boundaries. further morbidity is because of retraction, compression of nerve endings, intumescence and seroma formation or meshes infection. Laparoscopic repair is also a transabdominal or associate extraperitoneal repair with placement of mesh (Read More…)

There is no current recommendation for the utilization of any explicit technique, tho’laparoscopic surgery has less morbidity, less pain, and shorter hospital keep. Treatment alternative must be tailored to a selected patient in terms of defect location, size, content, standing of close tissues and patient affordable.

Dr. Pramod Shinde is the best doctor for Best Hernia Treatment since 1987 in Nashik. He has experienced about his field and skill for surgery for treating the patient. Is the chief Laparoscopic, GI, Bariatric and Onco surgeon. After having Done his MS in Surgery from Miraj Medical College and the famous Wanless Hospital from Miraj, he Started his Practice at Nashik in 1987. He is trained in Cancer, GI, Vascular and Portal Hypertension,Best Hernia treatment,  Fistula Treatment,Epigastric\colorectal Cancer treatment in Kaushalya Hospital and  Research center.